Skip to main content
Download PDF

Competence over confidence: uncovering lower self-efficacy for women residents during central venous catheterization training

BMC Medical Education volume 24, Article number: 923 (2024) Cite this article

Abstract

Background

While women make up over 50% of students enrolled in medical school, disparities in self-efficacy of medical skills between men and women have been observed throughout medical education. This difference is significant because low self-efficacy can impact learning, achievement, and performance, and thus create gender-confidence gaps. Simulation-based training (SBT) employs assessments of self-efficacy, however, the Dunning-Kruger effect in self-assessment posits that trainees often struggle to recognize their skill level. Additionally, the impact of gender on self-efficacy during SBT has not been as widely studied. The objective of this study was to identify if the gender-confidence gap and the Dunning-Kruger effect exist in SBT for central venous catheterization (CVC) on the dynamic haptic robotic trainer (DHRT) utilizing comparisons of self-efficacy and performance.

Methods

173 surgical residents (Nwomen=61, Nmen=112) underwent training on the DHRT system over two years. Before and after using the DHRT, residents completed a 14-item Central Line Self-Efficacy survey (CLSE). During training on the DHRT, CVC performance metrics of the number of insertion attempts, backwall puncture, and successful venipuncture were also collected. The pre- and post-CLSE, DHRT performance and their relationship were compared between men and women.

Results

General estimating equation results indicated that women residents were significantly more likely to report lower self-efficacy for 9 of the 14 CLSE items (p < .0035). Mann-Whitney U and Fisher’s exact tests showed there were no performance differences between men and women for successfully accessing the vein on the DHRT. Regression models relating performance and self-efficacy found no correlation for either gender.

Conclusions

These results indicate that despite receiving the same SBT and performing at the same level, the gender-confidence gap exists in CVC SBT, and the Dunning-Kruger effect may also be evident.

Peer Review reports

Background

Despite the steady increase of the percentage of women enrolled in medical school in the United States from 27.9% in 2000 [1] to 54.6% in 2023 [2], researchers have identified a gender-confidence gap in medical training [3, 4]. This gender-confidence gap manifests as disparities in self-confidence where women underestimate and undervalue themselves compared to men [5]. This is worrisome because self-efficacy, or task- or goal- specific confidence [6, 7], has been shown to be vital in challenging environments, like medicine, due to its relationship with an individuals’ motivation to engage in tasks and to persevere when faced with training challenges [8]. Self-efficacy and self-confidence are often used interchangeably, with self-efficacy measures being used to understand confidence for specific tasks and procedures.

It is important to note that higher self-efficacy does not always correlate with improved accuracy and performance [9]. For example, research has shown that people with lower skill levels often overestimate their abilities, or people with higher skill levels underestimate their abilities, a phenomenon referred to as the Dunning-Kruger Effect [10]. This effect has been found throughout medical training, from medical students [11], to medical residency [12], to attending physicians [13] where underperformers often rate themselves higher than their actual skill levels while high performers often rate themselves lower. Understanding the Dunning-Kruger Effect is pertinent due to the clinical consequences of this phenomena. For example, medical residents with less knowledge may appear overconfident and knowledgeable but this may not be truly reflective of their actual competency for patient interaction [13] which can impact physician judgement and lead to misdiagnoses [14]. In addition, this can lead to mismatches in understanding of new physician skill levels between new physicians and their superiors [15].

Recent research has indicated that there may be gender effects in the Dunning-Kruger Effect [16]. For example, women medical students often report lower confidence than men in bedside procedures [17], and in self-rated performance on surgical clerkship [18] regardless of actual performance. Similarly, women in surgical residency often rate their knowledge on patient care [19] and general competency [20] lower than men despite no gender-based performance differences [21]. While it has been shown that women have disproportionately lower confidence than men, it is less known how different types of training may impact this.

One area that incorporates self-assessments of confidence is simulation-based training (SBT). SBT using imitations of real procedures and environments [22, 23], or simulators which can be full or part body manikins, part task trainers, or other forms, to allow physicians to practice before working with live patients [24, 25]. SBT has been widely integrated throughout medical education due to its low-risk, hands-on practice [26, 27] and often includes approaches to mastery-based learning including checklists and other forms of assessment [28, 29]. Measures of confidence, including self-efficacy, are sometimes used in SBT to provide an indication of trainee learning [8, 30], though self-assessments in medical education are often reinforced with other skills assessments [31]. Self-efficacy is an important construct in SBT due to its relationship with learning [6, 30] and achievement [32, 33]. For example, in medical training, participation in SBT has been shown to significantly increase trainee self-efficacy for acute skills [34], emergency room preparedness [35], intercostal drain insertion [36], and central venous catheterization (CVC) [37]. However, the gender-confidence gap has been shown to manifest in SBT [38] with one study showing that women had lower self-efficacy for obstetric emergency after SBT training despite the fact that there were no gendered performance differences [39]. However, few studies exist that explore the relationship between gender, confidence, and simulation training. Exploring these effects is important due to of the relationship between confidence and competence [40] in medicine and how they often change together.

