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**Learning Center: A Quantitative Study
**

John L. Plummer, PhD, AStat, and Harry Owen, MD, FRCA, FANZCA

Department of Anaesthesia, Flinders University of South Australia and Flinders Medical Centre, Bedford Park, Australia

This study aimed to develop statistical models describ-

ing the learning of endotracheal intubation (ETI). We

collected data from 100 subjects undergoing ETI train-

ingwithintubatable medical models andmanikins (air-

way trainers). Trainees initially viewed a video about

ETI andaninstructor demonstratedthe technique. Sub-

jects thenmade upto17 supervisedtrials. Eachtrial was

scoredas a success or failure; this score was the primary

outcome used in analyses. Random effects and

population-averaged logit models, and a learning

model intendedtoquantifythe relative contributions of

failedandsuccessful trials to the learning process, were

fittedtothe data. The logit models providedevidence of

differences in difficulty between different airway train-

ers and differences in success rate related to previous

ETI experience. Trainees became familiar with an air-

way trainer after multiple trials, as demonstrated by a

50% decrease in the odds of successful ETI when start-

ing on a newtrainer. The learning model indicated that

a trainee learns about as much from 1 successful ETI as

from12 (95%confidence interval, 2–23) failedtrials. The

results demonstrate the feasibility of statistical model-

ing of the learning of ETI and provide insight into the

learning process.

(Anesth Analg 2001;93:656–62)

I

n our institution, endotracheal intubation (ETI) is

taught to a range of health professionals, including

medical students and trainees in anesthesia. Initial

training occurs in a Clinical Skills Learning Center

equipped with a variety of manikins and medical

models (subsequently referred to as airway trainers).

Feedback from trainees has been very positive, but

teaching methods should be continually evaluated

and refined. To do this effectively, we must be able to

relate components of the teaching process to the out-

come, at least qualitatively and preferably quantita-

tively. This study was based on the hypothesis that the

process of learning to intubate airway trainers may be

subjected to quantitative analysis, and that such anal-

ysis would provide insight into how instruction could

be further improved.

Methods

This project was approved by the Flinders Clinical

Research Ethics Committee. All subjects provided

written, informed consent. Before beginning the

project, the three instructors involved discussed meth-

ods and criteria for assessment and jointly assessed a

number of intubation attempts to achieve uniform

scoring. Six airway trainers were used (Table 1). Air-

way trainer D was used both with and without a

cervical collar; these configurations were considered

to be different trainers, making a total of seven. Train-

ees attended the training laboratory in groups of two

to four. Each trainee provided demographic details,

history of previous experience in ETI, details of expe-

rience in 14 clinical procedures ranging from head tilt,

oral airway, and peripheral venous cannulation to

cardiac defibrillation, and level of confidence in their

ability to perform these procedures. For each proce-

dure, a score of 1–4 was assigned, according to

whether the trainee had performed the procedure on

patients 0, 1–5, 6–20, or more than 20 times, respec-

tively. The scores were summed to provide a global

clinical experience score. The level of confidence in

ability to perform these procedures was rated on a

scale from 1 (not confident at all) to 5 (extremely

confident). These scores were summed to give a clin-

ical skills confidence score.

The training sessions lasted 1.5 to 2 h. Initially the

aims of the teaching were discussed, and trainees

viewed a brief video presentation about ETI. The tech-

nique was then demonstrated by an instructor, after

which each trainee made up to 17 trials at ETI with

Supported, in part, by grants from the Laerdal Foundation for

Acute Medicine and the Australian and New Zealand College of

Anaesthetists.

Accepted for publication May 1, 2001.

Address correspondence and reprint requests to Dr. J. L. Plum-

mer, Department of Anaesthesia, Flinders Medical Centre, Bedford

Park, SA 5042, Australia. Address e-mail to john.plummer

@flinders.edu.au.

