Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains

Pediatric in-hospital emergencies: real life experiences, previous training and the need for training among physicians and nurses

Objective

Pediatric emergencies challenge professional teams by demanding substantial cognitive effort, skills and effective teamwork. Educational designs for team trainings must be aligned to the needs of participants in order to increase effectiveness. To assess these needs, a survey among physicians and nurses of a tertiary pediatric center in Germany was conducted, focusing on previous experience, previous training in emergency care, and individual training needs.

Results

Fifty-three physicians and 75 nurses participated. Most frequently experienced emergencies were respiratory failure, resuscitation, seizure, shock/sepsis and arrhythmia. Resuscitations were perceived as being particularly precarious. Team collaboration and communication were major issues arising from previous emergency situations, but perceptions differed between physicians and nurses. Regarding previous training, physicians were accustomed to self-directed learning, whereas nurses usually attended practical courses. Both physicians and nurses rated themselves as having moderate levels of knowledge and skills for pediatric emergencies, though residents reported the significantly lowest preparedness. Both professions reported a high need for training of basic procedures and emergency algorithms, physicians even more than nurses.

Conceptual Framework of Mentoring in Low- and Middle-Income Countries to Advance Global Health

Although mentoring is not a common practice in low- and middle-income countries (LMICs), there is a strong need for it. Conceptual frameworks provide the structure to design, study, and problem-solve complex phenomena. Following four workshops in South America, Asia, and Africa, and borrowing on theoretical models from higher education, this article proposes two conceptual frameworks of mentoring in LMICs. In the first model, we propose to focus the mentor-mentee relationship and interactions, and in the second, we look at mentoring activities from a mentees' perspective. Our models emphasize the importance of an ongoing dynamic between the mentor and mentee that is mutually beneficial. It also emphasizes the need for institutions to create enabling environments that encourage mentorship. We expect that these frameworks will help LMIC institutions to design new mentoring programs, clarify expectations, and analyze problems with existing mentoring programs. Our models, while being framed in the context of global health, have the potential for wider application geographically and across disciplines.

Evaluation of Perceived Technical Skill Development by Students During Instruction in Dental Extractions in Different Laboratory Settings-A Pilot Study

In veterinary general practice, dental extractions are common procedures that require a specific set of surgical skills. Veterinary medical educators are tasked with preparing students for general practice, equipping them with medical knowledge and surgical skills. Results of this pilot study demonstrate students' preference for circle-based laboratory setup, a perceived high value of immediate feedback when performing laboratory exercises, and a lack of preference for timing of the laboratory relative to the relevant material provided in lecture. The impact of lecture, supplemental information, and laboratory setup on development of these surgical skills are explored.

Cadaver Models in Residency Training for Uncommonly Encountered Ultrasound-Guided Procedures

BACKGROUND

Arthrocentesis of the ankle and elbow and brachial plexus nerve blocks are infrequently performed procedures; however, clinicians in specialties such as emergency medicine are required to be proficient in these procedures in the event of emergent or urgent necessity.

OBJECTIVES

The objective of this study was to create, implement, and assess a fresh cadaver-based educational model to help resident physicians learn how to perform ultrasound-guided arthrocentesis of the ankle and elbow and ultrasound-guided regional nerve blocks.

METHODS

This was a single-center cross-sectional study conducted at an academic medical center. After a brief didactic session, 26 emergency medicine residents with varying levels of clinical and ultrasound experience rotated through 4 fresh cadaver-based stations. The objective of each station was to understand the sonographic anatomy and to perform ultrasound-guided arthrocentesis or regional nerve block with hands-on feedback from ultrasound fellows and faculty. Participants were subsequently asked to complete a questionnaire which evaluated participants' experience level, opinions, and procedural confidence regarding the 4 stations.

RESULTS

A total of 26 residents participated in this study. All 26 residents agreed that the cadaver model (compared with clinical anatomy) was realistic regarding ultrasound quality of the joint space, ultrasound quality of the joint effusion, ultrasound quality of nerves, tissue density, needle guidance, and artifacts. Finally, there was a statistically significant difference between mean scores for pre-simulation and post-simulation session participant procedural confidence for all 4 procedures.

CONCLUSIONS

This fresh cadaver-based ultrasound-guided educational model was an engaging and well-received opportunity for residents to gain proficiency and statistically significant confidence in procedures which are uncommonly performed in clinical settings.

Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study

INTRODUCTION

Resident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR).

