Teaching Regional Anesthesia: Current Perspectives

Abstract

Regional anesthesia is an essential component of modern anesthesia practice, and there have been several changes in regional training methods in recent years. Effective anesthesia instructors must possess both clinical expertise and practical teaching skills. In order to ensure that future generations of anesthesia providers receive high-quality education and training, it is essential to train anesthesia instructors in the latest educational techniques and technical skills. This chapter aims to provide practical resources and tools for effectively training anesthesia providers in anesthesia programs. These may include simulation-based training models, online educational modules, peer-to-peer mentoring programs, hands-on workshops, and, finally, effective feedback.

1. Introduction

The high demand for regional anesthesia in adults and children in the last 20 years has represented one of the most critical global changes in anesthesia [1, 2, 3]. The advantages, in medical quality and socioeconomic terms, are associated with the increased safety performance of the procedures and the routine usage of ultrasound techniques, increasing the success rate and reducing the number of complications and costs associated with perioperative care.

The success of the use of regional anesthesia techniques, however, is linked mostly to the experience of the operator, not only in the procedural sphere but also in clinical reasoning. It is essential to guarantee the anesthesiologist, both in training and in practice, a teaching-learning process based on deliberate practice and mastery learning that guarantees learning and continuous improvement of professional performance [4, 5].

Although the literature reports a significant gap in the confidence of anesthesia residents to perform regional anesthesia procedures without supervision, there needs to be more evidence about the best way to teach regional anesthesia skills [5, 6]. The anesthesiologists can consult the Guidelines for Training in Regional Anesthesia, published in 2005 and revised every 3 years by the American Society of Regional Anesthesia and Pain Medicine; these are the consensus guidelines regarding learning objectives and curricular content [7, 8, 9]. This chapter addresses the fundamental aspects of the teaching framework in complementary form, not only at the training level during residency programs but also in supra-specialized training programs and throughout life.

2. How to learn to do technical procedures?

A practical or procedural skill is defined as any mental and motor activity that requires the execution of a manual task, regardless of its degree of difficulty. Anesthesia professionals must undergo training to achieve competency in a range of skills to enable them to work safely in complex, dynamic, and unpredictable clinical environments. Acquiring competency in procedural skills therefore is an essential goal of anesthesia programs, with the expectation that a graduate should be proficient in basic procedural and clinical skills and ability to assume responsibility for safe patient care upon entry into the profession.

There are different and complementary approaches to understanding the teaching and learning of procedural skills. We recommend a practical model that combines the procedural skill taxonomy of Anita Harrow and Taylor et al.’s framework (Figure 1) [10].

Figure 1.

Proposed pedagogical frameworks for procedural skills acquisition in medicine. Source: Adapted of Sawyer, T. et al. [10].

The taxonomy devised by Anita Harrow provides a clear and definitive breakdown of the five essential stages that every anesthesia provider must master. These stages have a strong correlation with the Dreyfus and Dreyfus level of competence, as demonstrated in Figure 1. Moreover, Taylor et al. have presented a concrete six-stage educational framework for procedural skill training in medicine that emphasizes deliberate practice and domain enhancement. These six stages encompass Learning, Seeing, Practicing, Probing, and Maintaining, which are expertly adapted from the conventional four-stage Peyton model, as depicted in Figure 1.

3. What skills do regional anesthesiologists need to learn and how to teach them?

Each practical skill that an anesthesiologist needs to learn (e.g., airway management, regional techniques, and invasive access) has a specific task. In the regional anesthesia skills case training, the students must learn different technical, cognitive, and behavioral skills (Figure 2) [3, 11].

Figure 2.

Regional anesthesia skills.

3.1 Cognitive skills

Cognitive capabilities encompass a range of abilities that allow a person to comprehend, deduce, recall, organize, and transform data into fresh perspectives; make informed choices; tackle challenges; and gain knowledge. Within the domain of cognition, it is essential to have a thorough understanding of anatomy and sonoanatomy concepts and familiarity with equipment, medications, and anesthesia techniques [5, 12, 13]. Mastering these areas can significantly enhance cognitive abilities and facilitate optimal performance [14].

3.1.1 Teaching human anatomy for regional anesthesia

A comprehensive understanding of human anatomy, particularly nerve pathways and structures relevant to the specific region they will be targeting is necessary for the learning and proper execution of techniques in regional anesthesia. Accurately identifying nerves and optimizing block placement depend on this knowledge. Understanding the human body’s structure and function is fundamental to regional anesthesia performance. Sonoanatomy, which involves using ultrasound to visualize anatomical structures in real time during medical procedures, is an essential skill in the field. A combination of didactic lectures, hands-on practical sessions, and interactive learning experiences is necessary to teach these skills effectively [1, 6, 7, 11, 12, 13, 15, 16].