One procedure that is useful for exploring the impact of the gender-confidence gap in SBT in medical residency is central venous catheterization (CVC). CVC is a complex, high volume [41] medical procedure with up to a 15% error rate [42] ranging from infectious to mechanical complications. CVC is a bi-manual task that requires a physician to utilize both their dominant and nondominant hands to manage an ultrasound probe and needle and insert a catheter into a central vein for critical medication delivery to the bloodstream [41]. A physician who was performed less than 50 catheterizations is twice as likely to cause complications [41], indicating a need to better understand CVC training.

CVC is typically taught using SBT [43] including one of the newest SBT systems, the Dynamic Haptic Robotic Trainer (DHRT) [44], see Fig. 1. The DHRT uses haptic robotic simulation and mock ultrasound to train residents on CVC needle insertion for multiple patient anatomies, because in live patients the location and depth of the internal jugular vein can vary [45]. The DHRT is as effective as manikin training for CVC in skill and self-efficacy gains [46, 47], and is more beneficial than manikin training due to its objective scoring and real-time feedback.

Fig. 1
figure 1

The DHRT trainer used in residency training

Full size image

In light of this previous work, the objective of this study was to compare self-efficacy and performance between men and women residents to answer the following research questions (RQs):

RQ1

Is there a gender-confidence gap in CVC SBT pre- or post-training?

RQ2

Are there gender-based performance differences in CVC SBT for technical skills at the end of training?

RQ3

RQ3: Does the Dunning-Kruger effect exist in CVC SBT post-training?

For RQ1, we hypothesized that women residents would have lower CVC self-efficacy than men residents both pre- and post-training based on previous work thatindicated that women in graduate and post-graduate medical training rate themselves lower in perceived clinical skills [20], performance [18], and confidence [39] than men. For RQ2, we hypothesized that there would be no significant differences in CVC SBT performance between genders based on prior work that found that men and women do not differ in performance for clinical knowledge or technical skills at the residency level [20, 39]. For RQ3, we hypothesized that there would be no significant relationship between these variables for either gender, thus supporting the existence of the Dunning-Kruger effect in CVC SBT based on prior literature that found that medical residents’ ability to accurately self-assess skills was weak, [12], and that medical trainees are often unaware of their actual skill level [10].

Methods

Procedures

At the start of the study, and prior to training, residents consented to participate in this research by providing informed consent, through an online platform. Next, participants completed an online central line training that consisted of a demographic survey, a pre-online training knowledge assessment, eight interactive video modules that focused on CVC content and steps of the procedure, and a post-online training knowledge assessment, see [48] and the appendix for detailed description of the online training protocol.

After completing the online training, residents attended an in-person training session. At the start of the training, residents completed a pre-training central line self-efficacy (CLSE) survey. Next, each resident completed a set of trials on the DHRT. In the 2021 cohort, residents at both medical centers performed a total of six trials on the DHRT regardless of performance. In 2022 the system was updated so that the number of trials each resident completed was based on previous performance. To complete training, residents in 2022 had to complete two successful venipunctures on the DHRT after a mandatory training trial, defined as vessel access with minimal insertion attempts and no serious error (e.g. arterial puncture). Thus, the minimum number of insertions required based on the procedure per 2022 resident was 3 and the maximum was 6. Additionally, surgical residents (June_M1) at medical center 1 in 2021, and all residents at medical center 1 in 2022 received additional hands-on procedural practice covering the steps of CVC in greater depth than provided on the DHRT system. For this extra procedural training, the DHRT was extended so residents had a full CVC kit and interactive feedback on steps of the procedure past the needle insertion that is covered on the DHRT. Finally, residents completed a post-training CLSE survey. All residents received the same training regardless of participation in the study. Non-study residents still filled out the CLSE survey for the flow of the training and so that they could visualize their own changes in self-efficacy, however, their results were destroyed after training and not use for analysis.” See Fig. 2 for the complete procedural flow.

Fig. 2
figure 2

Procedural flow for medical residents in CVC training

Full size image

Metrics

In order to answer our research questions, the following metrics were computed.

Performance metrics

The DHRT measures performance on each trial based on previous research [44, 49]. For the current study, the performance on the last trial was used as this was the Verification of Proficiency test. The performance variables of interest for the current study were number of insertion attempts, backwall puncture, and successful venipuncture without arterial puncture. These metrics are defined below.

Insertion attempts

Insertion attempts was computed by the system as the number of insertions it took to achieve access to the vein. For example, if the trainee pierced the needle into the DHRT and then removed the needle fully and re-insert it to readjust, two insertion attempts were computed. Limiting insertion attempts is important to reduce the likelihood of infectious complications associated with multiple needle sticks [50].

Backwall puncture

A backwall puncture was computed every time a resident inserted the needle into the vein but also punctured the back side of the vessel. Avoiding backwall puncture is necessary to limit the risk of accidental arterial puncture and decrease the risk of treatment complexity caused by mechanical complications [41].

Successful venipuncture

A successful trial was computed when a resident accessed the vein without puncturing the carotid artery or through the backwall of the vein. Puncturing the carotid artery can lead to serious complications like stroke and death [41] and potentially the insertion of the catheter into the wrong vessel and as such needs to be avoided [51].

