The American Board of Internal Medicine (ABIM) requires candidates for certification to be judged competent by their residency program director in 9 procedures including advanced cardiac life support (ACLS).1
Internal medicine residents frequently satisfy this requirement by completing an American Heart Association (AHA) ACLS provider course. These courses typically include 1 day of reading, lecture, and practical instruction about the recognition and treatment of ACLS events. Despite recommended ACLS renewal on a 2-year cycle,2
it has been shown that physicians, nurses, and laypersons display poor skill retention in shorter time periods.3–5
Several authors have argued that frequent refresher courses should be added to current training protocols to increase ACLS skill and knowledge retention.6,7
In addition to concerns about the adequacy of training in ACLS, another barrier to certifying residents as competent in these required procedures is the knowledge that in-hospital events prompting an ACLS response occur rarely. A recent review of 207 academic and community hospitals showed that the average number of annual events requiring an ACLS response was 54.1 per facility.8
Furthermore, data on in-hospital cardiac arrests from the University of Chicago demonstrated that the quality of resuscitation efforts varied and often did not meet published guidelines, even when performed by well-trained hospital personnel.9
Thus, internal medicine residents are expected to recognize and manage life-threatening events that occur infrequently, in which their performance is often not subject to audit or accountability assessment, and for which they may be poorly prepared and insufficiently practiced.
Medical education at all levels increasingly relies on simulation technology to provide a tool to increase learner knowledge, provide controlled, safe, and forgiving practice opportunities, and shape the acquisition of physicians' clinical skills.10–12
Simulations vary in fidelity from inert task trainers used to practice endotracheal intubation to standardized patients to sophisticated mannequins linked to computer systems that can mimic complex medical problems, display interacting physiologic and pharmacologic parameters, and present problems in “real time.”13
Combined with opportunities for controlled, deliberate practice with specific feedback,14,15
simulations are highly effective at promoting skill acquisition among medical learners15–17
and generalizing simulation-based learning into patient care settings.18,19
Gaining proficiency in clinical skills also gives rise to a sense of self-efficacy20
among medical learners, an affective outcome that accompanies mastery experiences.
an especially stringent variety of competency-based education
means that learners acquire essential knowledge and skill, measured rigorously against fixed achievement standards, without regard to the time needed to reach the outcome. Mastery indicates a much higher level of performance than competence alone. In mastery learning, educational results
are uniform, with little or no variation, while educational time
varies among trainees. This approach to education has its origins in theory and data beginning at least 4 decades ago,23–28
and yet finds contemporary expression in statements about outcome-based medical education29
and calls for accreditation reform in internal medicine residency programs.30
To our knowledge, a genuine mastery learning model has never been used in U.S. medical education. This is the first empirical report of a mastery learning application in clinical medical education.
The study reported in this article amplifies a randomized-controlled trial (RCT) about ACLS skill acquisition among internal medicine residents reported previously by our research group.31
In the earlier RCT, we demonstrated a 38% improvement in ACLS skills after an 8-hour simulation-based educational intervention compared with clinical experience alone. This report presents original research data that extend the previous RCT in 2 ways: (a) it uses research-based mastery standards as floors for resident performance of 6 ACLS scenarios; and (b) unlike previous research where learning time was fixed and learning outcomes were varied, in this study each resident met or exceeded the minimum mastery standard for each procedure while learning time varied. The intent was to produce high achievement among internal medicine residents in ACLS procedures required for board certification with little or no outcome variation.