Experienced instructors are crucial in guiding learners’ progress and addressing individual challenges. By integrating diverse teaching strategies, medical educators can effectively equip students and practitioners with the necessary anatomical and sonoanatomical skills, ensuring their competency and success in clinical practice [5, 10, 14, 17].

3.1.1.1 Lectures

Lectures as a teaching strategy can be highly effective when supplemented with multiple practical activities that enable students to bridge the gap between theory and practice. A recent scoping review on effective teaching strategies in surface anatomy has highlighted the importance of adopting a multimodal approach [18, 19]. Literature shows great acceptance of small-group teaching by medical instructors, integrated clinical skills sessions, and incorporation of anatomical plastic models and cadaveric specimens in their anatomy classes [19, 20].

To further enrich the learning experience, several additional strategies can be implemented [18]. Clinical-applied teaching, for instance, can be introduced to provide students with real-life medical scenarios that demonstrate the practical application of anatomical knowledge. The use of radiological imaging can also prove beneficial in helping students visualize anatomical structures in a clinical context [3, 21]. Moreover, engaging activities like body painting and topographical body massage can make learning interactive and improve the student’s performance [18].

By combining traditional lectures with these practical and engaging teaching methods, educators can create a dynamic and comprehensive learning environment that fosters a deeper understanding and appreciation of surface anatomy, contextualizes the teaching, embraces experiential learning, and facilitates the process [18, 22].

3.1.1.2 Videos, online modules, and virtual simulators

Explanatory videos and self-directed interactive virtual simulations are the most common and effective anatomy learning strategies. Research shows that virtual simulators can improve residents’ skills by up to 40%. A specific study evaluated the impact of a short educational video with an interactive simulation on ultrasound anatomy knowledge. The results showed that the video significantly improved theoretical knowledge but, surprisingly, did not translate into an improvement in practical ultrasound scanning skills to locate the nerve. However, combining these strategies with supervised practical learning models can enhance student performance. For instance, a training module that included a didactic lecture on ultrasound-facilitated neuraxial anesthesia and mentored teaching on cadaveric spine dissections and hands-on ultrasound scanning of live models resulted in superior performance by the residents compared to those who only received the didactic lecture.

Woodworth et al. believed that exposition to an educational video of relevant anatomical structures plus simulation could improve the ability to interpret and recognize structures on ultrasound. They compared an experimental group that was exposed to the teaching video and 5 minutes of simulation and a control group that watched a comedy video without simulation. They had a written pretest and a posttest and an ultrasound scanning pre- and posttest in live models. They found that watching a video improved the knowledge of anatomy structures and image interpretation but could not demonstrate improvement in scanning nerves at hands-on practice [16].

They confirm that video and computer simulations are tools that can improve explicit knowledge, which in peripheral nerve blocks (PNB) is represented by the recognition of anatomic structures and their localization around the nerve, so this can make a difference against residents or fellows who do not have the opportunity to practice in simulation scenarios [16].

Access to an interactive ultrasound spine module improves theoretical knowledge and practical skills before clinical care. In summary, using explanatory videos and interactive simulations is valuable for learning, but when complemented with supervised practical experience, it significantly enhances the development of skills and knowledge.

3.1.1.3 Cadaver review sessions

Studies have shown that by including cadaver review sessions (CRSs) in anesthesiology, programs can significantly enhance residents’ understanding of intricate anatomical structures involved in specific blockages, along with facilitating the honing of skills in ultrasound and needle use. In turn, this reduces the number of complications arising during clinical practice following peripheral nerve blocks.

In a recent study by Cale et al. [23] residents from the first and third years of anesthesiology programs took part in a 2-hour CRS once a month in a human anatomy laboratory. An anatomist and an anesthesiologist with training in regional anesthesia led the session, guiding the residents through critical anatomic structures and assisting them in integrating this knowledge to perform ultrasound-guided peripheral nerve blocks in the cadavers.

At the end of the study, the residents reported feeling more confident in recognizing anatomical structures on cadavers and using ultrasound. Most residents preferred CRS over online modules, with some noting that the practice on cadavers was relevant to their training and clinical practice. Overall, the experience helped the residents improve their performance in PNB and broaden their knowledge, making them better equipped to provide quality patient care.

3.2 Technical skills in regional anesthesia

It is important to note that more than explicit knowledge is needed; motor skills must also be developed. Unfortunately, teaching motor skills is often overlooked. Learning motor skills requires practicing and repeating procedures until the learning curve stabilizes; this is reached by overcoming several domains [10, 11, 16].