METHODS

We conducted a literature search on SBR practices using the terms "simulation," "remediation," and "simulation based remediation." We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM.

RESULTS

Faculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved.

CONCLUSION

Simulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

Training to Proficiency in the WHO Hand Hygiene Technique

OBJECTIVES

Hand hygiene is critical to patient safety, but low performance in terms of the quantity and quality of hand hygiene is often reported. Training-to-proficiency is common for other clinical skills, but no proficiency-based training program for hand hygiene has been reported in the literature. This study developed a proficiency-based training program to improve hand hygiene quality in line with World Health Organization (WHO) guidelines and assessed the amount of training required to reach proficiency. The training was delivered as part of a 5-day induction for students on the Physician Assistant online program.

METHODS

A total of 42 students used a simulator to objectively measure hand hygiene technique over a 5-day period. Proficiency was achieved when students demonstrated all 6 steps of the WHO technique in less than 42 seconds. The students also completed a postintervention questionnaire.

RESULTS

The average training episode lasted 2.5 minutes and consisted of 4.5 hand hygiene exercises. The average student completed 5 training episodes (1 per day) taking a total of 17 minutes. A total of 40% (17) of the students achieved proficiency within the 5 days. Proficiency was strongly correlated with the number of training exercises completed (r = 0.79, P < .001) and the total time spent training (r = 0.75, P < .001). Linear regression predicted that the 32 hand hygiene exercises or a total of 23-minute training were required to achieve proficiency.

CONCLUSIONS

This is the first study to develop a train-to-proficiency program for hand hygiene quality and estimate the amount of training required. Given the importance of hand hygiene quality to preventing health care-associated infections (HAIs), medical education programs should consider using proficiency-based training in hand hygiene technique.

A Randomized Trial Comparing Freely Moving and Zonal Instruction of Veterinary Surgical Skills Using Ovariohysterectomy Models

Timely, specific feedback is the most important feature of simulation-based training, but providing adequate instructor supervision is challenging. Students' (n = 76) surgical skills were assessed after training using either the traditional (T) method of large-group teaching by multiple instructors or the alternative method of one instructor assigned (A) to a defined group of students. Instructors rotated to a different group of students for each laboratory session. The instructor-to-student ratio and environment remained identical. No differences were found in raw assessment scores or the number of students requiring remediation, suggesting that students learned in this environment whether they received feedback from one instructor or multiple. Students had no preference between the methods, though 88% of the instructors preferred the assigned method, because they perceived an increased ability to teach and observe individual students. There was no difference in the number of students identified as at-risk of remediation between groups. When both groups were considered together, students identified as at-risk were more likely (40% vs. 10%) to require post-assessment remediation. However, only 22% of students requiring remediation had been identified as at-risk, and A-group instructors were more accurate than T-group instructors at identifying at-risk students. These results suggest that students accept either instructional method, but most instructors prefer to be assigned to a small group of students. Surgical skills were learned similarly well by students in both groups, although assigned instructors were more accurate at identifying at-risk students, which could prove beneficial if early intervention measures can be offered.

How Educational Theory Can Inform the Training and Practice of Plastic Surgeons

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger’s theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky’s theory); (3) skill acquisition and retention (Dreyfus’ and Dreyfus’, and Fitts’ and Posner’s theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson’s theory); and (5) the assessment of competence (Miller’s triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons.

Biomechanical profiles of tracheal intubation: a mannequin-based study to make an objective assessment of clinical skills by expert anesthesiologists and novice residents

BACKGROUND

Tracheal intubation (TI) is a key medical skill used by anesthesiologists and critical care physicians in airway management in operating rooms and critical care units. An objective assessment of dexterity in TI procedures would greatly enhance the quality of medical training. This study aims to investigate whether any biomechanical parameters obtained by 3D-motion analysis of body movements during TI procedures can objectively distinguish expert anesthesiologists from novice residents.

METHODS

Thirteen expert anesthesiologists and thirteen residents attempted TI procedures on an airway mannequin using a Macintosh laryngoscope. Motion capturing technology was utilized to digitally record movements during TI procedures. The skill with which experts and novices measured biomechanical parameters of body motions were comparatively examined.

RESULTS

The two groups showed similar outcomes (success rates and mean time needed to complete the TI procedures) as well as similar mean absolute velocity values in all 21 body parts examined. However, the experts exhibited significantly lower mean absolute acceleration values at the head and the left hand than the residents. In addition, the mean-absolute-jerk measurement revealed that the experts commanded potentially smoother motions at the head and the left hand. The Receiver Operating Characteristic (ROC) curves analysis demonstrated that mean-absolute-acceleration and -jerk measurements provide excellent measures for discriminating between experts and novices.