Central-line self-efficacy (CLSE)

A five-point, 14-item Likert-scale CVC self-efficacy, referred to as the Central-Line Self-Efficacy (CLSE) developed in prior work [39] was used to assess resident confidence on the procedure. On the CLSE, residents rated themselves in their belief in their ability where a one represented not at all confident and five represented extremely confident. The first ten items on the CLSE survey focused on the specific steps of the procedure such as “modifying the needle trajectory” while the last four questions related to broader aspects of the procedure such as “conducting the entire procedure on a simulator”. The full CLSE survey can be found here, however, please note that in later trainings the CLSE was updated to 19-items, so only the first 14 items are relevant to the current study.

Statistical analysis

To assess gender-confidence gaps in CVC SBT (RQ1), a general estimating equation (GEE) was computed with gender and self-efficacy type (pre- or post-training) and their interaction as the independent variables and the 14 CLSE questions as the dependent variables. To account for any potential effect of the additional procedural training in 2022 on self-efficacy, training year was also included as a variable. A GEE was used to extend the standard generalized linear regression model and account for the repeated measures of the pre and posttest. All assumptions were met for the GEE. To assess gender-based performance gaps (RQ2), a Mann-Whitney U test was conducted for the continuous variable, insertion attempts. Fisher’s exact test was conducted for the dichotomous performance variables, backwall puncture and successful venipuncture. All assumptions were met for both of these analyses. Finally, to assess the Dunning-Kruger effect (RQ3), regression analyses were conducted to determine if there was a correlation between self-efficacy and performance. Prior to this, the internal reliability of the CLSE was verified (Cronbach’s alpha = 0.952) justifying the aggregation of the 14 items on the CLSE into one average score. For each regression analysis, the performance metric was the response variable and post self-efficacy, gender, and their interaction were the predictor variables. Linear regression was conducted for the continuous variable, insertion attempts, and binary logistic regression was run for the two dichotomous variables, backwall puncture and successful venipuncture. The analysis was conducted with the entire dataset to determine the significance of the interaction term and then the dataset was split and a follow-up analysis was run within each gender to determine if one had a stronger significant relationship than the other. Assumptions were checked and outliers were found for all three variables, determined true outliers not due to measurement error, and kept in for the analysis. All other assumptions were met for all regression models. A power hoc power calculation was conducted based on the effect size from found the chi-square statistic used in the GEE and found that the statistical power ranged from 0.694 to 0.975.

Results

Participants

One hundred and seventy-three residents (Nwomen=61, Nmen=112) from two residency cohorts (N2021 = 72 and N2022 = 101) and two medical centers (NM1=103, NM2=70) were recruited from the new resident bootcamp over a span of two summers with trainings running from June through September, see Table 1 for participant breakdown. The sample size used in the study was a convenience sample dictated by the number of residents in training and willing to participate each year. While the bootcamp was mandatory for all residents, participation in this research was voluntary and only residents who provided informed consent were included in this study. There were no major demographic differences between the two training years.

RQ1: Is there a gender-confidence gap in CVC SBT pre- or post- training?

A Bonferroni adjustment was applied to account for repeated measures on the CLSE survey [52], resulting in an family wise error rate (α) of 0.0035. GEE results indicated that gender was a significant predictor with women ranking lower for 9 of the 14 variables (see Fig. 3 for mean values) including using tactile feedback during placement (Wald χ2 = 18.814, p < .001), using tactile feedback to identify the vessel (Wald χ2 = 20.045, p < .001), advancing the introducer needle (Wald χ2 = 11.053, p < .001), modifying the needle trajectory (Wald χ2 = 12.492, p < .001), identifying the needle in location (Wald χ2 = 8.733, p = .003), using tactile feedback to guide the needle (Wald χ2 = 14.216, p < .001), placing the needle in one attempt (Wald χ2 = 17.888, p < .001), placing the needle in multiple attempts (Wald χ2 = 9.314, p = .002), and conducting the entire procedure without mistakes (Wald χ2 = 9.975, p = .002), aligning with our hypothesis. Parameter estimates for the nine CLSE items where gender was a significant predictor indicated that a resident who identified as a woman was more likely to rate themselves lower than their men counterparts, see Table 1. Additionally, the interaction between self-efficacy type (pre or post) and gender was significant for conducting the entire procedure without mistakes (Wald χ2 = 12.350, p < .001) meaning that the impact of gender on this variable varied based on the test condition, though gender was not a significant predictor for this variable (p = .004). Positive parameter values [0.987(0.2822), < 0.001] for women indicate that identifying as a woman impacted pre-CLSE more than post-CLSE for this variable, though both were lower than for men. Training year did not have a significant impact on any of the 14 variables. See Table 1 for full significant results. For all 14 CLSE questions, there were significant increases pre- to post-test for both genders (p < .001), aligning with our hypothesis. These results indicate that the gender-confidence gap is evident in CVC training both before and after exposure to SBT.

Table 1 Significant model effects of the GEE
Full size table
Fig. 3
figure 3

Self efficacy means of men and women post training for significant values

Full size image

RQ2

Are there gender-based performance differences in CVC SBT for technical skills at the end of training?

