The main findings of this survey were that anesthesiologists who have attended the RA Course are more knowledgeable regarding the performance of peripheral blocks with neurostimulation and/or US guidance as compared to those who have not attended the Course. Attendees are also less likely to practice exclusively general anesthesia in their hospitals, more likely to attempt RA techniques and the insertion of peripheral nerve catheters and more likely to consider taking the EDRA exam as opposed to non-attendees. Both cohorts consider the Course of value and agree that the main reason for applying RA techniques is to ensure superior postoperative analgesia and that the main barrier in RA practice is the lack of relevant education in the techniques.
Our study also highlighted some interesting findings regarding RA pattern of practice. The majority of respondents declared that their technique of choice for lower extremity surgery is a neuraxial block as opposed to a peripheral block, with no difference between attendants and non-attendants of the Course. The ease of use, fast learning curve, high success rate of neuraxial blockade and broad exposure of residents to obstetric anesthesia with the preponderance of neuraxial approaches in it may underlie this finding [12–20]. This fact has been emphasized especially in older surveys. Some years ago, anesthesiology residents were much more likely to perform neuraxial blocks versus PNBs during their training years, while the former seem to be better assimilated than PNBs during residency training [6, 16]. Hadzic et al, showed that only 50% of anesthesiologists rated their training in PNBs as adequate, while those working at educational institutions apply PNBs more often [15]. Additionally, residents frequently reported limited access to PNBs during their training or failed to perform the minimum caseload of PNBs recommended by accreditation bodies [21, 22]. In another study evaluating confidence levels, residents at the end of their training did not report confidence in performing PNBs, in which they have little exposure [14]. Apparently, some years ago there seemed to be a gap in the teaching of PNBs and the number of PNBs performed during training was far less than the number of neuraxial blocks, perhaps reflecting the fact that neuraxial techniques were better mastered by the teachers themselves and therefore the most taught. This created a substantial problem however; confidence is a substantial factor in one’s ability to continue to perform blocks beyond residency and if graduating residents feel inadequately prepared for a variety of regional techniques, they will hardly use techniques in which they lack expertise [23–26]. In other words, lost training opportunities during residency can lead to graduates failing to incorporate respective techniques into future practice [27]. Consequently, infrequent use at consultant level makes attaining and retaining proficiency difficult, therefore it is of paramount importance that education in RA continuous post residency so that the pool of experienced teachers increases and stays abreast of the latest advances. Another aspect of the same problem is the fact that traditionally and before the era of US, PNBs for the lower extremities were practiced less frequently and were considered technically more demanding and cumbersome because of the need of the performance of multiple blocks to anesthetize the entire limb, whereas this was not the case for peripheral blocks of the upper extremity. This trend has been reported in various surveys [6, 8, 15, 22, 28, 29]. Additionally, neuraxial anesthesia in which anesthesiologists feel more confident as mentioned above, is usually a viable alternative for lower extremity surgery, whereas there is no alternative for upper extremity blocks. It appears though according to more recent surveys that lower extremity PNBs are gaining ground over upper extremity techniques and have now an upgraded role in clinical practice [30, 31]. Nowadays, we are witnessing an increasing trend of PNBs use over neuraxial blocks especially in orthopedics and the focus of training has shifted accordingly [31–33]. The advent and more universal application of US, which offers the ability to visualize neural structures in relation to surrounding tissues, needle advancement in real time and local anesthetic spread around nerves as well as today’s emphasis on ambulatory surgery and “fast-tracking” of patients might have accounted for this tendency of equilibration [34, 35]. Although the enhanced popularity of PNBs in recent years has been substantiated in other regions, it appears that this is not the case in the Greek territory as yet. According to the results of our survey, it seems that more needs to be done to fill the gap in confidence related to PNBs, to remedy training deficits and to shift the focus of RA education from neuraxial to PNBs in accordance to international trends and recommendations for a diverse case mix in training programs.