©2001 by the International Anesthesia Research Society

656 Anesth Analg 2001;93:656–62 0003-2999/01

three to six different airway trainers. Instructors 1–3

supervised 89, 7, and 4 trainees, respectively. There

was no fixed sequence of airway trainer use, but gen-

erally trainees commenced with trainers perceived to

be relatively easy (Trainers A and B) and moved to-

ward more difficult ones (e.g., Trainer DC). The in-

structor rated each trial as a “success” or “failure.” To

be scored as a success, the trial had to be considered to

be a satisfactory intubation, defined as an intubation

which, if it had been made on a patient, would have

achieved ETI without significant risk of adverse

events. Factors considered in scoring included han-

dling of the laryngoscope and endotracheal tube, care

taken to avoid trauma to oral structures (force used,

leverage on upper incisors, etc), and the time taken to

complete the ETI.

To identify factors predictive of successful intuba-

tion, three types of statistical models appropriate for a

repeated-measures design with a binary outcome

(here, success versus failure of intubation attempt)

were fitted to the data. These models were population-

averaged logistic regression models, random effects

logistic regression models, and a learning model (1,2)

intended to quantitate the relative contributions of

successful versus failed attempts to the learning pro-

cess. Parameter estimates from the logistic regression

models are presented as odds ratios and 95% confi-

dence intervals (95% CI) in relation to an arbitrarily

chosen reference category. Goodness of fit of different

random effects and learning models was compared by

Akaike’s Information Criterion (AIC) (3). A smaller

AIC corresponds to improved model fit. Further de-

tails of the statistical models are given in Appendix 1.

Initially models were fitted that included variables

believed a priori to affect success of ETI (occupational

group, previous ETI experience, type of airway trainer

attempted, and instructor). Other potential predictors

were then examined by adding them to the model.

Results

One hundred subjects participated in the training ses-

sions. Demographic data are given in Table 2. The

median global clinical experience score was 16 (range,

14–45), and the median clinical skills confidence score

was 24 (range, 14–55).

The rate of successful ETI increased from 6% on the

first trial to approximately 80% after 15 trials. To de-

termine an appropriate approximation to the shape of

the learning curve, population-averaged logistic mod-

els were fitted that included trial number on a linear,

quadratic, or logarithmic scale and covariates adjust-

ing for airway trainer type, previous ETI experience,

occupational category, and instructor. The predicted

success rates from the linear and logarithmic models

are shown together with the observed success rates in

Figure 1. The success rates predicted by the logarith-

mic model were substantially closer to the observed

success rate than were the predictions of the linear

model. The success rates predicted from the quadratic

model were close to observed success rates but still

inferior to those predicted from the logarithmic

model. Although the logarithmic model did not pre-

dict the success rate on the 16th or 17th trial well, only

five subjects and one subject contributed to these

points, respectively. When corresponding random ef-

fects models were fitted, AICs for models with trial

number on a linear, quadratic, or logarithmic scale

were 1171, 1144, and 1140, respectively. Consequently,

logarithm of trial number was used as a covariate in

the logit models.

The basic population-averaged logistic regression

model, which included logarithm of trial number, air-

way trainer, previous experience in ETI, occupation,

and instructor as covariates, gave a reasonably good

fit to the data. There was evidence of a significant

association between each category of predictor and

successful intubation (all P Ͻ 0.05). The only addi-

tional variable identified as an important predictor

was when a subject changed to a new airway trainer.

Results for the model including this variable, Model 1,

are given in Table 3.

Model 1 provided only weak evidence of heteroge-

neity in difficulty level among airway trainers. The

most important component of previous ETI experi-

ence was for trainees who had prior experience intu-

bating patients. There was a significant association

between occupational group and success rate, but no

strong evidence of heterogeneity among medical stu-

dents in Years 1–4 (P ϭ 0.07). This probably reflects

the small numbers of students from Year 1, 3, and 4 in

Table 1. Airway Trainers Used in Training Sessions

Airway

trainer Name/manufacturer

A Intubation Head

Medical Plastics Laboratory, Inc, South

Gatesville, TX

B Laerdal Airway Management Trainer, 25 00 00

Laerdal Medical Corporation, Wappingers Falls,

NY

C Laerdal Adult Intubation Model

Laerdal Medical Corporation

D Laerdal ALS Skillmaster Interactive Manikin

Laerdal Medical Corporation

DC Same as trainer D but with Stiffneck Adjustable

Collar

Laerdal Medical Corporation

E Trauma Intubation Head

Medical Plastics Laboratory, Inc

F Airway Larry airway trainer, LF03699U

Lifeform products, NASCO, Fort Atkinson, WI

ANESTH ANALG TECHNOLOGY, COMPUTING, AND SIMULATION PLUMMER AND OWEN 657

2001;93:656–62 LEARNING ENDOTRACHEAL INTUBATION

the sample. Despite attempts to standardize the as-

sessment procedure, the results indicated that there

was heterogeneity in scoring among different instruc-

tors. When a trainee changed to a new airway trainer,

the odds of successful ETI were halved, suggesting

that trainees adapt their intubation technique to suit

the particular airway trainer being used.