In the case of regional anesthesia, the evolution of skill is characterized by three stages [3, 11, 24]. The first one is cognitive, in which the residents get the concept of the skill. In this stage, residents behave timidly, inconsistently, and inaccurately; make many mistakes while doing the task; and need help interacting with the environment. The second stage is associative, where movements get more fluid, there are fewer mistakes, and residents can interact with the care team or patient. The last stage is autonomous, where movements are consistent, mistakes are rare, and residents can recognize them, solve unexpected situations, concentrate on other issues, and connect with the care team and patient.

Teaching strategies to train more confident, independent, and proficient anesthesiologists have been described as follows: To learn a new task, they should start by knowing the expected outcome and setting specific goals. They can prepare by reading, watching videos, or observing a mentor. Then, they can make a deconstruction of the task. This means breaking down the procedure into more straightforward steps. After that, temporally distributed simulation sessions are helpful to practice segmentation by performing steps sequentially until they can complete the task. Following the simulation, deliberate practice can be carried out with the guidance of a teacher, who assesses the learning level of the resident and, according to that, allows the resident to perform a procedure. When the tasks that residents are asked to do are in their zone of proximal development, skill development gets stimulated and reinforced [3, 11, 17].

Finally, feedback allows the residents to compare their previous concepts of the tasks with their actual performance and to receive information about how the teacher perceived it [25]. The teacher must give the residents a chance to share their sensations of the performance; then, it is necessary to make constructive criticism, identify the need for improvement, and highlight what the residents have done correctly. This feedback at the procedure’s end helps the residents strengthen their knowledge [26, 27].

In this way, regional anesthesia trainers must master various needle insertion techniques with precision, including single or multiple injections. Utilizing ultrasound guidance is crucial for accurate needle placement and improving patient safety during the procedure. In this case, the anesthesiologist needs other specific skills to improve their performance in this technique. Additionally, nerve stimulation techniques are fundamental for nerve localization, aiding in identifying nerve responses and further enhancing the accuracy of the regional block [1, 3, 8, 12, 13, 28].

3.2.1 How to teach technical skills?

The didactic component of the technical skills training provides a theoretical understanding of anatomical structures and their clinical relevance, while practical sessions, such as cadaver dissections simulations and live model workshops, develop tactile familiarity with anatomical landmarks and build confidence in needle techniques. Ultrasound simulators and patient simulations enhance sonoanatomy skills by providing a risk-free environment for real-time image interpretation and probe manipulation.

3.2.1.1 Simulation-based practices

Simulation-based training is an approach that employs artificial devices to recreate various clinical scenarios that resemble real-world experiences, providing an enhanced learning opportunity [3, 17]. The procedures or situations utilized in the simulation can be pre-planned, standardized, and practiced repeatedly without posing any risk to the patient. Although simulation-based training has gained popularity and is now integrated into several undergraduate and postgraduate programs, there is still much to be discovered concerning its potential [4, 6, 29].

3.2.1.1.1 Advantages of simulation teaching based practices

The literature has shown that simulation-based training increases clinical knowledge and skill acquisition compared to non-simulation training and conventional teaching tools [21, 30]. It is significantly more efficient and cost-effective than other teaching methods for learning ultrasound-guided regional anesthesia, reducing the learning curve time and optimizing the trainees’ training time [1, 21].

Simulation-based training is a superior alternative to traditional training methods in the medical field. This approach enables medical professionals to perfect procedures safely before applying them to real patients, resulting in improved outcomes and lower healthcare costs [6, 14, 21, 31, 32]. Not only does this create a safe learning space, but it also allows for immediate and accurate feedback, which is crucial for boosting confidence and competence [14, 33]. Feedback should be ongoing, reflective, and provided within a secure learning environment to ensure optimal results [1, 2, 3, 14, 30].

Additionally, simulation-based training focuses on improving and acquiring competencies rather than on volume-based training [29]. Finally, simulation has proven to be highly desirable in those programs, individuals, or training settings where it is infrequent or nonexistent [34].

3.2.1.1.2 Types of simulators on regional anesthesia

Among the variety of prototypes used in clinical simulation in regional anesthesia training are the following:

1. Cadaveric sessions

   Cadaveric sessions hold a special place in the training process since they allow for a 3-dimensional representation and tactile feedback, requiring visuospatial reasoning to perform an appropriate needle positioning and, ultimately, an adequate PNB [35]. Practicing on cadavers brings the learning process closer to reality, unlike online modules in a 2-dimensional plane. Lin et al. performed similar sessions with regional and pain anesthesia fellows, finding a positive response [31, 36]. They believe that trainees can benefit from the high fidelity of cadavers to make multiple PNBs and enhance their sonographic orientation, which otherwise cannot be done in the operating room for several reasons [31, 36]. To avoid these issues, using a simulation space, or “block room,” has been suggested to lead to a safe learning environment without stress or the risk of complications of PNB [31, 37, 38].