CONCLUSIONS

Biomechanical parameter measurements could be used as a means to objectively assess dexterity in TI procedures. Compared with novice residents, expert anesthesiologists possess a better ability to control their body movements during TI procedures, displaying smoother motions at the selected body parts.

LAP-VEGaS Practice Guidelines for Reporting of Educational Videos in Laparoscopic Surgery: A Joint Trainers and Trainees Consensus Statement

OBJECTIVE

Consensus statement by an international multispecialty trainers and trainees expert committee on guidelines for reporting of educational videos in laparoscopic surgery.

SUMMARY OF BACKGROUND DATA

Instructive laparoscopy videos with appropriate exposition could be ideal for initial training in laparoscopic surgery, but there are no guidelines for video annotation or procedural educational and safety evaluation.

METHODS

Delphi questionnaire of 45 statements prepared by a steering group and voted on over 2 rounds by committee members using an electronic survey tool. Committee selection design included representative surgical training experts worldwide across different laparoscopic specialties, including general surgery, lower and upper gastrointestinal surgery, gynecology and urology, and a proportion of aligned surgical trainees.

RESULTS

All 33 committee members completed both the first and the second round of the Delphi questionnaire related to 7 major domains: Video Introduction/Authors' information; Patient Details; Procedure Description; Procedure Outcome; Associated Educational Content; Peer Review; and Use in Educational Curriculae. The 17 statements that did not reach at least 80% agreement after the first round were revised and returned into the second round. The committee consensus approved 37 statements to at least an 82% agreement.

CONCLUSION

Consensus guidelines on how to report laparoscopic surgery videos for educational purposes have been developed. We anticipate that following our guidelines could help to improve video quality.These reporting guidelines may be useful as a standard for reviewing videos submitted for publication or conference presentation.

Arthroscopic simulation using a knee model can be used to train speed and gaze strategies in knee arthroscopy

PURPOSE

This study aimed to determine the effect of a simulation course on gaze fixation strategies of participants performing arthroscopy.

METHODS

Participants (n = 16) were recruited from two one-day simulation-based knee arthroscopy courses, and were asked to undergo a task before and after the course, which involved identifying a series of arthroscopic landmarks. The gaze fixation of the participants was recorded with a wearable eye-tracking system. The time taken to complete the task and proportion of time participants spent with their gaze fixated on the arthroscopic stack, the knee model, and away from the stack or knee model were recorded.

RESULTS

Participants demonstrated a statistically decreased completion time in their second attempt compared to the first attempt (P = 0.001). In their second attempt, they also demonstrated improved gaze fixation strategies, with a significantly increased amount (P = 0.008) and proportion of time (P = 0.003) spent fixated on the screen vs. knee model.

CONCLUSION

Simulation improved arthroscopic skills in orthopaedic surgeons, specifically by improving their gaze control strategies and decreasing the amount of time taken to identify and mark landmarks in an arthroscopic task.

Attributes of evidence-based occupational therapists in stroke rehabilitation

BACKGROUND.

A better understanding of the features characterizing expert evidence-based occupational therapists in stroke rehabilitation is needed to inform the design of educational and knowledge translation interventions aimed at addressing research-practice gaps.

PURPOSE.

The study aimed to identify the attributes of evidence-based occupational therapy stroke rehabilitation experts from the perspective of their peers.

METHOD.

Forty-six occupational therapy clinicians and managers completed an online questionnaire asking them to nominate "outstanding" and "expert evidence-based" occupational therapists in stroke rehabilitation and to explain their choices. A thematic analysis of respondents' statements was conducted.

FINDINGS.

Both outstanding and expert evidence-based occupational therapists were perceived to be motivated self-learners; to have extensive knowledge, skills, and experience; to act as scholarly practitioners; to achieve superior client outcomes; and to work in specialized settings.

IMPLICATIONS.

The development of future strategies supporting occupational therapy students and clinicians to become lifelong learners should take into account key attributes of expertise, such as motivation for continuous learning and professional development.

