Deliberate practice and acquisition of expert performance: a general overview

Monitoring communication with patients: analyzing judgments of satisfaction (JOS)

Medical students struggle to put into practice communication skills learned in medical school. In order to improve our instructional designs, better insight into the cause of this lack of transfer is foundational. We therefore explored students' cognitions by soliciting self-evaluations of their history-taking skills, coined 'judgments of satisfaction (JOSs)'. Our cognitive-psychological approach was guided by Koriat's cue-utilization framework (J Exp Psychol Gen 126:349-370. doi: 10.1037/0096-3445.126.4.349 , 1997) which rests on the assumption that internal and external cues inform learners' metacognitive judgments, which, in turn, steer their actions. Judgments based on unsuitable cues will cause ineffective behavior. Consequently, students are unable to adequately master these skills or properly apply them in similar situations. For the analysis, we had 524 medical undergraduates select scenes they were satisfied or dissatisfied with from their video-recorded simulated-patient encounters and explain why. Twenty transcripts were sampled for directed content analysis. We found that approximately one-third of students' judgments focused on content (JOS-type-a); about half on the quality of the communication skills (JOS-type-b); and about ten percent targeted the appropriateness of the skills harnessed (JOS-type-c). This lack of reflection on appropriateness may explain why students experience problems adapting to new situations. It was primarily high-performance students who formed type-c judgments; poor performers tended to give type-a and type-b judgments. Future research would benefit from the use of our modified version of Koriat's framework in order to further explore how high and poor performing medical students differ in the way they form JOSs during communications skills training.

Simulation Improves Procedural Protocol Adherence During Central Venous Catheter Placement: A Randomized Controlled Trial

BACKGROUND

Simulation training may improve proficiency at and reduce complications from central venous catheter (CVC) placement, but the scope of simulation's effect remains unclear. This randomized controlled trial evaluated the effects of a pragmatic CVC simulation program on procedural protocol adherence, technical skill, and patient outcomes.

METHODS

Internal medicine interns were randomized to standard training for CVC insertion or standard training plus simulation-based mastery training. Standard training involved a lecture, a video-based online module, and instruction by the supervising physician during actual CVC insertions. Intervention-group subjects additionally underwent supervised training on a venous access simulator until they demonstrated procedural competence. Raters evaluated interns' performance during internal jugular CVC placement on actual patients in the medical intensive care unit. Generalized estimating equations were used to account for outcome clustering within trainees.

RESULTS

We observed 52 interns placing 87 CVCs. Simulation-trained interns exhibited better adherence to prescribed procedural technique than interns who received only standard training (P = 0.024). There were no significant differences detected in first-attempt or overall cannulation success rates, mean needle passes, global assessment scores, or complication rates.

CONCLUSIONS

Simulation training added to standard training improved protocol adherence during CVC insertion by novice practitioners. This study may have been too small to detect meaningful differences in venous cannulation proficiency and other clinical outcomes, highlighting the difficulty of patient-centered simulation research in settings where poor outcomes are rare. For high-performing systems, where protocol deviations may provide an important proxy for rare procedural complications, simulation may improve CVC insertion quality and safety.

[Surgical simulation on the lateral skull base]

Critical neurovascular structures are confined in a small bony space at the lateral skull base. Thus, high quality of surgical training and planning of minimally invasive procedures is crucial. Simulation of lateral skull base procedures can improve motor skills, anatomical orientation, and complication management in a safe environment. Thus, simulation training can be beneficial for skull base surgeons. Minimally invasive interventions at the lateral skull base are under research, and several authors have presented approaches through single or multiple drilled ports. Precise planning and simulation of such interventions is essential because even submillimeter errors can lead to damage to critical anatomical structures. Therefore, high demands have been set for the accuracy of computer-assisted surgery.

The Future of Plastic Surgery Resident Education

The challenge of the current graduate medical education environment requires in plastic surgery acceptance of those contemporary pressures that cannot be substantially modified and address of those that can be successfully met. To do so implies an examination of conference didactics, intraoperative teaching, and a valid assessment of resident performance.

Deliberate Practice as a Theoretical Framework for Interprofessional Experiential Education

OBJECTIVE

The theory of deliberate practice has been applied to many skill-based performance activities. The primary aim of this project was to integrate synergistic principles from deliberate practice and consensus-derived competencies for interprofessional education into a framework upon which educational models to advance interprofessional experiential education (IEE) might be built.

METHODS

CINAHL, ERIC, and MEDLINE databases were searched using the keywords "deliberate practice" and "interprofessional education," both individually and in combination. Relevant articles were selected from the catalog based on support for the premise of the project. Defining characteristics of deliberate practice were distilled with particular emphasis on their application to the Interprofessional Education Collaborative's (IPEC) core competencies. Recommendations for IEE development were identified through the synthesis of deliberate practice principles and IPEC competencies.

RESULTS

There is a high degree of synergy between deliberate practice principles and IPEC competencies. Our synthesis of the literature yielded a cyclical four-step process to advance IEE: (1) implement an IEE plan guided by the student's strengths/weaknesses and in consideration of the collaborative practice skills they wish to develop, (2) engage in IPE experiences that will challenge targeted skills according to the IEE plan, (3) embed frequent opportunities for student reflection and preceptor/team feedback within IEE plan, and (4) revise the IEE plan and the IPE experience based on insights gained during step 3.

CONCLUSION

The cyclical four-step process synthesized through this literature review may be used to guide the development of new IEE models. The purposeful development of IEE models grounded in a theory that has already been operationalized in other skill-based performance areas is an important step to address expanding accreditation standards throughout the health professions mandating interprofessional education for pre-licensure health professional students.

The effect of peer-group size on the delivery of feedback in basic life support refresher training: a cluster randomized controlled trial

BACKGROUND

Students are largely providing feedback to one another when instructor facilitates peer feedback rather than teaching in group training. The number of students in a group affect the learning of students in the group training. We aimed to investigate whether a larger group size increases students' test scores on a post-training test with peer feedback facilitated by instructor after video-guided basic life support (BLS) refresher training. Students' one-rescuer adult BLS skills were assessed by a 2-min checklist-based test 1 year after the initial training.

METHODS

A cluster randomized controlled trial was conducted to evaluate the effect of student number in a group on BLS refresher training. Participants included 115 final-year medical students undergoing their emergency medicine clerkship. The median number of students was 8 in the large groups and 4 in the standard group. The primary outcome was to examine group differences in post-training test scores after video-guided BLS training. Secondary outcomes included the feedback time, number of feedback topics, and results of end-of-training evaluation questionnaires.