The global clinical experience score and clinical

skills confidence score were not important predictors

when added to Model 1 (odds ratios 1.04 and 1.01 per

unit, P ϭ0.2 and 0.6, respectively). Because the level of

clinical experience is associated with occupational

group, the global clinical experience score was

included in Model 1, but variables denoting occupa-

tional group were omitted. In this context, the global

clinical experience score was an important predictor of

successful intubation (odds ratio 1.07 per unit, 95% CI

1.03–1.11). However, this model did not fit the data as

well as Model 1, as judged by the Hosmer-Lemeshow

test.

A random effects model, Model 2, was fitted by

using the same predictor variables as in Model 1.

Estimates from Model 2 are given in Table 4. Qualita-

tively the parameter estimates were similar to those of

Model 1. There was significant evidence of heteroge-

neity in difficulty among airway trainers, with trainer

D the most difficult.

The learning model described by Bush and Mos-

teller (1) is of the form

P

failure

ϭ 

1

s

ϫ 

2

f

, (1)

where P

failure

is the predicted probability of failure on the

ith trial for the jth subject, s is the number of successes

and f the number of failures before the ith trial by the jth

subject (subscripts i and j have been omitted from equa-

tion for clarity), and 

1

and 

2

are variables to be esti-

mated. For this study, this model was modified to allow

the inclusion of airway trainer, occupational group, and

so forth as additional predictors (Appendix 1). Because

of the difficulty in fitting multivariable learning models,

the following variables each were collapsed into two

categories: previous ETI experience (experience on pa-

tients versus no experience on patients), occupational

category (medical student or nurse versus other), and

instructor (Instructor 1 versus Instructor 2 or 3). The

model containing all these predictors, as well as type of

airway trainer, had an AIC of 1167. The best-fitting

model was obtained by removing the variables previous

ETI experience and instructor and adding a variable

denoting whether the trainee had previously attempted

to intubate the same trainer. This final model had an AIC

of 1149. Parameter estimates for this model, Model 3, are

given in Table 5. The predicted probabilities of successful

ETI for Model 3 range from 0 to 0.97, with a predicted

success rate on the first trial of 5% (observed ϭ 6%).

The ratio log(

1

)/log(

2

) gives the relative contribu-

tion of a successful trial versus a failed trial to the

learning process. Here, this ratio is approximately 12

(95% CI, 2–23), suggesting that a trainee learns about

as much from one successful trial as from 12 failed

trials.

Discussion

The learning of clinical skills has been studied in a

variety of ways. Descriptive studies (4,5) may be ap-

propriate for providing feedback to trainees about

their progress or for summarizing large amounts of

Figure 1. Observed and predicted success rates for endotracheal

intubation. F Observed success rate. Open symbols indicate success

rate predicted by models adjusting for airway trainer type, previous

intubation experience, occupational group, instructor, and trial

number on a linear () or logarithmic (⅙) scale. For Trial 1, the data

point for the logarithmic model overlaps that for the observed

success rate.

Table 2. Demographic Data

Variable

No.

Subjects

Occupation

Medical student (Year 1) 3

Medical student (Year 2) 63

Medical student (Year 3) 15

Medical student (Year 4) 4

Ambulance paramedic trainee 13

Nurse (Royal Flying Doctor Service) 1

Specialist (nonanesthesia) 1

Level of prior ETI experience

None 13

Theory only 24

Practice on airway trainers only 50

Experience intubating patients 13

Primary reason for training

Compulsory 37

To refresh previously acquired skills 1

Will probably be called upon to use ETI 33

Small chance of being called upon to use

ETI

1

General interest 28

ETI ϭ endotracheal intubation.