The popularity of central nerve blocks was confirmed in this survey and is in accordance to the results of the previous survey performed in the Greek region [10] since the majority of anesthesiologists who responded to the survey ascertained their very good level of knowledge in central blocks, which did not seem to be affected by the attendance of the Course. Greek anesthesiologists also often use epidural catheters for the provision of postoperative analgesia, whereas this practice is not affected by the attendance or not of the Course either. This is in accordance with an older survey highlighting the popularity of epidural catheter use in Greek Anesthesia Departments [36]. Nevertheless, this is not the case regarding the use of peripheral nerve catheters, since a high percentage of respondents do not use this form of postoperative analgesia. It appears though that the attendance of the Course has an impact on the use of peripheral nerve catheters as there are significant differences in the use of peripheral catheters between attendants and non-attendants.
The benefits of regional block performance under US are multiple and include among others reliable nerve localization, improved local anesthetic spread and block success rate, decreased block performance time, facilitation of block placement in patients with challenging anatomy, overall decreased local anesthetic volume, improved safety and patient comfort [37–41]. US-guided techniques have enhanced our ability to achieve effective and consistent blocks and implementation of US guidance has been hailed as the new gold standard as far as efficacy and safety are concerned [42]. The main barriers to US use, both at an institutional and personal level, are unavailability of equipment and lack of training [42–44]. The cost-effectiveness of US-guided regional nerve blocks in comparison to landmark techniques has also been noted [45]. However, respondents to our survey overall confirmed that their knowledge of US application in peripheral block performance is inferior to using neurostimulation guidance in the performance of such blocks and that their knowledge and use of US in central block performance is much more inferior to the performance of central blocks with anatomical landmarks only. It is common knowledge that US-focused workshops play a vital role in the acquisition of the necessary skills to both safely and effectively practice RA techniques under US guidance [46]. It has been emphasized that three major components are an integral part of achieving expertise in US-guided RA: understanding the equipment, recognition of anatomical structures and technical skills associated with needle placement encompassing the development of hand-eye coordination and needle visualization dexterity [47]. The gradual development of factual knowledge and motor skills is essential for residents and anesthesiologists in post-residency posts alike, while the integration of multiple technical and cognitive skills is necessary to achieve proficiency in the long term [26]. The Greek RA Course seems to fulfil some of these goals since, according to the results of this survey, attendees of the RA Workshop ascertained that the Workshop contributed significantly to the acquisition of the theoretical knowledge in all aspects of RA, including the basics of US guidance for nerve localization. Therefore, the Course seems to fulfil (at least partially) the knowledge gap of training opportunities in the Greek region.
However, the majority of participants in the Course, by stating that the Course changed their practice only a little, seem to be reluctant to universally incorporate US use in their everyday routine, admitting that even after the Course, they lack the confidence in broad US application and implementation in their daily practice. It appears therefore that despite the intensive structure of the Greek RA Workshop and an attempt from the instructors to teach the basics of the aforementioned three components, participants feel that more is needed in terms of quantity of learning so that key competencies taught can safely be extrapolated to the clinical realm and true day-to-day incorporation of RA in routine practice can be achieved [48]. In a study by Barrington and colleagues, in which the authors examined the amount of training required for naïve learners to identify the necessary anatomy for ultrasound-guided axillary block, they deduced that sonographic competence was achieved after eight to ten practice sessions [49]. According to Kopacz, confidence in RA techniques stems from two sources; first wondering whether the correct steps are being performed and secondly wondering whether the suitable endpoints are being achieved [50]. Both sources can be addressed by the appropriate amount of training, a fact consistent with the recommendations put forth by the ASRA and ESRA Joint Committee [51]. It appears therefore that more teaching time, including frequent exposure to learning opportunities and learning aids that help shorten a trainee’s learning curve (peer-to-peer learning, participation in e-learning modules and hands-on Workshops), are required to bring naïve learners form baseline to competence and to enable them to effectuate a change in practice [28, 52, 53]. It has also been shown that repetitive opportunities are essential to reinforce learning and enable the acquisition of procedural skills [54]. This was actually reflected in participants’ replies when asked to provide written feedback and make suggestions towards improvement of the Course in the only free-text question of the survey, where many people suggested expanding time allocated in US hands-on practice and application. This might be of particular importance in the case of US use for the performance of the central blocks as, according to our survey, the adoption of US as an aid in the performance of central blocks considerably lags behind US use for peripheral blocks and most respondents never or seldom use it for neuraxial anesthesia. This discrepancy has been highlighted in other studies and efforts towards its reversal could provide a valuable tool in the anesthesiologists’ armamentarium when facing patients with challenging anatomy and generally in cases where one might consider aborting the effort for regional anesthesia [25, 44, 55]. In fact, with more recent technological advances, the use of US has been expanded to include guiding more technically demanding procedures, such as neuraxial blockade.