Using Critical Care Simulations to Prepare Nursing Students for Capstone Clinical Experiences

The purpose of this innovative learning strategy was to decrease students' fear and anxiety within the critical care environment before the initiation of a critical care capstone clinical experience by enhancing their familiarity of the critical care environment through deliberate practice and experiential learning. This will in turn increase student knowledge and competence in the critical care setting.Critical care units are often used during a capstone clinical experience to enhance critical thinking and clinical reasoning. Student preparation for these rotations, however, is varied and often inadequate. The resulting fear and anxiety impair learning and also contribute to an unsafe environment for this at-risk population.Before the capstone experience, students participated in 3 simulation experiences, each addressing a core concept of critical care nursing. Faculty engaged students during the simulations, while modeling the confidence and critical thinking of a critical care nurse.After both the critical care simulation and the capstone rotation, students stated that the simulation allowed them the time in a safe environment to critically think through the steps to care for critical patients before the capstone rotation. The experience provided them with increased confidence necessary to discharge the responsibilities of a critical care nurse-attention to critical thinking and reasoning.Mindfully constructed simulations with clear objectives help to inoculate the student against fears associated with high-risk patients. This decrease in fear and anxiety before a hands-on clinical experience may improve patient safety. More confident students are also better able to engage in both experiential and deliberate learning, resulting in a more enhanced and meaningful clinical experience.

Flipped Classroom Use in Veterinary Education: A Multinational Survey of Faculty Experiences

Active teaching approaches such as the flipped classroom are linked to better quality student learning outcomes across health care disciplines, with the potential to support students' preparedness for practice. In the flipped classroom instructional approach, students engage in significant pre-class preparation to learn foundational knowledge and skills, then undertake instructional activities in the classroom that require them to integrate, apply and extend their learning to new contexts. This study reports the results of a multinational survey of flipped classroom use in veterinary education. Participants' ( n = 165) familiarity with and extent of use of the flipped classroom technique were investigated, together with the teaching strategies used and the perceived benefits and barriers to implementation. Relationships between respondent characteristics and flipped classroom use were also explored. The results indicated that 95% of participants were familiar with the flipped classroom technique, although fewer (64%) used it in their teaching. Pre-class activities included reviewing online and printed material, and engaging in preparatory learning activities such as quizzes, case analyses, reflective assignments and group activities. A variety of active learning strategies were used in class, including discussions, presentations, quizzes, group activities, problem solving and laboratory/practical exercises. Most participants perceived that the flipped classroom technique benefited student learning, with some also identifying benefits for the faculty involved. A range of student-, faculty- and institution-related barriers to implementing the flipped classroom technique were identified. These barriers need to be considered and addressed by teachers and administrators seeking to improve students' preparedness for practice by implementing flipped classrooms in veterinary education.

Remote Mentoring of Point-of-Care Ultrasound Skills to Inexperienced Operators Using Multiple Telemedicine Platforms: Is a Cell Phone Good Enough?

OBJECTIVES

Telemedicine technology contributes to the teaching of point-of-care ultrasound (US); however, expensive equipment can limit its deployment in resource-challenged settings. We assessed 3 low-cost telemedicine solutions capable of supporting remote US training to determine feasibility, acceptability, and effectiveness. We also explored the value of instructional videos immediately before telementoring.

METHODS

Thirty-six participants were randomly assigned to receive US mentoring in 1 of 3 telemedicine conditions: multiple fixed cameras, a smartphone, and traditional audio with a live US stream. Participants were then asked to perform a standardized US examination of the right upper quadrant under remote guidance. We measured observer's global ratings of performance along with the mentor's and student's rating of effort and satisfaction to determine which of the 3 approaches was most feasible, acceptable, and effective. During the second phase, students were randomized to watch an instructional video or not before receiving remote coaching on how to complete a subxiphoid cardiac examination. Effort, satisfaction, and performance from the independent observer's and student's perspective were surveyed.

RESULTS

There was no significant difference between the different telemedicine setups from the observer's perspective; however, the mentor rated the smartphone significantly worse (P = .028-.04) than other technologies. Platforms were rated equivalent from the student's perspective. No benefit was detected for watching an instructional video before the mentored task.

CONCLUSIONS

Remote US skills can be taught equally effectively by using a variety of telemedicine technologies. Smartphones represent a viable option for US training in resource-challenged settings.