RESULTS

Scores on the post-training test increased over three consecutive tests with instructor-led peer feedback, but not differ between large and standard groups. The feedback time was longer and number of feedback topics generated by students were higher in standard groups compared to large groups on the first and second tests. The end-of-training questionnaire revealed that the students in large groups preferred the smaller group size compared to their actual group size.

CONCLUSIONS

In this BLS refresher training, the instructor-led group feedback increased the test score after tutorial video-guided BLS learning, irrespective of the group size. A smaller group size allowed more participations in peer feedback.

Social Workers as Workplace-Based Instructors of Alcohol and Drug Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Emergency Medicine Residents

PROBLEM

Residency education is challenged by a shortage of personnel and time, particularly for teaching behavioral interventions such as screening, brief intervention, and referral to treatment (SBIRT) to reduce hazardous drinking and drug use. However, social workers may be well placed to teach SBIRT in clinical training settings.

INTERVENTION

We describe a curriculum with social workers as SBIRT trainers of emergency medicine (EM) residents during actual clinical shifts in an EM residency training program. The curriculum required 1 EM faculty member working with social workers and 1 additional hour of formal residency conference teaching time.

CONTEXT

We implemented the curriculum at both a university tertiary care hospital emergency department and a county trauma center. We trained 8 social workers at both sites as SBIRT superusers to teach and assess EM resident SBIRT performance with actual patients. We measured the length and number of sessions to attain SBIRT competence, residents' satisfaction, and resident comments (coded by authors).

OUTCOME

Five of the 8 social workers trained residents between June 2013 and May 2014, 31 EM residents trained to a level indicating SBIRT competence with 114 patients. Each patient interaction averaged 8.8 minutes and residents averaged 3.13 patients. Twenty-four (77%) residents gave ratings of 1.58 (SD = .58) for the quality of teaching, 2.33 (SD = .87) for recommending the training to a colleague, 1.38 (SD = .49) for superusers' knowledge, 1.88 (SD = .95) for usefulness of instruction, 1.54 (SD = .72) for workplace learning, and 1.58 (SD = .78) for valuing learning from social workers (on a scale of 1 [very satisfied/strongly agree] to 5 [very dissatisfied/strongly disagree]). Residents preferred learning SBIRT during the 1st and 2nd training years and in the workplace.

LESSONS LEARNED

Social work colleagues can be effective in teaching SBIRT to residents in the workplace, and our residents highly valued learning from social workers, who all had prior training in motivational interviewing. In the implementation of this curriculum, the clinical demands of residents must be taken into account when teaching occurs, and having multiple social worker instructors was instrumental.

Physical Therapy Residency and Fellowship Education: Reflections on the Past, Present, and Future

The physical therapy profession continues to respond to the complex and changing landscape of health care to meet the needs of patients and the demands of patient care. Consistent with this evolution is the rapid development and expansion of residency and fellowship postprofessional programs. With the interested number of applicants exceeding the number of residency and fellowship slots available, a "critical period" in the educational process is emerging. The purposes of this perspective article are: (1) to analyze the state of residency and fellowship education within the profession, (2) to identify best practice elements from other health professions that are applicable to physical therapy residency and fellowship education, and (3) to propose a working framework grounded in common domains of competence to be used as a platform for dialogue, consistency, and quality across all residency and fellowship programs. Seven domains of competence are proposed to theoretically ground residency and fellowship programs and facilitate a more consistent approach to curricular development and assessment. Although the recent proliferation of residency and fellowship programs attempts to meet the demand of physical therapists seeking advanced educational opportunities, it is imperative that these programs are consistently delivering high-quality education with a common focus on delivering health care in the context of societal needs.

Advances in Pediatric Surgical Education: A Critical Appraisal of Two Consecutive Minimally Invasive Pediatric Surgery Training Courses

BACKGROUND

Mandates for improved patient safety and increasing work hour restrictions have resulted in changes in surgical education. Educational courses increasingly must meet those needs. We sought to determine the experience, skill level, and the impact of simulation-based education (SBE) on two cohorts of pediatric surgery trainees.

MATERIALS AND METHODS

After Institutional Review Board (IRB) exempt determination, a retrospective review was performed of evaluations for an annual advanced minimally invasive surgery (MIS) course over 2 consecutive years. The courses included didactic content and hands-on skills training. Simulation included neonatal/infant models for rigid bronchoscopy-airway foreign body retrieval, laparoscopic common bile duct exploration, and real tissue diaphragmatic hernia (DH), duodenal atresia (DA), pulmonary lobectomy, and tracheoesophageal fistula models. Categorical data were analyzed with chi-squared analyses with t-tests for continuous data.

RESULTS

Participants had limited prior advanced neonatal MIS experience, with 1.95 ± 2.84 and 1.16 ± 1.54 prior cases in the 2014 and 2015 cohorts, respectively. The 2015 cohort had significantly less previous experience in lobectomy (P = .04) and overall advanced MIS (P = .007). Before both courses, a significant percentage of participants were not comfortable with DH repair (39%-42%), DA repair (50%-74%), lobectomy (34%-43%), and tracheoesophageal fistula repair (54%-81%). After course completion, > 60% of participants reported improvement in comfort with procedures and over 90% reported that the course significantly improved their perceived ability to perform each operation safely.

CONCLUSION

Pediatric surgery trainees continue to have limited exposure to advanced MIS during clinical training. SBE results in significant improvement in both cognitive knowledge and trainee comfort with safe operative techniques for advanced MIS.

Communication Skills Training in Pediatric Oncology: Moving Beyond Role Modeling

Communication is central to pediatric oncology care. Pediatric oncologists disclose life-threatening diagnoses, explain complicated treatment options, and endeavor to give honest prognoses, to maintain hope, to describe treatment complications, and to support families in difficult circumstances ranging from loss of function and fertility to treatment-related or disease-related death. However, parents, patients, and providers report substantial communication deficits. Poor communication outcomes may stem, in part, from insufficient communication skills training, overreliance on role modeling, and failure to utilize best practices. This review summarizes evidence for existing methods to enhance communication skills and calls for revitalizing communication skills training within pediatric oncology.

