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Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches
  1. Grace C Huang1,2,
  2. Jakob I McSparron2,3,
  3. Ethan M Balk4,
  4. Jeremy B Richards5,
  5. C Christopher Smith1,
  6. Julia S Whelan6,
  7. Lori R Newman2,
  8. Gerald W Smetana1
  1. 1Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  2. 2Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  3. 3Division of Pulmonary and Critical Care, Department of Medicine, Beth Israel Deaconess Medical, Center
  4. 4Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
  5. 5Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, South Carolina, USA
  6. 6Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Grace C Huang, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, E/ES-212, Boston, MA 02215, USA; ghuang{at}


Importance Optimal approaches to teaching bedside procedures are unknown.

Objective To identify effective instructional approaches in procedural training.

Data sources We searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014.

Study selection We included research articles that addressed procedural training among physicians or physician trainees for 12 bedside procedures. Two independent reviewers screened 9312 citations and identified 344 articles for full-text review.

Data extraction and synthesis Two independent reviewers extracted data from full-text articles.

Main outcomes and measures We included measurements as classified by translational science outcomes T1 (testing settings), T2 (patient care practices) and T3 (patient/public health outcomes). Due to incomplete reporting, we post hoc classified study outcomes as ‘negative’ or ‘positive’ based on statistical significance. We performed meta-analyses of outcomes on the subset of studies sharing similar outcomes.

Results We found 161 eligible studies (44 randomised controlled trials (RCTs), 34 non-RCTs and 83 uncontrolled trials). Simulation was the most frequently published educational mode (78%). Our post hoc classification showed that studies involving simulation, competency-based approaches and RCTs had higher frequencies of T2/T3 outcomes. Meta-analyses showed that simulation (risk ratio (RR) 1.54 vs 0.55 for studies with vs without simulation, p=0.013) and competency-based approaches (RR 3.17 vs 0.89, p<0.001) were effective forms of training.

Conclusions and relevance This systematic review of bedside procedural skills demonstrates that the current literature is heterogeneous and of varying quality and rigour. Evidence is strongest for the use of simulation and competency-based paradigms in teaching procedures, and these approaches should be the mainstay of programmes that train physicians to perform procedures. Further research should clarify differences among instructional methods (eg, forms of hands-on training) rather than among educational modes (eg, lecture vs simulation).

  • Evidence-based medicine
  • Simulation
  • Patient safety

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