Still, it appears that the Course, despite its weaknesses, created the foundation for the consolidation of basic knowledge in the performance of central and peripheral blocks via US guidance. Participants had statistically significant gains in knowledge as compared to non-attendees. Additionally, despite the aforementioned difficulties, it seems that the Course fulfils the target of familiarizing participants with RA practice, by creating interest and motivation in the use of RA procedures and perhaps enabling long-term retention of skills taught. In fact, as it was shown in our survey, anesthesiologists who have attended the Workshop are less likely to administer exclusively general anesthesia and more likely to use all types of anesthetic techniques and in particular peripheral blocks for lower limb surgery as opposed to those who have not attended the Course and the differences were statistically significant. Training can act as a major driving factor on the application of RA [14]. It appears therefore that the Course provides participants with the opportunity to acquire new skills, to develop a larger repertoire of techniques and to return to their clinical settings with new knowledge and strategies and thus to be more conducive to expanding their practice.
Anesthesiologists nowadays realize the importance of training in acquiring the requisite skills for the safe and effective practice of RA and the requirement for formal structured training programs towards achieving this goal. Teaching has been shown to dramatically increase the number of blocks performed and anesthesiologists have realized that didactic teaching can supply them with a basic framework of factual knowledge [24, 52]. This is reflected in our survey since the vast majority of people who attended the Course (almost 90%) attested that they did so in order to improve knowledge and skills in RA. Another noteworthy finding of the study is that all respondents to the survey consider that the RA Course contributes to Greek Anesthesiologists’ education with no difference between attendants and non-attendants. It seems that the Course is quite popular and people who have not attended it also rate it highly and attribute non-attendance to their busy work schedule and lack of time. It appears that anesthesiologists’ attitude has changed in recent years towards seeking high quality education activities, therefore they highly value opportunities for structured hands-on training.
The general view of respondents regarding reasons for performing regional techniques is in accordance to other studies. In fact, the notion that the main reason to use RA is to provide optimal postoperative analgesia has barely changed throughout the years [56]. On the other hand, respondents identified the lack of training as the major hindrance for broader RA application in everyday practice, a fact that has been extensively pinpointed in other studies [6, 57]. It is of interest that in an older study performed in the UK, the main barrier to RA was the length of time required to establish the block [56]. It appears that the realization of today’s training opportunities along with the considerable assistance of novel techniques aiding in the performance of regional blocks and in the reduction of performance time account for this change in mindset. In our survey, surgeon and time-related reasons took the second and third place as key barriers in the performance of RA. Interestingly, the percentage corresponding to reluctance from surgeons is higher than the one corresponding to reluctance from patients. Lack of support from surgeons and erroneous perceptions are ongoing institutional challenges. A survey of Canadian orthopedic surgeons revealed that only 40% of them directed their patients towards RA [58]. Surgeons not in favor were most probably unfamiliar with the benefits of PNBs and thought that RA is a complex procedure, which results in delays and unpredictable success rates with possible conversion to general anesthesia. In such situations, it has been shown that the availability of designated block rooms can expedite operating room flow, provide an unhurried and less stressful environment for teaching, reduce delays between cases and overcome logistical impediments in fast-paced clinical environments and high-volume institutions, where rapid turnover of cases is of the essence [59, 60]. As to the availability of Intralipid, which is crucial in the management of LAST, the fact that Intralipid was stored in only 70% of the Hospitals according to the replies provided, shows that more needs to be done to create awareness about LAST and to conform to current recommendations that a lipid rescue kit should be available in any setting in which RA is practiced [61].