Simulation education as a single intervention does not improve hand hygiene practices: A randomized controlled follow-up study

BACKGROUND

To evaluate how critical nurses' knowledge of and adherence to current care hand hygiene (HH) guidelines differ between randomly allocated intervention and control groups before and after simulation education in both a simulation setting and clinical practice during a 2-year follow-up period. It was hypothesized that intervention group knowledge of and adherence to current HH guidelines might increase compared with a control group after simulation education.

METHODS

A prospective, parallel, randomized controlled trial with repeated measurements was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Oulu, Finland. Thirty out of 40 initially randomized critical care nurses participated in the baseline measurements; of these, 17 completed all the study procedures. Participants' HH adherence was observed only in high-risk contact situations prior to and postendotracheal suctioning events using a direct, nonparticipatory method of observation. Participants' HH knowledge was evaluated at the end of each observational session.

RESULTS

The overall HH adherence increased from a baseline value of 40.8% to 50.8% in the final postintervention measurement at 24 months (P = .002). However, the linear mixed model did not identify any significant group (P = .77) or time-group interactions (P = .17) between the study groups after 2 years of simulation education. In addition, simulation education had no impact on participants' HH knowledge.

CONCLUSIONS

After a single simulation education session, critical care nurses' knowledge of and adherence to current HH guidelines remained below targeted behavior rates.

Ten Tips for Maximizing the Effectiveness of Emergency Medicine Procedure Laboratories

Incorporating simulation-based medical education techniques is paramount to ongoing training of emergency physicians. Effective procedure laboratories give learners hands-on experience in life-saving procedures they may otherwise not have clinical exposure to and also prevent skill decay. Using procedural education, adult learning theory, deliberate practice, and mastery learning strategies, the authors offer 10 tips to educators for designing an effective emergency medicine procedure laboratory.

Learning curve patterns generated by a training method for laparoscopic small bowel anastomosis

Background

The identification of developmental curve patterns generated by a simulation-based educational method and the variables that can accelerate the learning process will result in cost-effective training. This study describes the learning curves of a simulation-based instructional design (ID) that uses ex vivo animal models to teach laparoscopic latero-lateral small bowel anastomosis.

Methods

Twenty general surgery residents were evaluated on their performance of laparoscopic latero-lateral jejuno-jejunal anastomoses (JJA) and gastro-jejunal anastomoses (GJA), using swine small bowel and stomach on an endotrainer. The ID included the following steps: (1) provision of references and videos demonstrating the surgical technique, (2) creation of an engaging context for learning, (3) critical review of the literature and video on the procedures, (4) demonstration of the critical steps, (5) hands-on practice, (6) in-action instructor’s feedback, (7) quality assessment, (8) debriefing at the end of the session, and (9) deliberate and repetitive practice. Time was recorded from the beginning to the completion of the procedure, along with the presence or absence of anastomotic leaks.

Results

The participants needed to perform 23.8 ± 6.96 GJA (12–35) and 24.2 ± 6.96 JJA (9–43) to attain proficiency. The starting point of the learning curve was higher for the GJA than for the JJA, although the slope and plateau were parallel. Further, four types of learning curves were identified: (1) exponential, (2) rapid, (3) slow, and (4) no tendency. The type of pattern could be predicted after procedure number 8.

Conclusions

These findings may help to identify the learning curve of a trainee early in the developmental process, estimate the number of sessions required to reach a performance goal, determine a trainee’s readiness to practice the procedure on patients, and identify the subjects who lack the innate technical abilities. It may help motivated individuals to become reflective and self-regulated learners. Moreover, the standardization of the ID may help to measure the effectiveness of learning strategies and make comparisons with other educational strategies.

What factors influence ward nurses' recognition of and response to patient deterioration? An integrative review of the literature

Aim

In this integrative review, we aimed to: first, identify and summarize published studies relating to ward nurses' recognition of and response to patient deterioration; second, to critically evaluate studies that described or appraised the practice of ward nurses in recognizing and responding to patient deterioration; and third, identify gaps in the literature for further research.

Design

An integrative review.

Methods

The Cumulative Index to Nursing and Allied Health Literature (CINAHL) Ovid Medline, Informit and Google Scholar databases were accessed for the years 1990–2014. Data were extracted and summarized in tables and then appraised using the Mixed Method Appraisal Tool. Data were grouped into two domains; recognizing and responding to deterioration and then thematic analysis was used to identify the emerging themes.

Results

Seventeen studies were reviewed and appraised. Recognizing patient deterioration was encapsulated in four themes: (1) assessing the patient; (2) knowing the patient; (3) education and (4) environmental factors. Responding to patient deterioration was encapsulated in three themes; (1) non‐technical skills; (2) access to support and (3) negative emotional responses.

Conclusion

Issues involved in timely recognition of and response to clinical deterioration remain complex, yet patient safety relies on nurses’ timely assessments and actions.

Assessing clinical reasoning in optometry using the script concordance test

BACKGROUND

Clinical reasoning is central to any health profession but its development among learners is difficult to assess. Over the last few decades, the script concordance test (SCT) has been developed to solve this dilemma and has been used in many health professions; however, no study has been published on the use of the script concordance test in optometry. The purpose of this study was to develop and validate a script concordance test for the field of optometry.

METHODS

A 101-question script concordance test (27 short clinical scenarios) was developed and administered online to a convenience sample of 23 second-year and 19 fourth-year students of optometry. It was also administered to a reference panel of 12 experienced optometrists to develop the scoring key. An item-total correlation was calculated for each question. Cronbach's alpha coefficient was used to evaluate the script concordance test reliability and a t-test compared the two groups.

RESULTS

A final 77-question script concordance test was created by eliminating questions with low item-total correlation. Cronbach's alpha for this optimised 77-question script concordance test was 0.80. A group comparison revealed that the second-year students' scores (n = 23; mean score = 66.4 ± 7.87 per cent) were statistically lower (t = -4.141; p < 0.001) than those of the fourth-year students (n = 19; mean score = 75.5 ± 5.97 per cent).

CONCLUSION

The online script concordance test developed for this study was found to be both reliable and capable of discriminating between second- and fourth-year optometric students. These results demonstrate that the script concordance test may be considered as a new tool in the optometric educators' assessment arsenal. Further studies will be needed to cover additional levels of professional development.

Airway Management: A Structured Curriculum for Critical Care Transport Providers

OBJECTIVE

Airway assessment and management are vital skills for the critical care transport provider. Nurses and paramedics often enter a transport program with limited or no exposure to airway management. Many programs lack a structured curriculum to show skill competence. Optimal methods in the development of airway management competence and the frequency of training needed to maintain skills have not been clearly defined. Because of this lack of standardization, the actual level of competence in both new and experienced critical care transport providers is unknown.