A Bonferroni adjustment was applied to account for repeat testing for the three performance variables [52], resulting in an family wise error rate (α) of 0.017. For backwall puncture, 95.5% of men avoided backwall puncture and 95.1% of women avoided backwall puncture, with Fisher’s exact test finding no statistically significant difference (p = 1.00). For successful venipuncture, 84.8% of men successfully accessed the vein and 90.1% of women successfully accessed the vein, with Fisher’s exact test finding no significant difference (p = .360). Finally, for the number of insertion attempts, a Mann-Whitney U-test found no significant differences (U = 271.94, z = 0.507, p = .612) between men (M = 1.78, SD = 1.324) and women (M = 1.75, SD = 1.633). These results support our hypothesis that no gender differences in performance in CVC SBT exist post-training.

RQ3: Does the Dunning-Kruger effect exist in CVC SBT post-training?

A Bonferroni adjustment was applied to account for repeat testing for the three performance variables [52], resulting in an family wise error rate (α) of 0.017. For insertion attempts, the linear regression model was unable to significantly predict performance for the whole population based on gender, self-efficacy, and their interaction F(3,169) = 2.719, p = .046. When divided by gender, the linear regression models for insertion attempts were unable to significantly predict performance for men, F(1,109) = 4.214, p = .042, or for women, F [1, 53] = 3.308, p = .074 based on self-efficacy. For backwall puncture, the binary logistic regression model was not significant for the whole population χ2 [3] = 0.720, p = .869. When divided by gender, the binary logistic regression models for backwall puncture were not significant for men, χ2 [1] = 0.570, p = .450 or for women χ2 [1] = 0.604, p = .437. For successful insertion, the binary logistic regression model was not significant for the whole population χ2 [3] = 4.306, p = .230. When divided by gender, the binary logistic regression models for successful insertion were not significant for men, χ2 [1] = 1.349, p = .245 or for women χ2 [1] = 0.2.473, p = .116. The results indicating that no models were able to significantly predict performance based on the aggregated post CLSE support our hypothesis that neither men nor women would be able to accurately assess their performance based on confidence. These results indicate that the Dunning-Kruger effect may exist for both genders in CVC SBT.

Discussion

The objective of this study was to compare self-efficacy and DHRT performance between men and women residents to assess for the gender confidence gap and the Dunning-Kruger effect. The main findings were that the gender confidence gap was evident for nine of the variables on the CLSE, there were no significant differences in CVC SBT performance between men and women, and initial evidence of the Dunning-Kruger effect was found.

These results on self-efficacy support previous literature in obstetrics [39] and general and plastic surgery [20] that found that women had lower self-efficacy than men in training despite there being no performance differences [16–17].Of the variables that women had lower self-efficacy for, three were related to using tactile feedback, five were related to using the needle, and one was related to overall procedural confidence. Importantly, despite having lower self-efficacy for items related to the use of the needle, there were no actual differences in the ability to achieve successful venipuncture, avoid backwall puncture, or reduce insertion attempts on the DHRT, making these lower self-efficacy ratings unfounded and aligning with previous studies [20, 39, 54].

Previous literature has also indicated the existence of the Dunning-Kruger effect in medical training for decades [10] positing that new medical trainees are unable to accurately assess their performance [11] regardless of gender [14], [34]. Our results align with previous literature in this area, finding that neither men nor women were able to accurately assess their performance. Regardless of inaccuracies, women still rated themselves lower on the majority of items on the post training CLSE compared to men, suggesting a potential variance in self-rating between genders. To fully explain this finding, a follow-up study should be conducted with a larger, more balanced sample size. Both the Dunning-Kruger effect and the gender confidence gap are important in medical education because they can impact a physician’s performance in clinical practice [14, 20]. As such, this study adds to the literature that these phenomena may be occurring early in training.

This study focused specifically on self-efficacy and performance for CVC SBT based on training with the DHRT, but the results are reflective of a greater problem with the gender-confidence gap in residency training. Understanding the gender-confidence gap in medicine and why women underestimate their abilities more than men do is pertinent because of the impact that low self-efficacy can gave on learning, achievement, persistence [55], well-being and burnout [56]. Leaving confidence discrepancies unaddressed could lead to increased challenges as women progress in their fields [56, 57], and more women leaving the field [58].

Some programs have started to highlight resources or created tasks forces for physicians to utilize to help fix gender disparities in medicine [59], including The American Medical Association (AMA) [60]. More studies should also be conducted exploring the gender-confidence gap in simulation training for other procedures to better understand how this impacts medical education and mastery-based learning. The field of medical education would benefit greatly by lessening the gender-confidence gap for trainees due to the relationships between confidence and competence in the medical profession [40].