Neonatal resuscitation experience curves: simulation based mastery learning booster sessions and skill decay patterns among pediatric residents

Background Following neonatal resuscitation program (NRP) training, decay in clinical skills can occur. Simulation-based deliberate practice (SBDP) has been shown to maintain NRP skills to a variable extent. Our study objectives were (a) to determine whether a single 30 min simulation-based intervention that incorporates SBDP and mastery learning (ML) can effectively restore skills and prevent skill decay and (b) to compare different timing options. Methods Following NRP certification, pediatric residents were randomly assigned to receive a video-recorded baseline assessment plus SBDP-ML refresher education at between 6 and 9 months (early) or between 9 and 12 months (late). One year following initial certification, participants had repeat skill retention videotaped evaluations. Participants were scored by blinded NRP instructors using validated criteria scoring tools and assigned a global performance rating score (GRS). Results Twenty-seven participants were included. Residents in both early and late groups showed significant skill decay 7 and 10 months after initial NRP. SBDP-ML booster sessions significantly improved participants' immediate NRP performance scores (p<0.001), which persisted for 2 months, but were again lower 4 months later. Conclusions NRP skills may be boosted to mastery levels after a short SBDP-ML intervention and do not appear to significantly decline after 2 months. Brief booster training could potentially serve as a useful supplement to traditional NRP training for pediatric residents.

Using virtual-reality simulation to ensure basic competence in hysteroscopy

BACKGROUND

Hysteroscopy is a technically challenging procedure. Specialty curricula of obstetrics and gynaecology appraise hysteroscopy for trainees but there is no present evidence-based training program that certifies the fundamental technical skills before performance on patients. The objectives of this study were to develop and gather validity evidence for a simulation-based test that can ensure basic competence in hysteroscopy.

METHODS

We used the virtual-reality simulator HystMentor™. Six experts evaluated the feasibility and clinical relevance of the simulator modules. Six modules were selected for the test and a pilot study was carried out. Subsequently, medical students, residents, and experienced gynaecologists were enrolled for testing. Outcomes were based on generated simulator metrics. Validity evidence was explored for all five sources of evidence (content, response process, internal structure, relations to other variables, consequences of testing).

RESULTS

Inter-case reliability was high for four out of five metrics (Cronbach's alpha ≥ 0.80). Significant differences were identified when comparing the three groups' performances (p values < 0.05). Participants' clinical experience was significantly correlated to their simulator test score (Pearson's r = 0.49, p < 0.001). A single medical student managed to achieve the established pass/fail score (6.7% false positive) and three experienced gynaecologists failed the test (27.3% false negative).

CONCLUSIONS

We developed a virtual-reality simulation-based test in hysteroscopy with supporting validity evidence. The test is intended to ensure competency in a mastery learning program where trainees practise on the simulator until they are able to pass before they proceed to supervised training on patients.

The role of the individual in the coming era of process-based therapy

For decades the development of evidence-based therapy has been based on experimental tests of protocols designed to impact psychiatric syndromes. As this paradigm weakens, a more process-based therapy approach is rising in its place, focused on how to best target and change core biopsychosocial processes in specific situations for given goals with given clients. This is an inherently more idiographic question than has normally been at issue in evidence-based therapy over the last few decades. In this article we explore methods of assessment and analysis that can integrate idiographic and nomothetic approaches in a process-based era.

Serious game versus online course for pretraining medical students before a simulation-based mastery learning course on cardiopulmonary resuscitation: A randomised controlled study

BACKGROUND

Although both recorded lectures and serious games have been used to pretrain health professionals before simulation training on cardiopulmonary resuscitation, they have never been compared.

OBJECTIVE

The aim of this study was to compare an online course and a serious game for pretraining medical students before simulation-based mastery learning on the management of sudden cardiac arrest.

DESIGN

A randomised controlled trial. Participants were pretrained using the online course or the serious game on day 1 and day 7. On day 8, each participant was evaluated repeatedly on a scenario of cardiac arrest until reaching a minimum passing score.

SETTING

Department of Simulation in Healthcare in a French medical faculty.

PARTICIPANTS

Eighty-two volunteer second-year medical students participated between June and October 2016 and 79 were assessed for primary outcome.

INTERVENTIONS

The serious game used was Staying Alive, which involved a 3D realistic environment, and the online course involved a PowerPoint lecture.

MAIN OUTCOME MEASURES

The median total training time needed for students to reach the minimum passing score on day 8. This same outcome was also assessed 4 months later.

RESULTS

The median training time (interquartile range) necessary for students to reach the minimum passing score was similar between the two groups: 20.5 (15.8 to 30.3) minutes in the serious game group versus 23 (15 to 32) minutes in the online course group, P = 0.51. Achieving an appropriate degree of chest compression was the most difficult requirement to fulfil for students in both groups. Four months later, the median training time decreased significantly in both groups, but no correlation was found at an individual level with the training times observed on day 8.