METHODS

A pretest, post-test repeated measures approach using an online curriculum combined with a deliberate practice model was used. Competence in airway management was measured using 3 evaluation points: static mannequin head, simulation scenario, and the live patient.

RESULTS

A convenience sample of critical care transport providers participated (N = 9). Knowledge improvement was significant, with a higher percentage of participants scoring above 85% on the post-test compared with the pretest (P = .028). Mean scores in completion of the airway checklist pre- versus postintervention were significantly increased on all 3 evaluation points (P < .001 for all comparisons). Significant changes were noted in the response profile evaluating participants' confidence in their ability to verbalize indications for endotracheal intubation (P < .05).

CONCLUSION

The development of a standardized, blended learning curriculum combined with deliberate simulation practice and rigorous assessment showed improvements in multiple areas of airway assessment and management.

Voxel-based morphometry in opera singers: Increased gray-matter volume in right somatosensory and auditory cortices

In contrast to instrumental musicians, professional singers do not train on a specific instrument but perfect a motor system that has already been extensively trained during speech motor development. Previous functional imaging studies suggest that experience with singing is associated with enhanced somatosensory-based vocal motor control. However, experience-dependent structural plasticity in vocal musicians has rarely been studied. We investigated voxel-based morphometry (VBM) in 27 professional classical singers and compared gray matter volume in regions of the "singing-network" to an age-matched group of 28 healthy volunteers with no special singing experience. We found right hemispheric volume increases in professional singers in ventral primary somatosensory cortex (larynx S1) and adjacent rostral supramarginal gyrus (BA40), as well as in secondary somatosensory (S2) and primary auditory cortices (A1). Moreover, we found that earlier commencement with vocal training correlated with increased gray-matter volume in S1. However, in contrast to studies with instrumental musicians, this correlation only emerged in singers who began their formal training after the age of 14years, when speech motor development has reached its first plateau. Structural data thus confirm and extend previous functional reports suggesting a pivotal role of somatosensation in vocal motor control with increased experience in singing. Results furthermore indicate a sensitive period for developing additional vocal skills after speech motor coordination has matured.

Development and Evaluation of a Three-Dimensional Multistation Cardiovascular Simulator

BACKGROUND

To facilitate deliberate practice, we developed and evaluated a three-dimensional multistation cardiovascular simulator with low-fidelity, anatomically correct materials.

METHODS

Surgical educators and senior fellows at several national institutions who are a part of the Thoracic Education Cooperative Group completed expert validation surveys that feature a self-report rating scale, ranging from 0 (don't know) to 4 (highly realistic, no changes needed), and a global recommendation rating scale, ranging from 0 to 3. To analyze the survey results, we used paired Student t tests and a many-facet Rasch model.

RESULTS

We analyzed the results of 18 expert validation surveys (completed by 9 senior fellows and by 9 staff surgeons). The overall realism-of-experience rating for the simulator was 3.23 (of 4), suggesting adequate realism with room remaining for improvement. Senior fellows rated the aortic graft replacement station and overall physical attributes more favorably than staff. Staff surgeons favored the simulator for realism of the mitral valve annuloplasty station and the cannulation station and for its use as a training tool. The overall global recommendation rating for the simulator was 2.38 (of 3), suggesting that the simulator can be considered for use in cardiovascular surgery training programs with minor improvements.

CONCLUSIONS

This three-dimensional multistation cardiovascular simulator has adequate realism and can be considered for use in cardiovascular training programs. Platforms such as this may facilitate deliberate home practice and reinforcement of technical skills.

Identifying educator behaviours for high quality verbal feedback in health professions education: literature review and expert refinement

BACKGROUND

Health professions education is characterised by work-based learning and relies on effective verbal feedback. However the literature reports problems in feedback practice, including lack of both learner engagement and explicit strategies for improving performance. It is not clear what constitutes high quality, learner-centred feedback or how educators can promote it. We hoped to enhance feedback in clinical practice by distinguishing the elements of an educator's role in feedback considered to influence learner outcomes, then develop descriptions of observable educator behaviours that exemplify them.

METHODS

An extensive literature review was conducted to identify i) information substantiating specific components of an educator's role in feedback asserted to have an important influence on learner outcomes and ii) verbal feedback instruments in health professions education, that may describe important educator activities in effective feedback. This information was used to construct a list of elements thought to be important in effective feedback. Based on these elements, descriptions of observable educator behaviours that represent effective feedback were developed and refined during three rounds of a Delphi process and a face-to-face meeting with experts across the health professions and education.

RESULTS

The review identified more than 170 relevant articles (involving health professions, education, psychology and business literature) and ten verbal feedback instruments in health professions education (plus modified versions). Eighteen distinct elements of an educator's role in effective feedback were delineated. Twenty five descriptions of educator behaviours that align with the elements were ratified by the expert panel.

CONCLUSIONS

This research clarifies the distinct elements of an educator's role in feedback considered to enhance learner outcomes. The corresponding set of observable educator behaviours aim to describe how an educator could engage, motivate and enable a learner to improve. This creates the foundation for developing a method to systematically evaluate the impact of verbal feedback on learner performance.

Assessing faculty professional development in STEM higher education: Sustainability of outcomes

We tested the effectiveness of Faculty Institutes for Reforming Science Teaching IV (FIRST), a professional development program for postdoctoral scholars, by conducting a study of program alumni. Faculty professional development programs are critical components of efforts to improve teaching and learning in the STEM (Science, Technology, Engineering, and Mathematics) disciplines, but reliable evidence of the sustained impacts of these programs is lacking. We used a paired design in which we matched a FIRST alumnus employed in a tenure-track position with a non-FIRST faculty member at the same institution. The members of a pair taught courses that were of similar size and level. To determine whether teaching practices of FIRST participants were more learner-centered than those of non-FIRST faculty, we compared faculty perceptions of their teaching strategies, perceptions of environmental factors that influence teaching, and actual teaching practice. Non-FIRST and FIRST faculty reported similar perceptions of their teaching strategies and teaching environment. FIRST faculty reported using active learning and interactive engagement in lecture sessions more frequently compared with non-FIRST faculty. Ratings from external reviewers also documented that FIRST faculty taught class sessions that were learner-centered, contrasting with the teacher-centered class sessions of most non-FIRST faculty. Despite marked differences in teaching practice, FIRST and non-FIRST participants used assessments that targeted lower-level cognitive skills. Our study demonstrated the effectiveness of the FIRST program and the empirical utility of comparison groups, where groups are well matched and controlled for contextual variables (for example, departments), for evaluating the effectiveness of professional development for subsequent teaching practices.