   Improving technical skills is crucial to gain expertise in performing procedures. Woodworth et al. suggest that this can be achieved by using dynamic ultrasound images to help trainees understand unclear anatomy [39].

2. Ultrasound-guided training of simulated participants

   The simulated participant, often referred to as an “SP,” is an individual specially trained to portray a particular role or scenario in simulated environments, such as medical simulations, educational simulations, or communication exercises. The key characteristic of an SP is their ability to realistically replicate the characteristics, behaviors, and emotions of a specific person or patient, contributing to the authenticity and immersion of the simulated experience [29]. This resource is limited to teaching, learning, and reviewing ultrasound fundamentals and sonoanatomy, which are fundamental for developing an adequate and successful regional block technique [1]. It also improves the confidence and skill in using the ultrasound machine in invasive patients, reducing technique times and complications [6].

3. Ultrasound-guided training on manikins

   There are exceptional ultrasound simulators on the market that provide realistic images and enable students to perform a wide range of procedures. These simulators are perfect for teaching basic skills such as identifying superficial anatomy and sonoanatomy and handling equipment and transducers [1, 30, 39]. They also offer training for more advanced skills, including needle handling, visualization, and the placement of local anesthetic or perineural catheters. However, it is important to note that these simulators come with high acquisition and maintenance costs and are not easily transportable.

4. Simulation crisis with manikins

   This type of training is limited to management training in response to systemic toxicity of the local anesthetic. A disadvantage is that it prevents the trainee from assessing the possibilities of anatomical and pulse variants as anatomical repair in life patients [6].

5. Training on three-dimensional phantom models

   This type of training improves understanding of anatomical principles and blocking techniques [6, 33]. It also enhances the novice trainees’ needs focusing on anatomical principles and blocking techniques has improved novice trainees’ needle orientation, hand-eye coordination, and understanding and recall of anatomy [32, 34]. These skills are crucial for the optimal development of a peripheral nerve block.

   The 3D Phantom models used in ultrasound-guided regional anesthesia training are the Jelly Phantom, Meat Phantom, Elastomeric Rubber, and Cadaveric Piece. Each model has different processing dynamics but similar learning performances [21, 30, 32, 33]. Although some reports mention the high cost of using commercial models for this type of training, similar efficacy has been demonstrated in low-cost models [33].

   Each model has different processing dynamics but similar learning performances (Table 1) [40]. Each one has different processing dynamics but similar learning performances, not to mention the trainer’s perception of a more realistic environment with the cadaveric and meat models [1, 2, 3]. The literature requires more extensive descriptions of each simulation technique available today.

Model used	Time for target identification	Time for task completion	Needle placement time	Characteristics
Transparent model	Shortest time	Shortest time	No significant difference	Less mistakes but less realistic
Opaque model	Longer time	Longer time	No significant difference	More realistic for learning target identification skills
Meat model	Longer time	Shortest time	No significant difference	Requires refrigeration, cannot be used after multiple needle uses, and is associated with more failures

Table 1.

Comparison of different low-cost models [33].

3.2.1.2 Clinical practice

Hands-on teaching in regional anesthesia involves a practical and experiential approach to training medical professionals in performing various nerve block techniques and procedures [13, 41]. In this educational method, learners actively engage in real-life situations, allowing them to gain firsthand experience and develop their skills in a supervised environment [23, 42]. By immersing themselves in the process, learners can better understand the intricacies of regional anesthesia, its challenges, and how to overcome them and allow the simulation phase [10, 11].

It is essential to recognize the value of hands-on teaching in regional anesthesia. This type of learning provides a dynamic experience that complements theoretical knowledge and helps learners bridge the gap between simulation and real-world practice [10]. By participating in hands-on training, medical professionals can refine their technical skills, improve decision-making, and enhance patient safety during regional anesthesia procedures. This interactive approach fosters a deeper understanding of the complexities and better prepares learners to handle real-life patient cases with greater competence and confidence [13, 43, 44].

Supervision is a critical aspect of hands-on teaching in regional anesthesia. Experienced mentors guide learners through the process, offering real-time feedback and constructive critiques [45, 46]. This close supervision ensures that learners perform procedures safely and effectively, minimizing the risk of complications and errors [28, 47]. Supervision may gradually decrease as learners progress, allowing them to develop their autonomy in regional anesthesia practice.