There are several limitations in this study that must be addressed. One limitation of this study was that we did not evaluate gender and race/ethnicity interactions due to the limited sample size in race/ethnicity. Another limitation is that the dataset lacked adequate representation for genders other than men and women and therefore we were only able to study gender as binary. Future work should explore larger sample sizes with more demographic representation to analyze self-efficacy on a larger scale. In addition, this study contained data from only two U.S. medical centers that integrated the DHRT training. As such, the generalizability of the findings is needed across training systems and across institutions. Another limitation of this work is the duality of the Dunning-Kruger effect meaning that it is impossible to know from this study if women were rating themselves lower than men for self-efficacy because they were truly less confident, or if it could be because they were learning more and more aware of where their skills lacked. To this point, we also cannot tell from this study if men overestimated their abilities. To validate this, future work should include a longitudinal study to follow their progression of learning throughout training and to fully understand if and how these phenomena impact clinical skill transfer and patient care. Finally, the system flow of the DHRT changed between training years modifying how many trials each person needed to complete which may have contributed to changes in self-efficacy between years. As such, this should be explored in future work.

Conclusion

While medical education has reached gender parity, the gender-confidence gap and the Dunning-Kruger effect are still found to impact self-efficacy at the residency level for SBT. We found that women were significantly more likely to have lower self-efficacy for half of the CLSE survey items, there were no performance differences between men and women on the DHRT, and no performance and self-efficacy correlation. These results indicate an increased need to evaluate gender-differences and the Dunning-Kruger effect in resident SBT. Future work should be conducted to further evaluate these findings.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

NIH:

National Institutes of Health

CVC:

Central Venous Catheterization

US-IJCVC:

Ultrasound Guided Central Venous Catheterization

DHRT:

Dynamic Haptic Robotic Trainer

SBT:

Simulation-Based Training

CLSE:

Central Line Self-Efficacy Survey

References

  1. Campbell KE, Mccammon HJ. Elizabeth Blackwell’s heirs: women as physicians in the United States, 1880–1920. Work Occup. 2005;32(3):290–318.

    Article  Google Scholar 

  2. AAMC, Total US. Medical School Enrollment by Race/Ethnicity (Alone) and Gender 2019–2024. 2023.

  3. Zern N, Shalhub S, Wood D, Calhoun K. Association of sex with perceived career barriers among surgeons. J Bone Jt Surg - Am Vol. 2019;154(12):1155–7.

    Google Scholar 

  4. Colbert-Getz JM, Fleishman C, Jung J, Shilkofski N. How do gender and anxiety affect students’ self-assessment and actual performance on a high-stakes clinical skills examination? Acad Med. 2013;88(1):44–8.

    Article  Google Scholar 

  5. Kay K, Shipman C. The confidence gap. The Atlantic [Internet]. 2014;56–66. http://www.washingtonpost.com/wp-dyn/content/article/2009/07/10/AR2009071002358.html.

  6. Artino AR. Academic self-efficacy: from educational theory to instructional practice. Perspect Med Educ. 2012;1(2):76–85.

    Article  Google Scholar 

  7. Morony S, Kleitman S, Lee YP, Stankov L. Predicting achievement: Confidence vs self-efficacy, anxiety, and self-concept in Confucian and European countries. Int J Educ Res [Internet]. 2013;58:79–96. https://doi.org/10.1016/j.ijer.2012.11.002.

  8. Klassen RM, Klassen JRL. Self-efficacy beliefs of medical students: a critical review. Perspect Med Educ. 2018;7(2):76–82.

    Article  Google Scholar 

  9. Zwaan L, Hautz WE. Bridging the gap between uncertainty, confidence and diagnostic accuracy: calibration is key. BMJ Qual Saf. 2019;28(5):352–5.

    Article  Google Scholar 

  10. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999;77(6):1121–34.

    Article  Google Scholar 

  11. Sawdon M, Finn G. The unskilled and unaware effect is linear in a real-world setting. J Anat. 2014;224(3):279–85.

    Article  Google Scholar 

  12. Gude T, Finset A, Anvik T, Bærheim A, Fasmer OB, Grimstad H, et al. Do medical students and young physicians assess reliably their self-efficacy regarding communication skills? A prospective study from end of medical school until end of internship. BMC Med Educ. 2017;17(1):1–7.

    Article  Google Scholar 

  13. Rahmani M. Medical trainees and the Dunning–Kruger Effect: when they don’t know what they don’t know. J Grad Med Educ. 2020;34:532–4.

    Article  Google Scholar 

  14. Rubin A, Froustis E. How the Dunning-Kruger Effect impairs Professional Judgement in High-risk professions. J Student Res. 2023;12(4):1–10.

    Article  Google Scholar 

  15. Prozesky DR, Molwantwa MC, Nkomazana O, Kebaetse MB. Intern preparedness for the CanMEDS roles and the Dunning-Kruger effect: a survey. BMC Med Educ. 2019;19(1):1–13.

    Article  Google Scholar 

  16. Vajapey SP, Weber KL, Samora JB. Confidence gap between men and women in Medicine: a systematic review. Educ Pract Manag. 2020;31(5):494–502.

    Google Scholar 

  17. Barr J, Graffeo CS. Procedural Experience and Confidence Among Graduating Medical Students. J Surg Educ [Internet]. 2016;73(3):466–73. https://doi.org/10.1016/j.jsurg.2015.11.014.

  18. Lind DS, Rekkas S, Bui V, Lam T, Beierle E, Copeland EM. Competency-based student self-assessment on a surgery rotation. J Surg Res. 2002;105(1):31–4.