Understanding deliberate practice in preschool-aged children

Deliberate practice is essential for skill acquisition and expertise and may be a direct consequence of episodic foresight. However, little is known about how deliberate practice develops in children. We present two experiments testing children's ability to selectively practise a behaviour that was going to be useful in future and to reason about the role of practice in skill formation. Five-year-olds demonstrated an explicit understanding of deliberate practice both in selectively choosing to practise a future-relevant skill and in predicting skill change in others based on their practice. Four-year-olds showed some capacities, but failed to demonstrate consistent understanding of the relationship between practice and skill improvement. Children's understanding of this relationship was significantly related to their understanding of how information leads to knowledge, suggesting that both may draw on similar cognitive developmental changes.

Considering cognition. Current challenges and future directions in pulmonary and critical care fellowship training

Fellowship training in pulmonary and critical care has evolved substantially over the past decade. Training programs are increasingly focused on a rigorous, multifaceted assessment of an individual trainee's progress toward achieving specific curricular milestones, and their ability to independently manage a series of entrustable professional activities. This new system has provided programs with an enormous amount of detailed information related to the specific goals and outcomes of training. However, it has not addressed the unmet need for fellowship programs to systematically assess and teach advanced clinical reasoning and judgment. Training programs must address these cognitive processes in a proactive and supportive way, and are challenged to develop novel approaches that encourage continuous self-evaluation. Only by addressing these critical deficiencies will programs enable trainees to progress beyond a level of clinical competence to one of true expertise. These efforts will also encourage physicians at all levels of training to embrace their commitment to lifelong learning.

Trauma Boot Camp: A Simulation-Based Pilot Study

Introduction: Interns are often unprepared to effectively communicate in the acute trauma setting. Despite the many strengths of the Advanced Trauma Life Support (ATLS) program, the main shortcoming within the course is the deficiency of teamwork and leadership training. In this study, we describe the creation of an interdisciplinary boot camp in which interns' basic trauma knowledge, level of confidence, and teamwork skills are assessed.

Methods: We designed a one-day, boot camp curriculum for interns of various specialties with the purpose of improving communication and teamwork skills for effective management of acute trauma patients. Our curriculum consisted of a one-day, twelve-hour experience, which included trauma patient simulations, content expert lectures, group discussion of video demonstrations, and skill development workstations. Baseline and acquired knowledge were assessed through the use of confidence surveys, cognitive questionnaires, and a validated evaluation tool of teamwork and leadership skills for trauma

Results: Fifteen interns entered the boot camp with an overall confidence score of 3.2 (1-5 scale) in the management of trauma cases. At the culmination of the study, there was a significant increase in the overall confidence level of interns in role delegation, leadership, Crisis Resource Management (CRM) principles, and in the performance of primary and secondary surveys. No significant changes were seen in determining and effectively using the Glasgow Coma Scale, Orthopedic splinting/reduction skills, and effective use of closed-loop communication.

Conclusion: An intensive one-day trauma boot camp demonstrated significant improvement in self-reported confidence of CRM concepts, role delegation, leadership, and performance of primary and secondary surveys. Despite the intensive curriculum, there was no significant improvement in overall teamwork and leadership performance during simulated cases. Our boot camp curriculum offers educators a unique framework to which they can apply to their own training program as a foundation for effective leadership and teamwork training for interns.

Integration of high-resolution data for temporal bone surgical simulations

PURPOSE

To report on the state of the art in obtaining high-resolution 3D data of the microanatomy of the temporal bone and to process that data for integration into a surgical simulator. Specifically, we report on our experience in this area and discuss the issues involved to further the field.

DATA SOURCES

Current temporal bone image acquisition and image processing established in the literature as well as in house methodological development.

REVIEW METHODS

We reviewed the current English literature for the techniques used in computer-based temporal bone simulation systems to obtain and process anatomical data for use within the simulation. Search terms included "temporal bone simulation, surgical simulation, temporal bone." Articles were chosen and reviewed that directly addressed data acquisition and processing/segmentation and enhancement with emphasis given to computer-based systems. We present the results from this review in relationship to our approach.

CONCLUSIONS

High-resolution CT imaging ([Formula: see text] voxel resolution), along with unique image processing and rendering algorithms, and structure-specific enhancement are needed for high-level training and assessment using temporal bone surgical simulators. Higher-resolution clinical scanning and automated processes that run in efficient time frames are needed before these systems can routinely support pre-surgical planning. Additionally, protocols such as that provided in this manuscript need to be disseminated to increase the number and variety of virtual temporal bones available for training and performance assessment.

Improving patient-centered communication: Results of a randomized controlled trial

OBJECTIVE

Patient-centered communication is a key element for improving the quality of care in terms of therapeutic relationship, patient participation, and treatment process. Postgraduate trainings provide an essential way of promoting patient centeredness on the job where learning opportunities are often limited by time, patient volume, and economic pressure. In the present study, changes in patient centeredness during clinical routines of postgraduate physicians (internal medicine) after a three-day communication training were assessed.

METHODS

A randomized controlled trial was conducted in a primary care clinic. The intervention consisted of a communication training that aimed to enhance patient centeredness in postgraduate physicians. The training was based on a need assessment and the principles of deliberate practice. Workplace-based assessment of physicians' communication behavior was obtained using the Roter Interaction Analysis System.

RESULTS

Three months after the intervention, trained physicians showed significantly increased patient centeredness (F=5.36, p=.04; d=0.42).

CONCLUSION

The communication training significantly improved patient centeredness during routine clinical practice. Thus, this training provides a structured and theory-based concept to foster patient centeredness.

PRACTICE IMPLICATIONS

The results support the implementation of communication trainings as a part of faculty development and medical specialization training.

Development of a PROficiency-Based StePwise Endovascular Curricular Training (PROSPECT) Program

OBJECTIVES

Focus on patient safety, work-hour limitations, and cost-effective education is putting pressure to improve curricula to acquire minimally invasive techniques during surgical training. This study aimed to design a structured training program for endovascular skills and validate its assessment methods.