Gaining confidence and autonomy is a significant outcome of hands-on teaching in regional anesthesia [28]. As learners master different nerve block techniques and gain experience with various patient scenarios, they become more self-assured in their abilities [11, 48]. This newfound confidence empowers them to take on more complex cases and adapt their skills to different clinical situations [17]. Ultimately, hands-on teaching instills in learners a sense of autonomy, allowing them to provide high-quality regional anesthesia care independently and contribute positively to patient outcomes.

3.2.1.2.1 When is it suitable for a resident to conduct a regional block on a patient?

Defining the capability of a student to perform autonomous regional anesthesia involves assessing their proficiency, knowledge, and decision-making skills in executing these specialized tasks independently (see assessment session). Here are vital steps to determine a student’s capability in autonomous regional blocks:

1. Supervised Practice: Allow the student to initially practice regional anesthesia techniques under direct supervision. Observe their performance, provide guidance, and assess their technical skills during this phase.

2. Case Complexity: Gradually expose the student to various complex cases. Evaluate their ability to choose appropriate regional anesthesia techniques based on patient needs, surgical requirements, and medical history.

3. Patient Safety: Assess the student’s focus on patient safety throughout the process, including proper patient positioning, accurate nerve localization, and monitoring during the procedure.

4. Decision-making: Evaluate the student’s ability to make critical decisions independently, such as choosing the appropriate nerve block technique, adjusting anesthesia dosage, and managing complications.

5. Procedural Efficiency: Assess the student’s efficiency in performing regional anesthesia procedures, including time management and minimizing patient discomfort.

6. Communication Skills: Evaluate how effectively the student communicates with patients, colleagues, and other healthcare providers involved in the procedure.

7. Documentation: Review the student’s ability to maintain accurate and comprehensive documentation of the regional anesthesia procedures, including preoperative assessments, procedural details, and postoperative care.

8. Adherence to Guidelines: Ensure the student follows established guidelines, protocols, and best practices for regional anesthesia, including infection control measures and patient consent procedures.

9. Independent Problem-solving: Observe how students handle unexpected challenges or complications during the procedure and assess their problem-solving skills.

10. Self-assessment and Reflection: Encourage the student to reflect on their performance, identify areas for improvement, and develop a plan for ongoing professional development.

11. Gradual Autonomy: Gradually allow the student to perform regional procedures with less direct supervision, increasing their level of autonomy as they demonstrate competence and confidence.

12. Continuous Feedback: Provide regular and constructive feedback to the students throughout the assessment process, helping them understand their strengths and areas for growth.

By following these steps and considering multiple aspects of the student’s performance, educators can accurately determine the capability of the student to autonomously perform regional anesthesia procedures and confidently transition them to independent practice in this specialized field.

3.3 Behavioral skills in regional anesthesia

Behavioral skills or anesthetists’ nontechnical skills (ANTS) refer to a set of cognitive and social skills and personal resources that enable safe and efficient task performance beyond the technical aspects of anesthesia administration [49, 50, 51]. These skills are essential for anesthetists to ensure patient safety, effective communication, and efficient teamwork during surgical procedures. ANTS encompass various competencies, including situational awareness, communication, decision-making, teamwork, leadership, and adaptability. Situational awareness involves perceiving and comprehending the surgical environment, anticipating potential challenges, and responding appropriately [52].

Teaching ANTS requires a comprehensive and structured approach to ensure anesthetists develop these critical skills effectively. In the clinical practice of anesthesiology, the acquisition of ANTS is highly important [52, 53]. However, despite efforts to evaluate and improve these skills [53, 54, 55], training strategies are still needed. To reinforce automatic behaviors when handling complex and stressful situations, it is recommended to draw from other specialties such as interactive workshops, simulation-based training, horror rooms, role-playing games, and analysis of adverse events [54, 55].

To engage anesthetists actively, it is recommended to organize interactive workshops and simulation-based training sessions [56, 57, 58]. These simulations allow them to practice ANTS in realistic scenarios, thereby fostering decision-making, communication, and teamwork in a controlled environment. Debriefing sessions are also crucial as they encourage self-reflection, identify areas for improvement, and reinforce positive behaviors. Encouraging senior anesthetists with strong ANTS to act as role models for junior colleagues can also be highly beneficial.

Utilizing video-based training modules can showcase examples of ANTS in action, demonstrating effective communication, teamwork, and situational awareness in various clinical scenarios [59, 60, 61]. Integrate the use of case-based learning into the training, permit anesthetists to analyze and discuss real-life cases that highlight the importance of ANTS. This approach allows for practical application and critical thinking.