    Article  Google Scholar 

  19. Kwasny L, Shebrain S, Munene G, Sawyer R. Is there a gender bias in milestones evaluations in general surgery residency training? Am J Surg [Internet]. 2021;221(3):505–8. https://doi.org/10.1016/j.amjsurg.2020.12.020.

  20. Minter RM, Gruppen LD, Napolitano KS, Gauger PG. Gender differences in the self-assessment of surgical residents. Am J Surg. 2005;189(6):647–50.

    Article  Google Scholar 

  21. Watson RS, Borgert AJ, Heron CTO, Kallies KJ, Sidwell RA, Mellinger JD et al. A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident. J Surg Educ [Internet]. 2017;74(6):e8–14. https://doi.org/10.1016/j.jsurg.2017.06.009.

  22. Vozenilek J, Huff JS, Reznek M, Gordon JA. See one, do one, teach one: Advanced technology in medical education. Acad Emerg Med. 2004;11(11):1149–54.

    Article  Google Scholar 

  23. So HY, Chen PP, Wong GKC, Chan TTN. Simulation in medical education. J R Coll Physicians Edinb. 2019;49(1):52–7.

    Article  Google Scholar 

  24. Kunkler K. The role of medical simulation: an overview. Int J Med Robot Comput Assist Surg. 2006;2(April):203–10.

    Article  Google Scholar 

  25. Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Postgrad Med J. 2004;84(997):563–70.

    Article  Google Scholar 

  26. Pinar G. An Educational Revolution and innovative technologies: the role of Simulation. Creat Educ. 2020;11(11):2218–32.

    Article  Google Scholar 

  27. Okuda Y, Bond W, Bonfante G, McLaughlin S, Spillane L, Wang E, et al. National growth in simulation training within emergency medicine residency programs, 2003–2008. Acad Emerg Med. 2008;15(11):1113–6.

    Article  Google Scholar 

  28. Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4(7):397–403.

    Article  Google Scholar 

  29. Kattan E, De La Fuente R, Putz F, Vera M, Corvetto M, Inzunza O, et al. Simulation-based mastery learning of bronchoscopy-guided percutaneous dilatational tracheostomy: competency acquisition and skills transfer to a cadaveric model. Simul Healthc. 2021;16(3):157–62.

    Article  Google Scholar 

  30. Nayar SK, Musto L, Baruah G, Fernandes R, Bharathan R. Self-Assessment of Surgical Skills: A Systematic Review. J Surg Educ [Internet]. 2020;77(2):348–61. https://doi.org/10.1016/j.jsurg.2019.09.016.

  31. Downing SM, Yudkowsk R. Assessment in health professions education. Assessment in Health professions Education. Routledge; 2009. pp. 1–317.

  32. Hayat AA, Shateri K, Amini M, Shokrpour N. Relationships between academic self-efficacy, learning-related emotions, and metacognitive learning strategies with academic performance in medical students: a structural equation model. BMC Med Educ. 2020;20(1):1–11.

    Article  Google Scholar 

  33. Talsma K, Schüz B, Schwarzer R, Norris K. I believe, therefore I achieve (and vice versa): A meta-analytic cross-lagged panel analysis of self-efficacy and academic performance. Learn Individ Differ [Internet]. 2018;61(April 2017):136–50. https://doi.org/10.1016/j.lindif.2017.11.015.

  34. Paskins Z, Peile E. Final year medical students’ views on simulation-based teaching: a comparison with the best evidence medical education systematic review. Med Teach. 2010;32(7):569–77.

    Article  Google Scholar 

  35. Stroben F, Schröder T, Dannenberg KA, Thomas A, Exadaktylos A, Hautz WE. A simulated night shift in the emergency room increases students ’ self-efficacy independent of role taking over during simulation. BMC Med Educ [Internet]. 2016;1–7. https://doi.org/10.1186/s12909-016-0699-9.

  36. Kerins J, McCully E, Stirling SA, Smith SE, Tiernan J, Tallentire VR. The impact of simulation-based mastery learning, booster session timing and clinical exposure on confidence in intercostal drain insertion: a survey of internal medicine trainees in Scotland. BMC Med Educ [Internet]. 2022;22(1):1–9. https://doi.org/10.1186/s12909-022-03654-7.

  37. Schwab K, Friedman J, Lazarus M, Williams J. Preparing residents for Emergent Vascular Access: the comparative effectiveness of central venous and Intraosseous Catheter Simulation-based training. Int J Crit Care Emerg Med. 2019;5(1):1–8.

    Google Scholar 

  38. Amacher SA, Schumacher C, Legeret C, Tschan F, Semmer NK, Marsch S, et al. Influence of gender on the performance of cardiopulmonary rescue teams: a randomized, prospective Simulator Study. Crit Care Med. 2017;45(7):1184–91.

    Article  Google Scholar 

  39. Fritz J, Montoya A, Lamadrid-figueroa H, Flores-pimentel D, Walker D, Treviño-siller S, et al. Training in obstetric and neonatal emergencies in Mexico: effect on knowledge and self-efficacy by gender, age, shift, and profession. BMC Med Educ. 2020;20(97):1–10.

