Bone Marrow Biopsy Simulation Training for Fellows

A bone marrow aspirate and biopsy is the single most common procedure that hematologists and oncologists carry out day in and day out throughout their career. Therefore, it is also the most common procedure that fellows in hematology/oncology training programs have to learn and then perform during their training. It is very important for fellows to become proficient and confident in doing this procedure independently and safely. In order to achieve this level of competence, they must learn not only the necessary steps but also master the correct technique.

Table. The evaluation criteria for observation of new fellows performing bone marrow biopsy procedures

Patient Care

‘Time Out’ performed

Anatomic landmarks identified

Aseptic technique maintained

Adequate local anesthesia used

Appropriate technique

Medical Knowledge

Understands indications

Understands what specimens are needed, ie, cytogenetics, flocytometry

Communication/Interpersonal skills

Explains the indication for the procedure

Explains what the patient will experience

Explains the potential risks; consent properly obtained

Uses clear, understandable terms

Professionalism

Accepts instruction and suggestions

Respects patient privacy and dignity

Uses respectful language

Courteous to nursing and allied health staff

Practice-Based Learning

Reviews final results of the test

Systems-Based Practice

Understands logistics of setting up a bone marrow biopsy

Understands logistics of specimen handling, transportation to lab

Typically, in most training programs, new fellows learn how to do a bone marrow biopsy from either their senior fellows or attending physicians. They will usually observe a few procedures first and then learn to carry them out on patients under supervision. This training process is often unstructured, and there is no way to monitor the fellow’s progress or proficiency.Moreover, different fellows and attending physicians have different procedural techniques and skills, as well as teaching ability. This combination leads to a haphazard method of learning for the new fellows in training.

Program Setup

At our institution, we recognized this deficiency and devised a plan to address it. We have recently developed a program for new fellows that allows them to learn the correct indications, contraindications, and technique for doing a bone marrow aspirate and biopsy. They can then demonstrate their learning by simulating it on a mannequin or patient actor. In order to help others who may want to set up a similar program, we will describe how we structured it.The first step is to identify a space where the program will be run. At our institution, and at many academic centers, a simulation center is available. Such centers provide examination rooms, conference rooms, audiovisual equipment, medical instruments, monitors, and mannequins.

The next step is scheduling. It is important to arrange a suitable time when all of the new fellows will be free for 3 hours for the training program. Cross-coverage must be arranged if needed.

To run the program, you need to have the following equipment available: a bone marrow biopsy kit, an examination room, an anatomical model of the pelvis, and audiovisual equipment. We also employed the services of a patient actor for demonstration purposes.

Alternatively, if an anatomy lab is available, the procedure can be performed on a cadaver. Each fellow then demonstrated how he/she would carry out the procedure. Teaching faculty and senior fellows observed these demonstrations and provided critiques. They also demonstrated their ability in making slides, using fake blood. Specific attention was paid to the communication aspects of the demonstration, especially ensuring that correct consent was obtained, the indications and complications of the procedure were explained, and that adequate anesthetic and pain control was offered.

Conclusion

References

This simulation lesson must be followed up with reinforcement of the procedures taught in this program during livepatient encounters. We have developed an evaluation form that is used by an attending physician or a senior fellow to evaluate the junior fellows on their performance when they perform a bone marrow biopsy on their first 5 patients. This is an invaluable tool in helping to streamline the process of feedback and helps the fellows hone their skills further. The specific areas on which each fellow is graded are shown in the Table. In these areas, each fellow is graded on a 5-point scale from “superior performance,” “good,” “fair,” “sub-standard,” to “unable to grade because of lack of observation.”Feedback from the participating fellows and attending physicians has been very encouraging. The fellows now have greater self-confidence when carrying out their first bone marrow biopsy and their learning curve is much steeper. We plan to offer this program to incoming fellows every year. We strongly believe that this program will streamline the process of fellows learning this essential procedure. The more detailed training offered in this program helps fellows become skilled at performing a bone marrow biopsy, and these abilities are practiced and reinforced further during their live-patient encounters.

1. Malempati S, Joshi S, Lai S, et al. Videos in clinical medicine: bone marrow aspiration and biopsy. N Engl J Med. 2009;361(15): e28.
2. Khan C, Moffa C. How to do the perfect bone marrow biopsy. Onc Fellows. 2011;3(3):12-16.

When this article was written, Cyrus Khan, MD, was chief fellow in the hematology/oncology fellowship program at the West Penn Allegheny Health System in Pittsburgh, Pennsylvania. He is now a member of the faculty in the Division of Stem Cell Transplantation and Cellular Therapy at the same institution. Ghulam Rehman Mohyuddin is a final-year medical student at the Aga Khan University, Karachi, Pakistan, who has completed a clinical elective in hematology/oncology at the same institution.