CONCLUSION

The serious game used in this study was not superior to an online course to pretrain medical students in the management of a cardiac arrest. The absence of any correlation between the performances of students evaluated during two training sessions separated by 4 months suggests that some elements in the management of cardiac arrest such as compression depth can only be partially learned and retained after a simulation-based training.

TRIAL REGISTRATION

ClinicalTrials.gov-NCT02758119.

Effect of Different Instructional Methods on Contamination and Personal Protective Equipment Protocol Adherence among Veterinary Students

Proper use of personal protective equipment (PPE) is crucial to prevent disease spread. Recent studies in human medicine have shown disconcerting inconsistencies in the use of PPE in hospital wards. In this study, we compared the effect of three instructional methods for PPE use on contamination and protocol adherence among veterinary students. Students were divided into three groups according to the instructional method to which they had access (instructional video, wall chart, or both). They underwent an isolation exercise consisting of donning, patient examination (mock patient prepared with contamination marker), and doffing. Student contamination after the exercise was evaluated using UV light. Videos of student performance were reviewed for errors committed. Results showed that the number of students with contamination was higher in the group who only had access to video instruction than in the two other groups. The number of students with contamination on forearms, hands, and wrists was higher in the group who only had access to charts. Disinfecting gloves between doffing steps was the most frequently omitted step. The number of students who touched the environment with unprotected areas of their bodies was higher in the group who only had access to video instruction than in the other two groups. In conclusion, video instruction was less effective in achieving PPE protocol adherence among veterinary students than was instruction with a chart or chart-video combination. Incorporating video instruction as part of the instructions may be valuable to reinforce individual steps of donning and doffing.

Subjective awareness of ultrasound expertise development: individual experience as a determinant of overconfidence

Medical decision-making requires years of experience in order to develop an adequate level of competence to successfully engage in safe practice. While diagnostic and technical skills are essential, an awareness of the extent and limits of our own knowledge and skills is critical. The present study examines clinicians' subjective awareness in a diagnostic cardiac ultrasound task. Clinicians answered diagnostic and treatment related questions for a range of pathologies. Following these questions, clinicians indicated their level of confidence in their response. A comparison of response accuracy and confidence revealed that clinicians were generally overconfident in their responses. Critically, we observed that a clinician's overconfidence was negatively correlated with prior experience: clinicians that had more prior experience expressed less overconfidence in their performance such that some clinicians were in fact underconfident. We discuss the implications for training in medical education and decision-making.

Exploring the sources and mechanisms of cognitive errors in medical diagnosis with associative memory models

BACKGROUND

One of the central challenges of third millennium medicine is the abatement of medical errors. Among the most frequent and hardiest causes of misdiagnosis are cognitive errors produced by faulty medical reasoning. These errors have been analyzed from the perspectives of cognitive psychology and empirical medical studies. We introduce a neurocognitive model of medical diagnosis to address this issue.

METHODS

We construct a connectionist model based on the associative nature of human memory to explore the non-analytical, pattern-recognition mode of diagnosis. A context-dependent matrix memory associates signs and symptoms with their corresponding diseases. The weights of these associations depend on the frequencies of occurrence of each disease and on the different combinations of signs and symptoms of each presentation of that disease. The system receives signs and symptoms and by a second input, the degree of diagnostic uncertainty. Its output is a probabilistic map on the set of possible diseases.

RESULTS

The model reproduces different kinds of well-known cognitive errors in diagnosis. Errors in the model come from two sources. One, dependent on the knowledge stored in memory, varies with the accumulated experience of the physician and explains age-dependent errors and effects such as epidemiological masking. The other is independent of experience and explains contextual effects such as anchoring.

CONCLUSIONS

Our results strongly suggest that cognitive biases are inevitable consequences of associative storage and recall. We found that this model provides valuable insight into the mechanisms of cognitive error and we hope it will prove useful in medical education.

