Using simulation to teach patient‐centered ultrasound‐guided FNA skills

Sadia Sayeed, MD, Adele O. Kraft, MD, and Austin Blackburn Wiles, MD. Fine-needle aspiration (FNA) biopsy procedures have a deceptive simplicity.1 The gauge of the needle, the number of passes, and what suffices for adequacy all may vary with the specific situation. The challenge of performing a biopsy comes from knowing which technique or criteria to use for a given scenario. Our explicit knowledge only hints at the deeper wisdom necessary for approaching novel cases. The art of medicine is the process of finding answers to questions of technique in unfamiliar situations. The style in which we step into unfamiliar territory is relevant to both trainees and seasoned interventional cytopathologists. For trainees, every case is novel. A trainee needs to “learn how to learn.” The teaching cytopathologist must both impart this wisdom and use it. He or she must be ready for anything. He or she must balance the humble limits of experience with a tolerance for risk while learning new things. This is a reason why physicians “practice.” In the theme of deceptive simplicity, we propose a simple question that deserves attention: how do we physically position our patient and ourselves when performing an ultrasound-guided FNA biopsy? Every patient has a different body and physiology. Identical lesions in different patients may require radically different approaches. A patient with shoulder osteoarthritis might not be able to assume a position that is easy for many other patients. A patient with heart failure might not tolerate lying in a supine position. Managing these idiosyncrasies is an important part of interventional cytopathology. Because we practice other skills in cytopathology, such as making smears, we propose a simple solution: practice optimal physical positioning of the patient and the interventionalist physician. At Virginia Commonwealth University Health, we teach ultrasound probe and needle hand placement technique ultrasound-guided FNA biopsy using a massage/acupuncture training mannequin bust (Fig. 1 Top). This concept was proposed and developed at Virginia Commonwealth University Health by one of the authors (A.O.K.), with immediate gratifying results. The mannequin is inexpensive, durable, and easy to manipulate because it lacks a torso. It is available for online purchase. This mannequin can be considered a low-fidelity medical simulator, with sufficient anatomic accuracy of the head and neck to be appropriate for the exercise. In fact, its limitations are important to the fundamentals of the skills that it teaches. The aim of the exercise is to practice choreographing optimal patient positioning in addition to ultrasound probe and needle hand placement for biopsy safety, accuracy, and operator confidence. This activity is designed for 2 individuals: a learner and a teacher. The learner is directed toward a target lesion on the mannequin with a small indicator sticker. First, the learner positions the mannequin, with or without the help of the teacher. Then, the learner positions their probe and needle hands. Once in position, the learner mimes their biopsy procedure (Fig. 1 Bottom). The teacher then may begin the critique. We have found that a Socratic series of questions quickly provides the instructive result in the learner. “Is the patient in a reasonable position?” “Is your probe hand stable?” “Is the probe positioned well over the lesion?” “Can you perform appropriate needle excursions?” “Will your needle be visible to the probe?” “Are you comfortable?” One of the most important questions that the teacher can ask of the learner is, “will your hand positions make the patient uncomfortable?” Frequently, a learner will anchor their hands on the mannequin’s eyes, nose, or mouth. The realization of this transgression often is accompanied by a jolt of awareness and often some self-deprecating humor. Learners have expressed gratitude that they were “only practicing on a dummy” before working on a real patient. In our experience, this bemusement is a soft sign of successful enlightenment in the learner. Humor marks a spark of enlightenment bridging the gap between the learner and patient proxy. If the learner can empathize and think about the procedure from a stoic mannequin’s point of view, it is often even easier to work with a real patient. Positioning the mannequin with the assistance of the teacher also can be very useful. It forces the learner to explicitly articulate the position they are thinking about. Learning how to articulate the positioning of human bodies in space is a skill and language of its own, called choreography. Neglecting this skill results in the clichéd solipsism of a physician expecting others to “read their mind.” Moving and positioning human bodies in space often is erroneously treated as obvious or intuitive. The early modern physicians Dr. George Ryerson Fowler and Dr. Friedrich Trendelenburg are considered canonical innovators for their addressing this assumption and filling in a fundamental gap.2, 3 In our experience, having the learner confront the reasonableness of their expectations with a mannequin or patient proxy helps to bridge this gap and improves the quality of the learner’s communication. Ultrasound probes are expensive and needles are dangerous. We have found it useful to use a dummy probe and needle cap as props for teaching the early novice learner (Fig. 1 Bottom). The learner can focus on the position of their probe and needle hands without posing a risk to equipment or a danger to themselves or the teacher. Of course, more skilled learners can use a real ultrasound probe and needle to increase the fidelity of the simulation. The lesion target sticker is a simple and easy way to simulate a nonpalpable lesion. Probe orientation over the lesion is one of the most important skills for an interventional cytopathologist. A simple sticker provokes the learner to develop the necessary imagination for orienting the probe to visualize the lesion and allow needle access. Our cycle of targets includes submandibular, submental, inferior pole of the thyroid, occipital, and postauricular lesions. The teacher can ask the learner to talk about what anatomical structures and patient comfort concerns are at issue with each of these sites, thereby reinforcing practical anatomy learning. For example, a learner can recite the issues of needle angle and avoidance of the trachea and sternocleidomastoid in thyroid cases. Each scenario can be short to prevent learner fatigue and respect training time constraints. When an object represents a human, the degree of resemblance provokes an emotional response in the human viewer. Abstract schematic medical images of humans tend to provoke little empathy. Actual human beings tend to produce the most empathy. However, the relationship between the empathic positivity of the response and the degree of resemblance is not linear. Between cartoons and actual persons, there is a negative dip in empathic reaction provoked by objects that have an uncanny and unsettlingly close resemblance to people. This dip is called the “Uncanny Valley.”4 The low-fidelity resemblance of our mannequin to an actual person falls within the Uncanny Valley. Indeed, the gap between technical acumen and empathic care for a patient is similarly uncanny. There always will be gaps: chasms between technical facility and empathy, between patients and physicians, and the known and unknown. The Uncanny Valley is one instantiation of this gap. Our humble mannequin provides a gentle way of confronting the divide between patient and physician, which is strikingly similar to the Uncanny Valley. A patient can easily lose their tenuous confidence in a novice cytopathologist by sensing subtle hesitation. The indifference and strangeness of the mannequin combined with the guidance of a teacher stimulates the learner to build an empathic bridge of care and confidence over the gap in a safe setting. The persistence of these gaps is an opportunity for perpetual creativity and revitalization in medicine. A simulation does not need to fastidiously replicate all the details of a situation to provoke vital insights in a learner. Low-fidelity simulation tools such as our acupuncture/massage mannequin transform the gap between technical skill and patient-centered care into another learning opportunity with minimal expense and setup. Simplicity, uncanniness, and humor can all have their role in our bridge to a richer future as cytopathologists, if we take the care to include them. Austin Blackburn Wiles is assistant professor of pathology at Virginia Commonwealth University Health and the director of the autopsy pathology service. He is trained in both cytopathology and forensic pathology. Sadia Sayeed is assistant professor of pathology at Virginia Commonwealth University Health and associate director of the cytopathology laboratory. She trained in cytopathology at Virginia Commonwealth University Health and was mentored by both Dr. Adele O. Kraft and Dr. Celeste N. Powers. Adele O. Kraft is assistant professor of pathology, director of fine-needle aspiration services, and associate director of the cytopathology fellowship at Virginia Commonwealth University Health.

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