    Google Scholar 

  40. Gottlieb M, Chan TM, Zaver F, Ellaway R. Confidence-competence alignment and the role of self-confidence in medical education: a conceptual review. Med Educ. 2022;56(1):37–47.

    Article  Google Scholar 

  41. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123–33.

    Article  Google Scholar 

  42. Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg. 2007;204(4):681–96.

    Article  Google Scholar 

  43. Soffler MI, Hayes MM, Smith C. Central venous catheterization training: current perspectives on the role of simulation. Adv Med Educ Pract [Internet]. 2018;9–395. https://doi.org/10.2147/AMEP.S142605.

  44. Pepley DF, Gordon AB, Yovanoff MA, Mirkin KA, Miller SR, Han DC et al. Training Surgical Residents With a Haptic Robotic Central Venous Catheterization Simulator. J Surg Educ [Internet]. 2017;74(6):1066–73. https://doi.org/10.1016/j.jsurg.2017.06.003.

  45. Parmar S, Parikh S, Mehta H. Anatomical variations of the internal jugular vein in relation to carotid artery: an ultrasound study. Int J Med Sci Public Heal. 2013;2(2):223.

    Article  Google Scholar 

  46. Yovanoff M, Pepley D, Mirkin K, Moore J, Han D, Miller S. Improving medical education: simulating changes in patient anatomy using dynamic haptic feedback. Proc Hum Factors Ergon Soc. 2016;603–7.

  47. Yovanoff MA, Chen HE, Pepley DF, Mirkin KA, Han DC, Moore JZ et al. Investigating the Effect of Simulator Functional Fidelity and Personalized Feedback on Central Venous Catheterization Training. J Surg Educ [Internet]. 2018;75(5):1410–21. https://doi.org/10.1016/j.jsurg.2018.02.018.

  48. Gonzalez-Vargas JM, Tzamaras HM, Martinez J, Brown DC, Moore JZ, Han DC et al. Going the (social) distance: Comparing the effectiveness of online versus in-person Internal Jugular Central Venous Catheterization procedural training. Am J Surg [Internet]. 2022;224(3):903–7. https://doi.org/10.1016/j.amjsurg.2021.12.006.

  49. Gonzalez-vargas JM, Brown DC, Moore JZ, Han DC, Sinz EH, Sonntag CC, et al. OBJECTIVE ASSESSMENT METRICS FOR CENTRAL LINE SIMULATORS: AN EXPLORATION OF CAUSAL FACTORS. Proc Hum Factors Ergon Soc Annu Meet. 2020;64(1):2008–12.

    Article  Google Scholar 

  50. IJsselmuiden CB, Faden RR. Complications and failures of subclavian-vein catheterization. N Engl J Med. 1992;331(26):1735–8.

    Google Scholar 

  51. De Cassai A, Geraldini F, Pasin L, Boscolo A, Zarantonello F, Tocco M et al. Safety in training for ultrasound guided internal jugular vein CVC placement: a propensity score analysis. BMC Anesthesiol [Internet]. 2021;21(1):1–6. https://doi.org/10.1186/s12871-021-01460-0.

  52. Schober P, Thomas V. Adjustments for multiple testing in Medical Research. Anesth Anaglesia. 2020;130(1):2020.

    Google Scholar 

  53. Gann M, Sardi A. Improved results using ultrasound guidance for central venous access. Am Surg. 2003;69(12):1104–7.

    Article  Google Scholar 

  54. Reder SR, Rohou A, Keric N, Beiser KU, Othman AE, Abello Mercado MA et al. Gender differences in self-assessed performance and stress level during training of basic interventional radiology maneuvers. Eur Radiol [Internet]. 2023;(0123456789). https://doi.org/10.1007/s00330-023-09993-3.

  55. Nabavi RT. Bandura ’ s Social Learning Theory & Social Cognitive Learning Theory. Theor Dev Psychol Title. 2014;(January 2012):24.

  56. Milam LA, Cohen GL, Mueller C, Salles A. The Relationship Between Self-Efficacy and Well-Being Among Surgical Residents. J Surg Educ [Internet]. 2019;76(2):321–8. https://doi.org/10.1016/j.jsurg.2018.07.028.

  57. Stephens EH, Heisler CA, Temkin SM, Miller P. The current status of women in surgery: how to affect the future. JAMA Surg. 2020;155(9):876–85.

    Article  Google Scholar 

  58. Moak TN, Cress PE, Tenenbaum M, Casas LA. The leaky pipeline of women in plastic surgery: embracing diversity to close the gender disparity gap. Aesthetic Surg J. 2020;40(11):1241–8.

    Article  Google Scholar 

  59. McKinley SK, Wang LJ, Gartland RM, Westfal ML, Costantino CL, Schwartz D, et al. Yes, I’m the doctor: one Department’s Approach to assessing and addressing gender-based discrimination in the Modern Medical Training Era. Acad Med. 2019;94(11):1691–8.

    Article  Google Scholar 

  60. Advancing Gender Equity in Medicine: Resources for Physicians [Internet], American Medical Association. 2022. https://www.ama-assn.org/delivering-care/health-equity/advancing-gender-equity-medicine-resources-physicians.