ANTS training should be an ongoing process, with continual training and practice. Anesthetists should be encouraged to practice and reinforce these skills in their daily practice [11, 17]. Refresher courses or periodic workshops should be offered to reinforce learning. An environment where anesthetists feel comfortable discussing challenges and sharing experiences related to ANTS should also be created, encouraging open communication and learning from each other’s experiences.

4. How to assess student performance in regional anesthesia?

Assessment in anesthesia has traditionally been focused on evaluating clinical practice, patient interaction, and critical situation analysis at the end of the learning process [49]. However, it is crucial to prioritize real-time, sequential, and progressive process assessment; personalized learning; and feedback throughout this process [62].

4.1 Entrustable professional activities (EPAs) and assessment

The emergence of Entrustable Professional Activities (EPAs) has led to a call for change in medical and health profession curricula. EPAs are units of clinical practice, tasks, or responsibilities that students can perform without supervision once they have achieved the desired competency [28, 63, 64, 65]. Each EPA incorporates domains and subdomains of general competencies, integrated with specific content from the curriculum’s educational programs. Didactic activities are designed from concrete daily experiences in clinical practice at different levels depending on the year of study [28, 64, 65]. Three strategies, namely, situated learning, deliberate practice, and reflection, are used to help students achieve reliable clinical activities [66].

EPAs and the Dreyfus and Dreyfus model are complementary frameworks that can assess and guide regional learners’ progress and development. By aligning with competency-based medical education (CBME) principles, EPAs focus on learners’ achievement of specific competencies instead of relying solely on time-based training. EPAs are measurable milestones that demonstrate a trainee’s ability to conduct critical professional activities under appropriate supervision [67, 68]. The Dreyfus and Dreyfus model describes the stages of skill acquisition and expertise development, proposing five stages: Novice, Advanced Beginner, Competent, Proficient, and Expert. According to this model, individuals progress through these stages as they gain experience and expertise in a particular domain [10, 67, 68].

EPAs and the Dreyfus and Dreyfus model complement each other in medical education. EPAs can be mapped to the different stages of the Dreyfus and Dreyfus model. For instance, basic clinical skills required by EPAs might align with the Novice, Advanced, and Beginner stages. In contrast, complex decision-making and management may align with the Competent and Proficient stages [67, 68]. EPAs provide a concrete way to assess learners’ abilities to perform specific professional activities. As learners progress through their training, they can be evaluated against EPAs, and their performance can be compared to the expectations associated with the corresponding Dreyfus and Dreyfus stages. This assessment process enables educators to provide targeted feedback and support for learners at different skill levels [69].

The Dreyfus and Dreyfus model underscores the gradual development of expertise and autonomy. EPAs can serve as markers of a learner’s readiness to take on more responsibility and independence in their clinical practice as they transition from being supervised to being entrusted with certain professional activities [10, 11].

4.2 EPAS in regional anesthesia

The field of regional anesthesiology and acute pain medicine has recognized the need for standardizing assessments to effectively track trainee competency. The Accreditation Council for Graduate Medical Education (ACGME) provides competency descriptions and milestones, but other methods are necessary for accurate assessment [70]. To address this need, EPAs and special assessments models have emerged as promising approaches to evaluate the level of competency of residents and fellows.

To develop a comprehensive assessment framework, an expert group with experience in anesthesia education and competency assessment, established a list of 23 EPAs, a clearly defined entrustment scale, and a mapping to ACGME milestones [28]. This provides a standardized approach to assessing competency and ensuring well-prepared and competent fellows (Table 2). This rigorous methodology ensures that the RAAPM EPAs and procedural skills accurately reflect the required competencies for fellows, facilitating meaningful performance feedback.

EPA category	EPA title (assigned number)
Preoperative assessment	Peripheral nerve block—regional procedure evaluation and informed consent (1) Neuraxial technique—regional procedure evaluation and informed consent Preoperative assessment of the patient with preexisting neurological dysfunction for regional anesthesia Preoperative assessment of the patient on altered coagulation for regional anesthesia Evaluation and management of a patient with postoperative pain requiring rescue analgesia in the PACU
Patients with special conditions	Evaluation and management of regional anesthesia in the geriatric patient Evaluation and management of a patient with complex pain history Evaluation and management of regional anesthesia in a trauma patient Evaluation and management of acute pain in a pediatric patient
Perioperative care	Evaluation and management of a patient that would benefit from regional anesthesia of the upper extremity. Evaluation and management of a patient that would benefit from regional anesthesia of the lower extremity. Evaluation for and placement of a continuous peripheral nerve block Evaluation and management of a patient that would benefit from regional anesthesia of the thorax. Evaluation and management of a patient that would benefit from regional anesthesia of the abdomen. Perioperative management of a neuraxial block for surgical anesthesia Perioperative management of a peripheral or truncal nerve block for surgical anesthesia Appropriate conduct of handoff/transfer of care with an emphasis on minimizing barriers to communication
Regional and acute pain service	Postoperative evaluation and management of patients with continuous peripheral nerve blocks. Postoperative evaluation and management of patients with continuous neuraxial catheters (19). Postoperative evaluation and management of the ambulatory patient with a continuous peripheral nerve block. Management of an inpatient acute pain service. Evaluation and management of acute pain in the nonoperative setting
Other	Recognition, evaluation, and management of complications or potential complications related to regional anesthesia and acute pain management including assessment, documentation, and disclosure.