Current status of simulation training in plastic surgery residency programs: A review

Increased emphasis on competency-based learning modules and widespread departure from traditional models of Halstedian apprenticeship have made surgical simulation an increasingly appealing component of medical education. Surgical simulators are available in numerous modalities, including virtual, synthetic, animal, and non-living models. The ideal surgical simulator would facilitate the acquisition and refinement of surgical skills prior to clinical application, by mimicking the size, color, texture, recoil, and environment of the operating room. Simulation training has proven helpful for advancing specific surgical skills and techniques, aiding in early and late resident learning curves. In this review, the current applications and potential benefits of incorporating simulation-based surgical training into residency curriculum are explored in depth, specifically in the context of plastic surgery. Despite the prevalence of simulation-based training models, there is a paucity of research on integration into resident programs. Current curriculums emphasize the ability to identify anatomical landmarks and procedural steps through virtual simulation. Although transfer of these skills to the operating room is promising, careful attention must be paid to mastery versus memorization. In the authors’ opinions, curriculums should involve step-wise employment of diverse models in different stages of training to assess milestones. To date, the simulation of tactile experience that is reminiscent of real-time clinical scenarios remains challenging, and a sophisticated model has yet to be established.

The Implementation Gap in Laparoscopic Simulation Training

BACKGROUND AND AIMS

Simulation-based training in laparoscopy can improve patient safety and efficiency of care, but it depends on how it is used. Research in medical education has moved from demonstrating transferability of simulation training to the operating room to how to best implement it. This study aims to investigate how simulation-based training in laparoscopy has been implemented Scandinavia.

MATERIAL AND METHODS

An online survey was sent out to medical doctors at surgical, gynecological, and urological departments at 138 hospitals in Denmark, Norway, and Sweden. The questionnaire included questions on respondents' baseline characteristics, opinions, access, and actual use of simulation-based training in laparoscopy.

RESULTS

In total, 738 respondents completed the survey. Of these, 636 (86.2%) of respondents agreed or strongly agreed that simulation-based training in laparoscopy should be mandatory. A total of 602 (81.6%) had access to simulation-based training in laparoscopy. Of the total 738 respondents, 141 (19.1%) were offered structured training courses, 129 (17.5%) were required to reach a predefined level of competency, and 66 (8.9%) had mandatory courses in laparoscopy. In all, 72 (9.8%) had never used simulation-based training in laparoscopy.

CONCLUSION

An implementation gap in laparoscopic simulation-based training still exists in Scandinavia. Simulation equipment is generally available, but there is a lack of structured simulation-based training.

Training of clinical reasoning with a Serious Game versus small-group problem-based learning: A prospective study

INTRODUCTION

Serious Games are increasingly being used in undergraduate medical education. They are usually intended to enhance learning with a focus on knowledge acquisition and skills development. According to the current literature, few studies have assessed their effectiveness regarding clinical reasoning (CR). The aim of this prospective study was to compare a Serious Game, the virtual Accident & Emergency department 'EMERGE' to small-group problem-based learning (PBL) regarding student learning outcome on clinical reasoning in the short term.

METHODS

A total of 112 final-year medical students self-selected to participate in ten 90-minute sessions of either small-group PBL or playing EMERGE. CR was assessed in a formative examination consisting of six key feature cases and a final 45-minute EMERGE session.

RESULTS

Overall, the EMERGE group (n = 78) scored significantly higher than the PBL group (n = 34) in the key feature examination (62.5 (IQR: 17.7)% vs. 54.2 (IQR: 21.9)%; p = 0.015). There was no significant difference in performance levels between groups regarding those cases which had been discussed in both instructional formats during the training phase. In the final EMERGE session, the EMERGE group achieved significantly better results than the PBL group in all four cases regarding the total score as well as in three of four cases regarding the final diagnosis and the correct therapeutic interventions.

CONCLUSION

EMERGE can be used effectively for CR training in undergraduate medical education. The difference in key feature exam scores was driven by additional exposure to more cases in EMERGE compared to PBL despite identical learning time in both instructional formats. EMERGE is a potential alternative to intensive small-group teaching. Further work is needed to establish how Serious Games enhance CR most effectively.

Preoperative goal setting and perioperative communication in an academic training institution: Where do we stand?

BACKGROUND

We collected data regarding specific aspects of perioperative surgical education within our institution's Section of Surgical Sciences as a needs assessment.

METHODS

Categorical general surgery residents and attending surgeons were queried regarding their perceptions of resident preoperative planning and perioperative communication.

RESULTS

The overall response rate was 81%, with 35 resident and 54 faculty respondents. Residents reported selecting an operative learning objective a median of 50% (IQR 36-67) of the time, whereas attending surgeons perceived this to be the case a median of 26% (IQR 15-35) of the time (P < 0.001). The group reported median frequencies of 20% (IQR 9-31) for preoperative discussion of learning objectives, 12% (IQR 4-27) for preoperative discussion of competence and 27% (IQR 17-55) for postoperative debriefing.