DESIGN

A PROficiency-based StePwise Endovascular Curricular Training (PROSPECT) program was developed, consisting of e-learning and hands-on simulation modules, focusing on iliac and superficial femoral artery atherosclerotic disease. Construct validity was investigated. Performances were assessed using multiple-choice questionnaires, valid simulation parameters, global rating scorings, and examiner checklists. Feasibility was assessed by passage of 2 final-year medical students through this PROSPECT program.

SETTING

Ghent University Hospital, a tertiary clinical care and academic center in Belgium with general surgery residency program.

PARTICIPANTS

Senior-year medical students were recruited at Ghent University Hospital. Vascular surgeons were invited to participate during conferences and meetings if they had performed at least 100 endovascular procedures as the primary operator during the last 2 years.

RESULTS

Overall, 29 medical students and 20 vascular surgeons participated. Vascular surgeons obtained higher multiple-choice questionnaire scores (median: 24.5-22.0 vs. 15.0-12.0; p < 0.001). Students took significantly longer to treat any iliac or femoral artery stenosis (3.3-14.8 vs. 5.8-30.1min; p = 0.001-0.04), whereas in more complex cases, fluoroscopy time was significantly higher in students (8.3 vs. 21.3min; p = 0.002; 7.3 vs. 13.1min; p = 0.03). In all cases, vascular surgeons scored higher on global rating scorings (51.0-42.0 vs. 29.5-18.0; p < 0.001) and examiner checklist (81.5-75.0 vs. 54.5-43.0; p < 0.001). Hence, proficiency levels based on median expert scores could be determined. There were 2 students who completed the program and passed for each step within a 3-month period during their internships.

CONCLUSIONS

A feasible and construct validated surgical program to train cognitive, technical, and nontechnical endovascular skills was developed. A structured, stepwise, proficiency-based valid endovascular program to train cognitive, technical, and human factor skills has been developed and proven to be feasible. A randomized controlled trial has been initiated to investigate its effect on performances in real life, patient outcomes, and cost-effectiveness.

A Disease-Specific Hybrid Rotation Increases Opportunities for Deliberate Practice

IMPORTANCE

Incorporating deliberate practice (DP) into residency curricula may optimize education. DP includes educationally protected time, continuous expert feedback, and a focus on a limited number of technical skills. It is strongly associated with mastery level learning.

OBJECTIVE

Determine if a multidisciplinary breast rotation (MDB) increases DP opportunities.

DESIGN

Beginning in 2010, interns completed the 4-week MDB. Three days a week were spent in surgery and surgical clinic. Half-days were in breast radiology, pathology, medical oncology, and didactics. The MDB was retrospectively compared with a traditional community rotation (TCR) and a university surgical oncology service (USOS) using rotation feedback and resident operative volume. Data are presented as mean ± standard deviation.

SETTING

Oregon Health and Science University in Portland, Oregon; an academic tertiary care general surgery residency program.

PARTICIPANTS

General surgery residents at Oregon Health and Science University participating in either the MDB, TCR or USOS.

RESULTS

A total of 31 interns rated the opportunity to perform procedures significantly higher for MDB than TCR or USOS (4.6 ± 0.6 vs 4.2 ± 0.9 and 4.1 ± 1.0, p < 0.05). MDB was rated higher than TCR on quality of faculty teaching and educational materials (4.5 ± 0.7 vs 4.1 ± 0.9 and 4.0 ± 1.2 vs 3.5 ± 1.0, p < 0.05). Interns operated more on the MDB than on the USOS and were more focused on breast resections, lymph node dissections, and port placements than on the traditional surgical rotation or USOS.

CONCLUSIONS

The MDB incorporates multidisciplinary care into a unique, disease-specific, and educationally focused rotation. It is highly rated and affords a greater opportunity for DP than either the USOS or TCR. DP is strongly associated with mastery learning and this novel rotation structure could maximize intern education in the era of limited work hours.

Exploring Mechanisms for Effective Technology-Enhanced Simulation-based Education in Wilderness Medicine: A Systematic Review

BACKGROUND

 Technology-enhanced simulation is well-established in healthcare teaching curricula, including those regarding wilderness medicine. Compellingly, the evidence base for the value of this educational modality to improve learner competencies and patient outcomes are increasing.

AIMS

 The aim was to systematically review the characteristics of technology-enhanced simulation presented in the wilderness medicine literature to date. Then, the secondary aim was to explore how this technology has been used and if the use of this technology has been associated with improved learner or patient outcomes.

METHODS

 EMBASE and MEDLINE were systematically searched from 1946 to 2014, for articles on the provision of technology-enhanced simulation to teach wilderness medicine. Working independently, the team evaluated the information on the criteria of learners, setting, instructional design, content, and outcomes.

RESULTS

 From a pool of 37 articles, 11 publications were eligible for systematic review. The majority of learners in the included publications were medical students, settings included both indoors and outdoors, and the main focus clinical content was initial trauma management with some including leadership skills. The most prevalent instructional design components were clinical variation and cognitive interactivity, with learner satisfaction as the main outcome.

CONCLUSIONS

 The results confirm that the current provision of wilderness medicine utilizing technology-enhanced simulation is aligned with instructional design characteristics that have been used to achieve effective learning. Future research should aim to demonstrate the translation of learning into the clinical field to produce improved learner outcomes and create improved patient outcomes.

Evidence for Enhanced Interoceptive Accuracy in Professional Musicians

Interoception is defined as the perceptual activity involved in the processing of internal bodily signals. While the ability of internal perception is considered a relatively stable trait, recent data suggest that learning to integrate multisensory information can modulate it. Making music is a uniquely rich multisensory experience that has shown to alter motor, sensory, and multimodal representations in the brain of musicians. We hypothesize that musical training also heightens interoceptive accuracy comparable to other perceptual modalities. Thirteen professional singers, twelve string players, and thirteen matched non-musicians were examined using a well-established heartbeat discrimination paradigm complemented by self-reported dispositional traits. Results revealed that both groups of musicians displayed higher interoceptive accuracy than non-musicians, whereas no differences were found between singers and string-players. Regression analyses showed that accumulated musical practice explained about 49% variation in heartbeat perception accuracy in singers but not in string-players. Psychometric data yielded a number of psychologically plausible inter-correlations in musicians related to performance anxiety. However, dispositional traits were not a confounding factor on heartbeat discrimination accuracy. Together, these data provide first evidence indicating that professional musicians show enhanced interoceptive accuracy compared to non-musicians. We argue that musical training largely accounted for this effect.