658 TECHNOLOGY, COMPUTING, AND SIMULATION PLUMMER AND OWEN ANESTH ANALG

LEARNING ENDOTRACHEAL INTUBATION 2001;93:656–62

data into a more comprehensible form. Comparative

studies have demonstrated the efficacy of teaching

methods, including the use of medical models or sim-

ulators (6,7). This study demonstrates that the process

of learning a complex clinical skill, ETI, can be mod-

eled statistically, enabling the identification of factors

affecting the learning process. This statistical model-

ing provides a tool that will allow anesthesiologists to

study the effect of new educational methods or

technologies.

In this study, the subject group was heterogeneous,

three different instructors were involved, and differ-

ent subjects made differing numbers of trials on dif-

fering sets of airway trainers, so the data were

“messy.” This was because the purpose of the training

sessions was educational, and their design and con-

duct was aimed to optimize learning, not to provide a

standardized setting for data collection. Results ob-

tained from this real-world situation are probably

more widely applicable than those obtained in highly

controlled experimental settings. However, interpre-

tation of the results should take the data collection

method into account. For example, the relative diffi-

culty of the different airway trainers may depend on

the sequence in which they are presented. In this

study, the sequence was not balanced or randomized,

but generally progressed from the easier to the more

difficult trainers.

Results obtained from population-averaged and

random effects models were qualitatively similar. The

interpretation of the estimated parameters, however,

differs between these types of models. Population-

averaged models are more appropriate for comparing

groups that receive different teaching methods,

whereas random effects models are more appropriate

for assessing an intervention made at an individual

level. In practice, teaching includes elements at both a

group and an individual level, and so both classes of

models might be considered.

Although the primary goal of this preliminary study

was to establish the feasibility and utility of modeling

the learning process, the results do provide insight

into the learning process. If the odds of successful

intubation are taken as a measure of performance,

then these results conform to the commonly observed

pattern of a linear relationship between logarithm of

performance score and logarithm of the number of

trials made (8). Although this type of learning curve

leads to rapid early learning, the rate of learning rap-

idly declines, essentially reaching a plateau. At this

Table 3. Results for Population-Averaged Model, Model 1 Dependent Variable: Successful Intubation

Predictor

a

Odds ratio 95% CI

Log(trial number) (P Ͻ 0.001) 6.8 4.3–11

Airway trainers (P ϭ 0.09)

Trainer A (reference category) 1

Trainer B 1.3 0.9–2.1

Trainer C 1.1 0.6–2.0

Trainer D 0.1 0.01–1.6

Trainer DC 0.6 0.2–1.6

Trainer E 1.9 0.8–4.1

Trainer F 0.9 0.5–1.6

Previous experience (P ϭ 0.005)

None (reference category) 1

Theory only 0.6 0.3–1.4

Practice on airway trainers only 1.7 0.8–4.0

Experience intubating patients 4.2 1.0–16

Occupation (P Ͻ 0.001)

Medical student Year 1 (reference category) 1

Medical student Year 2 1.4 0.5–4.2

Medical student Year 3 0.7 0.2–2.3

Medical student Year 4 0.3 0.03–1.9

Ambulance paramedic trainee 7.8 2.1–29

Nurse (RFDS) 0.5 0.1–2.3

Specialist 6.1 1.7–21

Instructor (P Ͻ 0.001)

Instructor 1 (reference category) 1

Instructor 2 0.1 0.02–0.3

Instructor 3 0.1 0.01–0.7

Changing to a new airway trainer (P Ͻ 0.001)

No change of trainer (reference category) 1

First trial after change to new trainer 0.5 0.4–0.7

CI ϭ confidence interval; RFDS ϭ Royal Flying Doctor Service.

a

P values given after each category of predictor are fromWald tests of the null hypothesis that none of the predictors in that category is associated with success

of intubation.