  61. Ishizuka M, Nagata H, Takagi K, Kubota K. Right internal jugular vein is recommended for central venous catheterization. J Investig Surg. 2010;23(2):110–4.

    Article  Google Scholar 

  62. Hodzic S, Golic D, Smajic J, Sijercic S, Umihanic S, Umihanic S. Complications related to insertion and use of central venous catheters (CVC). Med Arch (Sarajevo Bosnia Herzegovina). 2014;68(5):300–3.

    Google Scholar 

  63. Yovanoff M, Pepley D, Mirkin K, Moore J, Han D, Miller S. Personalized learning in medical education: Designing a user interface for a dynamic haptic robotic trainer for central venous catheterization. Proc Hum Factors Ergon Soc. 2017;2017–Octob2014:615–9.

    Google Scholar 

  64. Blaivas M, Adhikari S. An unseen danger: frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med. 2009;37(8):2345–9.

    Article  Google Scholar 

  65. Graham A, Ozment C, Tegtmeyer K, Lai S, Braner D. Central Venous Catheterization [Internet]. 2007. https://www.nejm.org/doi/full/https://doi.org/10.1056/NEJMvcm055053.

Download references

Acknowledgements

Not applicable.

Funding

This work was supported by the National Institutes of Health (NIH) under Award Number RO1HL127316. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Author information

Authors and Affiliations

  1. Penn State, Department of Industrial Engineering, State College, 307 Engineering Design and Innovation Building, University Park, PA, 16801, USA

    Haroula Tzamaras & Scarlett Miller

  2. WVU Critical Care and Trauma Institute, Morgantown, WV, USA

    Elizabeth Sinz

  3. General Internal Medicine Cedars-Sinai, Los Angeles, CA, USA

    Michael Yang & Phillip Ng

  4. Penn State Department of Mechanical Engineering, State College, University Park, PA, USA

    Jason Moore

Authors
  1. Haroula Tzamaras
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elizabeth Sinz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Phillip Ng
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jason Moore
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Scarlett Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

HT performed study design, data collection, and analysis and wrote this manuscriptLS provided study design support, data collection support and manuscript editingMY provided data collection supportPN provided data collection supportJM provided study design support and data collection support SM acted as the PI, provided study design support, data collection support and manuscript editing.

Corresponding author

Correspondence to Scarlett Miller.

Ethics declarations

Ethics approval and consent

All experimental protocols used in this study were approved by the Institutional Review Board (IRB) at Penn State University. All participants in this study were over 18 and provided informed consent for this study, as per the IRB approved protocol. The participants elected to participate in this study as part of their required residency training. Before giving consent, residents were informed that the study was to “compare the learning gains on central venous catheterization (CVC) insertion procedures of first year residents” the data would be used to “guide the development of better training systems for central venous catheterization.” The decision to use existing data to analyze self-efficacy differences between men and women was made post hoc.”

Consent for publication

Not applicable.

Competing interests

Two of the authors (Drs. Miller and Moore) are listed as inventors for the DHRT system on a patent (United States Patent No. US 11,373,553 B2, approved June 28, 2022). Additionally, Drs. Miller and Moore own equity in Medulate, which has an interest in this project. Dr. Miller and Moore’s ownership in this company has been reviewed by the University’s Individual Conflict of Interest Committee and is currently being managed by the University.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendices

Appendix A: CVC Details

CVC is most commonly conducted with ultrasound guidance into the right internal jugular vein (US-IJCVC) [53, 61], and requires a series of bi-manual steps to complete the procedure. These steps include manipulating an ultrasound probe in one hand while inserting a needle into the internal jugular vein, while avoiding other anatomy like the carotid artery [62]. Once the vein is accessed, a catheter can be inserted; however, most training for CVC focuses just on the initial needle insertion.

Appendix B: DHRT details

Each time the trainee uses the system, they are presented with a graphical user interface (GUI) with personalized feedback on their performance, including number of insertion attempts and where to improve if insertion was not successful [63]. The focus of training on the DHRT is achieving successful venipuncture by inserting the needle into the vein in one attempt without puncturing through the backwall of the vein. The DHRT aims to reduce the likelihood of mechanical complications that are often caused by human error and training deficits [41] such as puncturing the vein backwall [64] or puncturing the carotid artery [41, 51].

Appendix C: description of online training

The eight online video modules trained residents on: [1] introduction to CVC, [2] an overview of CVC steps as defined by the New England Journal of Medicine [3, 65] an overview of the benefits and risks of each access site for CVC, [4] best practices to use CVC equipment, [5] rapid central vein assessment with ultrasound, [6] mechanical procedures for troubleshooting, [7] complication types and how to identify them, and [8] monitoring the patient and removing the catheter. To pass the online training, residents needed to receive a post-training assessment score of 80% or higher, multiple attempts were allowed.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tzamaras, H., Sinz, E., Yang, M. et al. Competence over confidence: uncovering lower self-efficacy for women residents during central venous catheterization training. BMC Med Educ 24, 923 (2024). https://doi.org/10.1186/s12909-024-05747-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12909-024-05747-x

Keywords

BMC Medical Education

ISSN: 1472-6920

Contact us