High level of patient satisfaction and comfort during diagnostic urological procedures performed by urologists and residents

OBJECTIVE

The aim of this study was to investigate how patients experience diagnostic urological procedures performed by urologists, junior residents and senior residents, and to assess the influence of procedure-related factors on patient experiences.

METHODS

Data were collected during 222 procedures: 84 transrectal ultrasound-guided prostate biopsies (TRUSP; urologists n = 39, residents n = 45) and 138 urethrocystoscopies (UCS; urologists n = 44, residents n = 94) in six hospitals. Patient experiences were assessed using a questionnaire focusing on pain, comfort and satisfaction (visual analogue scale, 0-10) and communication aspects on a four-point Likert scale. Clinical observations were made to identify influencing factors.

RESULTS

Median values for patient experiences across procedures were 10 (range 5-10) for patient satisfaction, 2 (0-9) for pain and 8 (0-10) for comfort. Generalized estimating equations revealed no significant differences between urologists, senior residents and junior residents in terms of experienced patient comfort, satisfaction or pain. Procedural time was longer for residents, but this did not correlate significantly with patient-experienced comfort (p = 0.3). In UCS, patient comfort and satisfaction were higher in the supine position for male and female patients, respectively (p < 0.01). In TRUSP, local anaesthesia resulted in a significant decrease in pain (p = 0.002) and an increase in comfort (p = 0.03). Finally, older patients experienced less pain and gave higher comfort and satisfaction responses than younger patients.

CONCLUSIONS

Patients expressed high levels of satisfaction and comfort during diagnostic urological procedures. Experiences were not affected by the level of training, suggesting highly developed interpersonal and communication skills for residents in an early stage of residency training. Patients demonstrated significant preferences for local anaesthesia in TRUSP and performance of UCS in the supine position over the lithotomy position.

The Perfect Preceptor

Every plastic surgeon can become a better teacher. One of the keys to improvement is to have a thoughtfully considered plan of what to teach and how to teach it. This article describes what any surgeon can do before, during, and after a rotation to create an excellent learning environment for a medical student, resident, or fellow. Before the rotation, the preceptor should collaborate with the program director to develop the goals and objectives. The defined content is then distributed by week so that each objective is consciously addressed. During the rotation, the resident and preceptor identify the critical clinical and surgical experiences germane to the week's topic and focus on those patients. After the rotation, giving and getting meaningful feedback is much easier as the assessment scope and tool is derived from the curriculum that the preceptor helped develop.

Educational Game Development Approach to a particular case: the donor's evaluation

BACKGROUND

Serious games are a current trend nowadays. Almost every sector has used serious games in recent years for different educational purposes. The eLearning research team of the Complutense University of Madrid main focus of research is the development of low-cost serious games. During the past 10 years, we have been working with and developing serious games, paying special attention to those related to healthcare.

METHODS

From all these studies, a methodology was defined-the Educational Game Development Approach (EGDA)-to design, develop, and evaluate game-like simulations or serious games in healthcare. We present the application of the EGDA to a particular case, the development of a serious game representing the donor's evaluation in an intensive care unit from the point of view of a hospital coordinator following the EGDA methodology. In this simulation, we changed the strategy of selection of teaching cases by exponentially increasing the number of teaching cases.

RESULTS

This kind of educational content provides several benefits to students as they learn while playing; they receive immediate feedback of mistakes and correct moves and an objective assessment. These simulations allow the students to practice in a risk-free environment. Moreover, the addition of game elements increases engagement and promotes the retention of important information.

CONCLUSIONS

A game-like simulation has been developed through the use of this methodology. This simulation represents a complex medical procedure.

Beyond the simulation laboratory: a realist synthesis review of clinical outcomes of simulation-based mastery learning

PURPOSE

Translational educational outcomes have been defined as starting in simulation laboratories (T1) and moving downstream to improved patient care practices (T2), patient outcomes (T3), and cost/other value outcomes (T4). The authors conducted a realist synthesis review of the literature to evaluate the translational effect of simulation-based mastery learning (SBML) principles beyond the laboratory. They also sought to address future directions in SBML to improve patient care processes and outcomes and, thus, the quality of health care delivery.

METHOD

The authors searched multiple databases for simulation-based medical education (SBME) studies published through April 2013. They screened articles using the PICO method-population (P), intervention (I), control (C), outcome (O)-to answer the research question: For (P) any health care providers, does the (I) implementation of SBML training, compared with (C) other training methodologies or no extra training, result in (O) a change in patient care practices or T2-T4 outcomes? Studies implementing SBME interventions with training methodologies that met all SBML principles and reporting T2-T4 outcomes were identified.

RESULTS

The 14 included studies used pre/post or cohort study designs; the majority were limited to individual performance and procedural competency. They reported improvement after SBML training in procedure performance, task success, patient discomfort, procedure time, complication rates, or T4 impacts (e.g., cost reduction).

CONCLUSIONS

Findings suggest health professions education conducted using SBML methodology can improve patient care processes and outcomes. Further research is needed to understand the translational impact of SBML for nontechnical skills, including teamwork, and skill retention.

Use of a formal assessment instrument for evaluation of resident operative skills in pediatric neurosurgery