Table 2.

List of entrustable professional activities (EPAs) [28].

4.3 Regional anesthesia and clinical competence

Assessing trainees’ proficiency in regional anesthesia aligns well with Miller’s Pyramid of Clinical Competence. At the pyramid’s base lies “Knows,” where learners acquire factual knowledge about regional anesthesia techniques, relevant anatomy, and pharmacology. Moving up, “Knows How” reflects their ability to demonstrate the procedural steps and principles in controlled environments, such as simulation labs. The next level, “Shows How,” pertains to their ability to apply regional anesthesia under direct supervision in natural clinical settings. The final and more recent level “Is Trusted” included by Ten Cate et al. (Figure 3) [67].

Figure 3.

Extending Miller’s pyramid. Source: Adapted of Ten Cate et al. [67].

As trainees gain experience and competence, they also progress to higher levels of Miller’s Pyramid. “Does,” the penultimate level, signifies the point at which trainees can perform regional anesthesia more autonomously, though with some guidance and oversight. Finally, the pyramid’s pinnacle is “Does Independently,” where learners exhibit mastery in regional anesthesia and can administer it safely and effectively without supervision [62, 67].

Overall, the assessment of EPAs like regional anesthesia aligns with the progression of competence achievement at Miller’s Pyramid, ensuring that trainees advance through stages of knowledge and competence, ultimately becoming skilled and independent practitioners in anesthesiology. This structured approach to assessment enhances patient safety and ensures a high standard of care in clinical practice.

Evaluating the skill level of trainees in regional anesthesia follows the framework of Miller’s Pyramid of Clinical Competence. The pyramid’s base is “Knows,” where learners acquire knowledge of regional anesthesia techniques, relevant anatomy, and pharmacology. Moving up, “Knows How” reflects their ability to demonstrate procedural steps and principles in controlled environments, like simulation labs. The next level, “Shows How,” pertains to their ability to apply regional anesthesia under direct supervision in natural clinical settings.

When trainees reach “Does”, they achieve the second-to-last level. This one signifies the point at which trainees can perform regional anesthesia more independently but with some guidance and supervision. Finally, the pyramid’s peak is “Does Independently,” where learners demonstrate mastery in regional anesthesia and can administer it safely and effectively without supervision.

Overall, the assessment of Entrustable Professional Activities (EPAs) such as regional anesthesia aligns with the progression of competence achievement at Miller’s Pyramid. This approach ensures that trainees advance through stages of knowledge and competence, ultimately becoming skilled and independent practitioners in anesthesiology. This structured methodology enhances patient safety and guarantees a high standard of care in clinical practice.

4.4 Assessment tools for regional anesthesia

In the field of regional anesthesia, programmatic assessment is utilized to evaluate the progress and competence of learners in a systematic and comprehensive manner [71]. This approach differs from traditional assessment methods that rely on individual examinations, as programmatic assessment involves continuous and longitudinal data collection through various tools and activities. These may include direct observations, simulation-based assessments, case-based discussions, and feedback from both faculty and patients. By gathering data over time, program directors and educators can gain a holistic view of the trainees’ abilities, identifying strengths and areas for improvement. This approach fosters a culture of continuous learning and improvement, allowing for tailored interventions and support to enhance the learners’ proficiency in regional anesthesia [49, 72, 73]. Moreover, programmatic assessment provides a more accurate and reliable representation of a trainee’s overall competency, ensuring that they are well-prepared to deliver safe and effective regional anesthesia services upon completing their training.

To enhance the effectiveness of programmatic assessment, various assessment tools have been proven helpful in the van der Vleuten assessment equation (Table 3).

