The Influence of Technology on Health Professions Education and Health Care Delivery: New Opportunities and Responsibilities for Health Professions Educators

摘要

As I walked through the critical care area of the emergency department, one of the residents asked me to verify her ultrasound reading before she placed a central line in the internal jugular vein of a woman with sepsis from an infected kidney stone. Because her supervising faculty member was busy with another patient, I looked at the screen and agreed that she had accurately identified the jugular vein. She was about to place the catheter when I asked her why the patient needed the central line. “It’s part of the protocol for sepsis,” she said. “The central line will allow the doctors in the ICU to treat hypotension, if it develops, with medications we could not give through the peripheral IV,” she added. “But she may not need those medicines,” I said. “Is her blood pressure okay, now?” “Yes, but it’s part of the protocol, and the ICU wants it.” I nodded. This was not my patient and I did not want to intrude, but I was concerned that we might be performing an unnecessary and potentially dangerous procedure without considering the risks and benefits. The patient did not seem confused or unstable. She was talking normally, asking appropriate questions. Recent published research on the treatment of sepsis had been less enthusiastic about the use of a central line as part of the treatment protocol. I asked the resident to hold off for a moment and walked away to discuss the procedure with the other attending. “Oh, the ICU wanted us to place the line before we send her up,” said the other attending. “I agree the patient might not need it, but they feel more comfortable with the central in and are really getting swamped. And Julie, our resident, is really slick at them. She’ll get it in two minutes.” And so we proceeded to place the central line. The patient went off to the ICU after receiving antibiotics, she received a stent for her obstructed kidney stone, the sepsis resolved, and she did well. The central line remained in place for the next three days without any complications. Most people would consider the case a success, but as I reviewed the literature about the need for central lines in sepsis,1–3 I became concerned because the recent literature no longer supports the routine placement of the central line. Even with the use of ultrasound for the line placement, there are risks of complications from insertion, such as bleeding of the vein or nearby carotid artery, and puncture of the lung. I could remember other similar procedures that had been adopted and later been abandoned after questions about their safety and usefulness were raised, such as the use of the Swan-Ganz catheter. Recently, Thakkar and Desai4 described the history of the Swan-Ganz catheter, which was another type of central line that was inserted further into the heart and pulmonary artery for measurement of cardiac output and to assess and treat heart failure. I remember learning how to insert these catheters and convincing patients of the benefits of the device for their treatment. Eventually, as more studies were done, the dangers of the device, such as pulmonary infarction, were recognized and the benefits were questioned, and it was largely abandoned. However, for many years, the catheters were used by doctors who may have unwittingly harmed patients. In the assessment of the problems with the catheter, Evans et al5 noted that in addition to problems associated with the insertion, maintenance, and manipulation of the catheter, “inappropriate clinical decisions and/or inaccurate hemodynamic data may well constitute a greater risk to the patient than all the other pulmonary-artery-catheter-related complications.” These comments about a particular health technology are an example of the need for education about the proper use of such technology and the assessment of health technology in the real world, including the educational needs of those likely to use the technology. If those who are most likely to use a technology cannot use it safely and effectivel