Intermediate level training: A paradigm requiring reflective competence

The role of echocardiography within the intensive care unit (ICU) has progressed dramatically in the past decade. It is now an expected part of the Intensivist’s armamentarium to diagnose and manage clinical conditions based on their ability to record and interpret ultrasound imaging. However, the acquisition of any new skill requires the responsibility to recognise the limitations of one’s knowledge, experience and expectations.

We admitted a 64-year-old male to the ICU with a two-day history of vomiting, worsening renal function and hypotension. Initial transthoracic echo (TTE) was reported as showing; ventricular-septal-defect (VSD); dyskinesis of the IV septum; possible dissecting thoracic aortic aneurysm. However, on closer inspection of the parasternal long axis view, it was recognized that there was an abnormal echo-free space adjacent to the aorta (Figure 1); the Doppler jet originated from the echo-free space and not the left ventricle and occurred in diastole (Figures 2 and 3). The apical four-chamber view also demonstrated Doppler flow from the abnormal echo-free space to the right ventricle (RV) and right atrium (RA) (Figures 4 and 5). Transoesophageal echocardiogram (TOE) demonstrated the echo-free space to be pulsatile, representing a sinus of valsalva aneurysm (SOVA) originating near the right coronary cusp communicating with the RA/RV junction (Figure 6(a) and (b)).

Figure 1.

Transthoracic parasternal long axis view: recognition of abnormal echo-free space (double headed arrow).

Figure 2.

Transthoracic parasternal long axis view, off-axis with colour flow Doppler: Note need for off axis imaging to assess extent of abnormal flow and to achieve best Doppler angle possible.

Figure 3.

Transthoracic parasternal long axis view, off-axis, continuous wave Doppler trace of abnormal diastolic flow from the echo-free space: note the need to not confuse this with right ventricle inflow velocities.

Figure 4.

Apical four chamber view without colour flow Doppler: recognition of abnormal echo-free space.

Figure 5.

Apical four chamber view with colour flow Doppler: recognition of abnormal echo-free space with unusual flow from right atrium to right ventricle.

Figure 6.

(a). Transeosphageal echocardiogram, with off-axis imaging at the mid-oesohpageal level. Large pulsatile echo free space representing Sinus of Valsalva aneurysm originating near the right coronary cusp. (b) Transeosphageal echocardiogram, with off-axis imaging at the mid-oesohpageal level. Flow is seen from the right coronary cusp region in the Sinus of Valsalva aneurysm communicating with right atrium/right ventricle junction. There is a need for off-axis imaging to display the full extent of the aneurysm and flow.

In a previous case, report of a ruptured SOVA being misdiagnosed as a VSD, it highlighted the need to demonstrate in which part of the cardiac cycle the abnormal jet is present (as above), however, the report also mentions the possibility of a coexisting VSD being masked by the ruptured SOVA, and another potential misdiagnosis being a coronary ateriovenous fistula. ¹ Our case and the case report highlight the learning-curve required when acquiring new skills, and the literature reinforces the danger of false positives (overcalling) and false-negatives (omission) as this skill is acquired ² . There is currently debate regarding the place for ‘intermediate level’ of training in echocardiography vs. simply ‘basic’ and ‘expert’^3,4; however, the desire for intermediate level training is not without risk.

There has been discussion in the educational literature about the concept of the competency matrix (Figure 7). It states that a learner acquiring new skills begins at level of unconscious incompetence; however, this is not correct. Most learners commence a learning process knowing they do not know it. Therefore, they are consciously incompetent. It is as their skills progress and expectations of performance increase that learners are at risk of being unconsciously incompetent: they can actually regress to this level. Only with further training do they recognise this, and once again become consciously incompetent. The length of time learners spend in this stage depends on the strength of the stimulus to learn mastery. ⁵ If a learner’s ceiling of desired mastery is ‘intermediate level’, then with no stimulus to achieve mastery at the ‘expert level’, the risk of ongoing unconscious incompetence is significant, leading to false-positives and false-negatives in interpretation. A practitioner who is at ‘intermediate level’ mastery needs to possess reflective competence to ensure that they recognise the constant potential of unconscious incompetence, and seek assistance when required.

Figure 7.

Unconscious incompetence: You don’t know what you don’t know.

Our case demonstrated the requirement to utilise off-axis imaging and optimise Doppler settings. These skills require ‘expert level’ knowledge and experience. We are not arguing that ‘intermediate level’ training should be abandoned as a principle; however, it requires specific cognitive abilities of reflective competence to operate between the level of beginner and expert (Figure 7).

Conscious incompetence: You become aware of how much you have to learn. You realise you require time and practice to progress.

Conscious incompetence: You are starting to master the new skill, but you still have to actively think if you are doing it right.

Unconscious competence: You don’t even think about your new skill anymore. The skills comes naturally as an expert.

Reflective competence: The background cognitive quality that is required at all stages, that allows a practitioner to progress to unconscious competence, and prevents a practitioner from regressing back to unconscious incompetence.