ANESTH ANALG TECHNOLOGY, COMPUTING, AND SIMULATION PLUMMER AND OWEN 659

2001;93:656–62 LEARNING ENDOTRACHEAL INTUBATION

Table 5. Results for Learning Model, Model 3 Dependent Variable: Failed Intubation

Predictor

a

Parameter

estimate

b

95% CI

Number of previous successes (P Ͻ 0.001) 0.72 0.68–0.76

Number of previous failures (P Ͻ 0.001) 0.97 0.95–1.00

Airway trainers (P ϭ 0.017)

Trainer A (reference category) 1

Trainer B 0.96 0.88–1.04

Trainer C 0.91 0.75–1.11

Trainer D 2.42 1.48–3.96

Trainer DC 1.75 1.10–2.80

Trainer E 0.77 0.44–1.35

Trainer F 0.92 0.72–1.17

Occupation (P Ͻ 0.001)

Medical student/nurse (reference category) 1

Ambulance paramedic trainee/specialist 0.74 0.62–0.88

New airway trainer (P Ͻ 0.001)

First trial on a new trainer (reference category) 1

Second or subsequent trial on a trainer 0.83 0.76–0.90

CI ϭ confidence interval.

a

P values given after each category of predictor are from likelihood ratio tests of the null hypothesis that none of the predictors in that category is associated

with success of intubation.

b

Because the modeled outcome is probability of a failed trial, the parameter estimates may be interpreted as the factor by which the probability of failure is

reduced. For example, other factors being equal, a trainee who is an ambulance paramedic trainee or specialist has only 74% as much chance of failing an

intubation trial as a medical student or nurse.

Table 4. Results for Random Effects Model, Model 2 Dependent Variable: Successful Intubation

Predictor

a

Odds ratio 95% CI

Log(trial number) (P Ͻ 0.001) 11.4 7.2–18.1

Airway trainers (P ϭ 0.002)

Trainer A (reference category) 1

Trainer B 1.3 0.8–2.0

Trainer C 1.0 0.6–1.9

Trainer D 0.1 0.01–0.4

Trainer DC 0.4 0.2–1.0

Trainer E 1.8 0.7–4.6

Trainer F 0.8 0.4–1.6

Previous experience (P ϭ 0.013)

None (reference category) 1

Theory only 0.7 0.2–1.9

Practice on airway trainers only 1.8 0.7–4.7

Experience intubating patients 5.1 1.2–21

Occupation (P ϭ 0.009)

Medical student Year 1 (reference category) 1

Medical student Year 2 1.5 0.3–8.6

Medical student Year 3 0.7 0.1–4.7

Medical student Year 4 0.2 0.02–2.7

Ambulance paramedic trainee 8.1 1.0–64

Nurse (RFDS) 0.5 0.01–23

Specialist 10.2 0.3–342

Instructor (P Ͻ 0.001)

Instructor 1 (reference category) 1

Instructor 2 0.1 0.02–0.5

Instructor 3 0.1 0.01–0.2

Changing to a new airway trainer (P Ͻ 0.001)

No change of trainer (reference category) 1

First trial after change to new trainer 0.4 0.3–0.6

CI ϭ confidence interval; RFDS ϭ Royal Flying Doctor Service.

a

P values given after each category of predictor are from likelihood ratio tests of the null hypothesis that none of the predictors in that category is associated

with success of intubation.

660 TECHNOLOGY, COMPUTING, AND SIMULATION PLUMMER AND OWEN ANESTH ANALG

LEARNING ENDOTRACHEAL INTUBATION 2001;93:656–62

stage, simply doing more of the same has little edu-

cational value. It may be that an appropriate interven-

tion, such as instruction, reflection, or a break from

training after approximately 12 trials, can be devel-

oped that would initiate a further acceleration in

learning.

Each time a trainee changed to a new airway trainer,

the odds of a successful intubation decreased by half,

suggesting that trainees became familiar with a trainer

on repeated use and tailored their technique to suit it.

Learning studies have shown that variation in the

training task slows acquisition but enhances both re-

tention and transfer to new settings (9,10). This leads

to the hypothesis that if trainees trained on only a

single airway trainer, they would become skilled at

intubating only that airway trainer but would have

more difficulty intubating a patient, and would lose

the skill more easily than a trainee who had trained on

a variety of trainers.

Another interesting result arose from the learning

model. It seems that trainees learn far more from

successful, as opposed to failed, trials at intubation.

This is consistent with the hypothesis that ETI is a

motor skill learned by the practice of the correct tech-

nique, such as with riding a bike. Initially it is difficult,

but by repetition of the correct motor skills it becomes

automatic. Repetition or performance of incorrect

skills is of little value. This supports the intuitive view

that training should commence with the easier airway

trainers and progress to more difficult ones only when

the trainee is able to approach them with a good

prospect of success.