Test	Reliability	Validity	Feasibility	Educational impact	Assessment target
Procedure logs	Low self-reporting, there may be errors and omissions	Low, there is no guarantee that the procedure will be carried out properly	Easy	Low	Technical skills
Procedure logs with a minimum number	Low self-reporting, there may be errors and omissions	Low, there is no guarantee that the procedure will be carried out properly	Easy to use	Low	Technical skills
Direct unstructured observation	Low	High apparent validity	Easy to use	Potentially high	Technical, nontechnical skills
Checklists and global rating scales (OSAT)	Good for observers trained in the educational context	High construct validity in epidural punctures, interscalene block	Easy to use, but requires training	High, depending on context	Technical, nontechnical skills
Naik scale	High	High	High	High, correlation with expertise level	Technical skills
Regional anesthesia procedural skills (RAPS) tool	High	High internal and external validity	Applicable to any type of block; using ultrasound or without surface anatomy-based techniques	High correlation with expertise level	Technical skills
McLeod checklist	High	High internal validity	Easy to use	High correlation with expertise level	Technical skills
Objective assessment tool (OAT)	High	High internal validity	Easy to use	High correlation with expertise level in clinical setting	Technical skills
Direct Observation of Procedural Skills (DOPS)	Good for observers trained in the educational context	Constructive validity in epidural punctures, interscalene block	Easy to use, but requires training	High, depending on context	Technical skills
Feedback 360	Moderate for non-trained observers	High	Expensive, time-consuming	Very High	Technical, nontechnical skills
Simulation-based assessment	Depends on the assessment instrument and regional model	Apparent validity, highly variable in any context	High cost related to the type of simulation used	Depends on the selected assessment tool	Technical, nontechnical skills
Objective Structured Assessment of Technical Skills (OSAT)	Good for observers trained in the educational context	High in ultrasound-guided regional anesthesia	Expensive, time-consuming, and requires special installations	Potentially high	Technical skills
Video-feedback	Excellent	Technical and nontechnical skills	Time-consuming and requires special equipment	High	Technical, nontechnical skills
Gaze pattern analysis	High	High, non-observer-dependent	High cost, requires special equipment	Moderate	Technical, nontechnical skills
Imperial College Surgical Assessment Device (ICSAD)	High	High, non-observer-dependent	High cost, requires previous training	Moderate	Technical skills
Anesthesia-Clinical Evaluation Exercise (A-CEX)	High	High	Easy, needs training to use	High	Technical, nontechnical skills

Table 3.

Assessment tools used in regional anesthesia [49, 73].

4.5 Feedback as assessment tool

Receiving feedback is essential for improving the learning process when acquiring, practicing, and reflecting on clinical skills [25]. However, trainers and teachers may not be familiar with this pedagogical tool, which limits the execution of the feedback process. To provide optimal feedback when teaching regional anesthesia, follow these short and precise tips:

1. Wait for the student to request feedback.

2. Provide feedback in a timely manner when it is relevant.

3. Balance positive and negative actions in the feedback.

4. Conduct feedback in a safe and private environment, with mutual respect and an appropriate tone of voice.

5. Offer a clear improvement plan and encourage the learner to develop specific actions for growth.

6. Keep the feedback concise and avoid unnecessary information.

However, some barriers can hinder effective feedback, such as inadequate communication skills, making moral and personal judgments, defensive learners, and closed-mindedness. By following these guidelines and being mindful of potential barriers, teachers and learners can ensure a more productive feedback process when teaching regional anesthesia.

5. Conclusions

In conclusion, anesthesiologists must be able to perform regional anesthesia with expertise and diminishing risks for the patients. To achieve that, anesthesiology programs should combine theoretical knowledge and strategical teaching to develop motor skills. Thus, it is imperative to have high-quality training before trainees or residents face actual patients. This training can involve multiple strategies such as lectures, multimedia, cadaver review sessions, simulation-based practices with manikins and ultrasound, and hands-on and supervised clinical practice and deliberate practice. This chapter allows to understand the way trainees learn and provides some useful tools that can be used to implement accurate procedural skills teaching and learning techniques, leading to more confident anesthesiologists and better results at performing regional anesthesia [74, 75, 76].

Acknowledgments

The authors thank Ernesto Rojas MD, Alexandra Vargas MD, German Gutierrez MD, and Juliana Salazar MD for taking part of their time to read this chapter and contribute to the final product.

Conflict of interest

The authors declare no conflict of interest.

Abbreviations

ANTS	anesthetists’ nontechnical skills
CBME	competency-based medical education
CRS	cadaver review sessions
DOPS	direct observation of procedural skills
EPAs	entrustable professional activities (EPAs)
ICSAD	Imperial College surgical assessment device
OAT	objective assessment tool
OSAT	objective structured assessment of technical skills
PNB	peripheral nerve blocks
RAPS	regional anesthesia procedural skills
SP	simulated participant
US	ultrasound