Finally, it is perhaps unsurprising that anesthesiologists who have attended the Course have a greater intention to attempt taking the EDRA Diploma in comparison to those who have not. This is in accordance with the fact that anesthesiologists who attended the Course are less likely to administer solely general anesthesia and more likely to work in orthopedic hospitals where a variety of regional techniques are attempted. Anesthesiologists who have attended the Course seem to be more interested in acquiring an extra accreditation related to regional anesthesia career-wise and in proving that their knowledge encompasses the field of RA, since proof of RA expertise may have employment implications [53]. Therefore, the willingness to take the exam may be an indirect indication of greater motivation for a RA qualification.
A limitation of the current survey, as with other surveys of this kind, is the non-respondent bias. There is always a risk of bias caused by clinicians left out of the survey, as anesthesiologists with little interest in RA might have not shown interest in completing a questionnaire forwarded by a RA Society. Although we took measures to optimize the response rate, we do not know whether non-respondents would have answered in the same manner as respondents. Another limitation is the fact that expertise or lack thereof was based on self-estimation and therefore, participants’ perception of competency and of procedural performance was subjective. The objective estimation of expertise cannot be based on a survey tool but rather requires systemic theoretical and practical evaluation of respondents, which however was beyond the scope of the current study. Finally, our survey is a cross-sectional study, not reflecting the longitudinal changes in training. Our survey though has many strengths. First, we achieved a satisfactory response rate (over 50% of the targeted individuals), within the range of previously published similar surveys [6, 9, 15, 19]. Therefore, we consider we provided useful insight into nationwide practice of RA and evaluation of the RA hands-on Workshop. It has been recommended that the minimal number of survey responses required for survey validity equals the number of questions times 10 [62]. The current 33-question survey required at least 330 responses and we received 424, which is a reasonable response rate. Notably, the anonymous design chosen reduces reservations to respond and to provide idealized answers, resulting in self-report bias. Additionally, questionnaires without a lot of open questions maximize response rate. Secondly, the majority of responders were consultants with > 10 years of experience in anesthesiology, which implies high reliability of the data. Finally, we consider that we obtained representative information about practice and opinions in the whole country since we had responses from a variety of health institutions from across all regions of Greece, including academic and non-academic centers, community hospitals and private practice settings. Therefore, this preliminary exploratory survey could create the basis for future comparisons and could be an important step towards future European or international initiatives using validated questionnaires to assess the impact of other educational activities in the field of RA in wider geographical scopes.
In conclusion, the results of the current survey highlight that despite its weaknesses, a dedicated RA Course may increase subsequent RA practice by concentrating learning experience into a focused period. At a national level, future advances in RA will be highly dependent on the quality of education. In the previous survey about RA practice in Greece the lack of a formal stepwise program incorporated in the curriculum of residency had been emphasized as a significant shortcoming to systematic training in RA techniques [10]. In the last couple of years, the situation has changed as relevant administrative authorities have realized the importance of standardized training and formalized teaching programs in many medical specialties including anesthesiology. Training programs have started moving away from apprenticeship models which prevailed in the last several decades and provided inconsistent learning experiences towards competency-based methods of education. Thus, the curriculum of the specialty has been redesigned, amendments have been suggested, deficiencies have been identified and a structured program of specific rotations offering more targeted education in RA by incorporating formal RA rotations has now been officially integrated into the residency curriculum of Greek anesthesiologists. The aim is to make RA techniques an integral part of professional training during residency and to ensure trainees receive exposure to both conceptual knowledge and practical experience, which can significantly impact the utilization of the techniques post-residency. Hopefully this fact, along with the improvement of the present Course as well as future educational initiatives especially targeting PNBs, the follow up of innovations and especially the increased exposure to US teaching might greatly enhance the training process in RA by not only providing core skills but also by creating the basis for the implementation of a solid curriculum in RA training.