OBJECT Currently there is no standardized tool for assessment of neurosurgical resident performance in the operating room. In light of enhanced requirements issued by the Accreditation Council for Graduate Medical Education's Milestone Project and the Matrix Curriculum Project from the Society of Neurological Surgeons, the implementation of such a tool seems essential for objective evaluation of resident competence. Beyond compliance with governing body guidelines, objective assessment tools may be useful to direct early intervention for trainees performing below the level of their peers so that they may be given more hands-on teaching, while strong residents can be encouraged by faculty members to progress to conducting operations more independently with passive supervision. The aims of this study were to implement a validated assessment tool for evaluation of operative skills in pediatric neurosurgery and determine its feasibility and reliability. METHODS All neurosurgery residents completing their pediatric rotation over a 6-month period from January 1, 2014, to June 30, 2014, at the authors' institution were enrolled in this study. For each procedure, residents were evaluated by means of a form, with one copy being completed by the resident and a separate copy being completed by the attending surgeon. The evaluation form was based on the validated Objective Structured Assessment of Technical Skills for Surgery (OSATS) and used a 5-point Likert-type scale with 7 categories: respect for tissue; time and motion; instrument handling; knowledge of instruments; flow of operation; use of assistants; and knowledge of specific procedure. Data were then stratified by faculty versus resident (self-) assessment; postgraduate year level; and difficulty of procedure. Descriptive statistics (means and SDs) were calculated, and the results were compared using the Wilcoxon signed-rank test and Student t-test. A p value < 0.05 was considered statistically significant. RESULTS Six faculty members, 1 fellow, and 8 residents completed evaluations for 299 procedures, including 32 ventriculoperitoneal (VP) shunt revisions, 23 VP shunt placements, 19 endoscopic third ventriculostomies, and 18 craniotomies for tumor resection. There was no significant difference between faculty and resident self-assessment scores overall or in any of the 7 domains scores for each of the involved residents. On self-assessment, senior residents scored themselves significantly higher (p < 0.02) than junior residents overall and in all domains except for "time and motion." Faculty members scored senior residents significantly higher than junior residents only for the "knowledge of instruments" domain (p = 0.05). When procedure difficulty was considered, senior residents' scores from faculty members were significantly higher (p = 0.04) than the scores given to junior residents for expert procedures only. Senior residents' self-evaluation scores were significantly higher than those of junior residents for both expert (p = 0.03) and novice (p = 0.006) procedures. CONCLUSIONS OSATS is a feasible and reliable assessment tool for the comprehensive evaluation of neurosurgery resident performance in the operating room. The authors plan to use this tool to assess resident operative skill development and to improve direct resident feedback.

Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice

As a part of a special collection in this issue of Academic Medicine, which is focused on mastery learning in medical education, this Perspective describes how the expert-performance approach with deliberate practice is consistent with many characteristics of mastery learning. Importantly, this Perspective also explains how the expert-performance approach provides a very different perspective on the acquisition of skill. Whereas traditional education with mastery learning focuses on having students attain an adequate level of performance that is based on goals set by the existing curricula, the expert-performance approach takes an empirical approach and first identifies the final goal of training-namely, reproducibly superior objective performance (superior patient outcomes) for individuals in particular medical specialties. Analyzing this superior complex performance reveals three types of mental representations that permit expert performers to plan, execute, and monitor their own performance. By reviewing research on medical performance and education, the author describes evidence for these representations and their development within the expert-performance framework. He uses the research to generate suggestions for improved training of medical students and professionals. Two strategies-designing learning environments with libraries of cases and creating opportunities for individualized teacher-guided training-should enable motivated individuals to acquire a full set of refined mental representations. Providing the right resources to support the expert-performance approach will allow such individuals to become self-regulated learners-that is, members of the medical community who have the tools to improve their own and their team members' performances throughout their entire professional careers.

An Examination of the Efficacy of a Multitiered Intervention on Early Reading Outcomes for First Grade Students at Risk for Reading Difficulties

This article presents findings of an efficacy trial examining the effect of a multitiered instruction and intervention model on first grade at-risk students' reading outcomes. Schools (N = 16) were randomly assigned to the treatment or control condition. In the fall of Grade 1, students were assigned to an instructional tier on the basis of Stanford Achievement Test-10th Edition scores (31st percentile and above = Tier 1; from the 10th to the 30th percentile = Tier 2). In both conditions, students identified as at risk (i.e., Tier 2; n = 267) received 90 min of whole group instruction (Tier 1) and an additional 30 min of daily small group intervention (Tier 2). In the treatment condition, teachers were trained to enhance core reading instruction by making instruction more explicit and increasing practice opportunities for students in Tier 1. In addition, at-risk readers were provided an additional 30-min daily small group intervention with content that was highly aligned with the Tier 1 core reading program. Results indicate significant, positive effects of the intervention on students' decoding and first semester fluent reading and potentially positive effects on reading comprehension and total reading achievement.

Structuring feedback and debriefing to achieve mastery learning goals

Mastery learning is a powerful educational strategy in which learners gain knowledge and skills that are rigorously measured against predetermined mastery standards with different learners needing variable time to reach uniform outcomes. Central to mastery learning are repetitive deliberate practice and robust feedback that promote performance improvement. Traditional health care simulation involves a simulation exercise followed by a facilitated postevent debriefing in which learners discuss what went well and what they should do differently next time, usually without additional opportunities to apply the specific new knowledge. Mastery learning approaches enable learners to "try again" until they master the skill in question. Despite the growing body of health care simulation literature documenting the efficacy of mastery learning models, to date insufficient details have been reported on how to design and implement the feedback and debriefing components of deliberate-practice-based educational interventions. Using simulation-based training for adult and pediatric advanced life support as case studies, this article focuses on how to prepare learners for feedback and debriefing by establishing a supportive yet challenging learning environment; how to implement educational interventions that maximize opportunities for deliberate practice with feedback and reflection during debriefing; describing the role of within-event debriefing or "microdebriefing" (i.e., during a pause in the simulation scenario or during ongoing case management without interruption), as a strategy to promote performance improvement; and highlighting directions for future research in feedback and debriefing for mastery learning.

Coaching Non-technical Skills Improves Surgical Residents' Performance in a Simulated Operating Room

OBJECTIVE

To investigate the effect of coaching on non-technical skills and performance during laparoscopic cholecystectomy in a simulated operating room (OR).

BACKGROUND

Non-technical skills (situation awareness, decision making, teamwork, and leadership) underpin technical ability and are critical to the success of operations and the safety of patients in the OR. The rate of developing assessment tools in this area has outpaced development of workable interventions to improve non-technical skills in surgical training and beyond.

METHOD

A randomized trial was conducted with senior surgical residents (n = 16). Participants were randomized to receive either non-technical skills coaching (intervention) or to self-reflect (control) after each of 5 simulated operations. Coaching was based on the Non-Technical Skills For Surgeons (NOTSS) behavior observation system. Surgeon-coaches trained in this method coached participants in the intervention group for 10 minutes after each simulation. Primary outcome measure was non-technical skills, assessed from video by a surgeon using the NOTSS system. Secondary outcomes were time to call for help during bleeding, operative time, and path length of laparoscopic instruments.

RESULTS

Non-technical skills improved in the intervention group from scenario 1 to scenario 5 compared with those in the control group (p = 0.04). The intervention group was faster to call for help when faced with unstoppable bleeding in the final scenario (no. 5; p = 0.03).

CONCLUSIONS

Coaching improved residents' non-technical skills in the simulated OR compared with those in the control group. Important next steps are to implement non-technical skills coaching in the real OR and assess effect on clinically important process measures and patient outcomes.