Ninety-four percent of graduating neurology residents say they are comfortable treating stroke patients with intravenous tissue plasminogen activator – a dramatic increase from the 73% who said this a decade earlier, investigators reported in an article published online Aug. 8 in Stroke.
The improvement is largely due to residents’ personal experience in using the treatment during their training. In particular, residents who were eventually allowed to administer tissue plasminogen activator (TPA) without direct faculty supervision were the most confident about using it in future practice, said Dr. Vera Fridman of the department of neurology, University of Pennsylvania, Philadelphia, and her associates.
"It is imperative that neurology residents attain a level of comfort with the use of TPA that will allow them to utilize the medication effectively in their clinical practice and guide other physicians in its use," the investigators noted.
Dr. Fridman and her colleagues used the American Medical Association Graduate Medical Education Database to identify all neurology residents completing their final year of training in the United States during 2010. These residents were sent a 12-item anonymous questionnaire assessing their experience with TPA. The questionnaire was identical to one that had been administered to neurology residents who graduated in 2000 – the first cohort to have completed all 4 years of training after FDA approval of TPA for acute ischemic stroke.
The response rate to the current survey was 58%, with 286 respondents comprising the study cohort.
Overall, 95% of the neurology residents graduating in 2010 who responded to the survey reported that they had personally used TPA to treat stroke, and another 4% had observed such treatment. A total of 94% said they would be comfortable using the treatment independently in their own practices, Dr. Fridman and her associates said (Stroke 2011 Aug. 8 [doi:10.1161/strokeaha.111.621839]).
Respondents were much more likely to feel confident using TPA if they had personal experience with the drug (96%) than if they were inexperienced (60%). Those who had treated a patient without direct faculty supervision were much more likely to feel comfortable (78%) than were those who had only used it under direct faculty supervision (52%).
In addition, residents at an institution that employed a stroke team were more likely to feel comfortable using TPA than those at institutions without a stroke team (68% vs. 37%, respectively). Residents who had received formal training in the National Institutes of Health Stroke Scale were more likely to feel comfortable using TPA than those who had not received such training (67% vs. 45%, respectively).
In comparison, only 73% of graduating neurology residents in the 2000 survey said they were comfortable using TPA. Only 88% had observed TPA administration during training (versus 99% in 2010), only 80% had personally used the drug during training (versus 95% in 2010), and only 89% had been involved in post-TPA care (versus 98% in 2010). Similarly, only 65% of neurology residents in 2000 had been trained in the NIH Stroke Scale and only 84% had a stroke team at their institution. All of these percentages from 2000 were significantly lower than the corresponding figures for 2010 (P < .001).
The finding that so many factors related to TPA use have improved so much in 10 years is "encouraging," but the study results also show that the amount of autonomy given to neurology residents caring for stroke patients still varies widely.
"Giving neurology residents more autonomy in decision making regarding TPA administration may increase their comfort using TPA in practice. This balance between supervision and independence is a fundamental tension throughout medical training," Dr. Fridman and her colleagues said.
The survey also showed that almost all current residents are confident in their ability to identify brain hemorrhage (99%-100%) and early infarct signs (94%-98%) on computed tomography, as were respondents to the survey in 2000.
No financial conflicts of interest were reported.