This study focused on the process of learning to

intubate airway trainers. It has identified means by

which such learning might be improved, for exam-

ple, by using a variety of trainers and structuring

the session to maximize the proportion of successful

trials. It remains to be determined whether optimiz-

ing training with airway trainers improves a train-

ee’s ability to intubate a patient or whether a sub-

ject’s performance during training on airway

trainers may be used to predict ability to intubate a

patient. This has major implications for clinical sim-

ulation. Data are currently being collected to exam-

ine these questions.

The authors are grateful to Ms. Val Follows, CN, and Dr. Madhavi

Singh, who supervised a number of training sessions.

Appendix 1

An important feature of data consisting of multiple

measurements on each of a number of individuals is

the lack of independence of observations within sub-

jects. The three types of models examined in this study

represent three different approaches to dealing with

this dependence. Models were fitted by using the xt-

logit or glm (generalized linear models) procedures of

the software package Stata version 7 (Stata Corpora-

tion, College Station, TX).

Population-averaged, or marginal, models model

the mean response of groups of subjects with the same

covariate patterns. These models were fitted by using

the generalized estimating equations method. Param-

eters are estimated assuming that the observations are

independent. The correlations within subjects are es-

timated and used to obtain correct ses and CIs. A

specific structure must be assumed for the correlations

between responses (in this case, an exchangeable

structure was assumed), but by basing ses on the

information sandwich, or robust, estimator, CIs for

parameters will be correct even if the correlation struc-

ture was misspecified (11,12). An odds ratio from a

population-averaged model compares the odds of dif-

ferent groups of subjects having different values for

the covariate of interest. Population-averaged models

are therefore most appropriate for comparison of

groups in which treatments are fairly uniform within

a group but differ between groups. Adequacy of fit of

these models was assessed by comparison of pre-

dicted and observed success rates and by the Hosmer-

Lemeshow test (12). Population-averaged models

have been criticized on a number of grounds, in par-

ticular because the predicted response profiles may

not apply to any possible individual subject (13). For

further information about population averaged mod-

els, see Diggle et al. (14).

The random effects model may be viewed as a

model in which some variables influencing the out-

come have been omitted. The values taken by these

omitted variables must be constant within each subject

but may vary among subjects. For example, in this

study, motor coordination might be an important pre-

dictive variable, but it was not measured and was not

included in the models. The consequence of omitting

these variables is that some subjects perform better

than others for reasons not explicitly explained by the

model. The random effects model absorbs this heter-

ogeneity into a random subject factor; that is, the

unexplained variation among subjects is considered to

follow some probability distribution. In the models

fitted here, this distribution was assumed to be a

normal distribution. An odds ratio from a random

effects logit model applies to subjects having the same

value for the random effect, for example, the odds of a

specific subject observed under different levels of a

covariate (12). Random effects models are most appro-

priate when it is desired to assess the effect of an

intervention made at an individual level. Adequacy of

fit of these models was assessed by comparison of

predicted and observed success rates and by the

Hosmer-Lemeshow test (12). For further information

ANESTH ANALG TECHNOLOGY, COMPUTING, AND SIMULATION PLUMMER AND OWEN 661

2001;93:656–62 LEARNING ENDOTRACHEAL INTUBATION

about random effects models, see Brown and Prescott

(15).

The learning models used here were of the form

P

failure

ϭ 

1

s

ϫ 

2

f

ϫ 

3

x1

ϫ 

4

x2

..., (1)

where P

failure

is the predicted probability that the ith

attempt of the jth subject will be a failure, s is the

number of successful and f the number of failed at-

tempts by the jth subject before the ith attempt, and x1,

x2, and so on are predictors denoting airway trainer,

occupational group, and so forth. Within-subject cor-

relation arises from the dependence of an observation

on past values for the same subject. Goodness of fit of

learning models was assessed by comparison of pre-

dicted and observed success rates and by examination

of Pearson and deviance residuals.

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Chichester: John Wiley & Sons, 1999.

662 TECHNOLOGY, COMPUTING, AND SIMULATION PLUMMER AND OWEN ANESTH ANALG

LEARNING ENDOTRACHEAL INTUBATION 2001;93:656–62

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