CONCLUSIONS

This study demonstrates deficits in resident goal setting and perioperative communication within our program, which are targets for future intervention. We share these results as a potential tool for other programs.

Encouraging residents' professional development and career planning: the role of a development-oriented performance assessment

BACKGROUND

Current postgraduate medical training programmes fall short regarding residents' development of generic competencies (communication, collaboration, leadership, professionalism) and reflective and deliberate practice. Paying attention to these non-technical skills in a structural manner during postgraduate training could result in a workforce better prepared for practice. A development-oriented performance assessment (PA), which assists residents with assessment of performance and deliberately planned learning activities, could potentially contribute to filling this gap. This study aims to explore residents experiences with the PA.

METHODS

We conducted a qualitative interview study with 16 residents from four different medical specialties who participated in the PA, scheduled halfway postgraduate training. The PA was conducted by an external facilitator, a psychologist, and focused specifically on professional development and career planning. Residents were interviewed 6 months after the PA. Data were analysed using the framework method for qualitative analysis.

RESULTS

Residents found the PA to be of additional value for their training. The overarching merit was the opportunity to evaluate competencies not usually addressed in workplace-based assessments and progress conversations. In addition, the PA proved a valuable tool for assisting residents with reflecting upon their work and formulating their learning objectives and activities. Residents reported increased awareness of capacity, self-confidence and enhanced feelings of career-ownership. An important factor contributing to these outcomes was the relationship of trust with the facilitator and programme director.

CONCLUSION

The PA is a promising tool in fostering the development of generic competencies and reflective and deliberate practice. The participating residents, facilitator and programme directors were able to contribute to a safe learning environment away from the busy workplace. The facilitator plays an important role by providing credible and informative feedback. Commitment of the programme director is important for the implementation of developmental plans and learning activities.

The Effectiveness of Bioskills Training for Simulated Lumbar Pedicle Screw Placement

STUDY DESIGN

Prospective randomized study.

OBJECTIVES

To define the impact of an inexpensive, user-friendly, and reproducible lumbar pedicle screw instrumentation bioskills training module and evaluation protocol.

METHODS

Participants were randomized to control (n = 9) or intervention (n = 10) groups controlling for level of experience (medical students, junior resident, or senior resident). The intervention group underwent a 20-minute bioskills training module while the control group spent the same time with self-directed study. Pre- and posttest performance was self-reported (Physician Performance Diagnostic Inventory Scale [PPDIS]). Objective outcome scores were obtained from a blinded fellowship-trained attending orthopedic spine surgeon using Objective Structured Assessment of Technical Skills (OSATS) and Objective Pedicle Instrumentation Score metrics. In addition, identification of pedicle breach and breach anatomic location was measured pre- and posttest in lumbar spine models.

RESULTS

The intervention group showed a 30.8% improvement in PPDIS scores, compared with 13.4% for the control group (P = .01). The intervention group demonstrated statistically significant 66% decrease in breaches (P = .001) compared with 28% decrease in the control group (P = .06). Breach identification demonstrated no change in accuracy of the control group (incorrect identification from 32.2% pre- to posttest 35%; P = .71), whereas the intervention group's improvement was statistically significant (42% pre- to posttest 36.5%; P = .0047).

CONCLUSIONS

We conclude that a concise lumbar pedicle screw instrumentation bioskills training session can be a useful educational tool to augment clinical education.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes

STUDY OBJECTIVE

Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications.

DESIGN

Retrospective, multicenter, cohort study (Canadian Task Force classification II-2).

SETTING

Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites.

PATIENTS

Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012.

INTERVENTION

ACS-NSQIP database.

MEASUREMENTS AND MAIN RESULTS

Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality.

CONCLUSION

Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Exploring the Role and Application of the Deliberate Practice Concept in Radiation Therapy

The concept of deliberate practice (DP) has been extensively applied to the development of skill and expert performance in many domains of professional practice. Although it has been widely reviewed in other health professions, there is a lack of evidence on its application in radiation therapy practice. This article aims to explore the concept of DP and how it can be applied to radiation therapy practice. The authors define DP, why it is essential, and how it can be implemented in radiation therapy. Evidence from the DP literature in the health professions was used to clarify the guiding principles for successful DP implementation within both the clinical and educational contexts. While the authors encourage radiation therapy practitioners to engage in DP approaches, every profession utilizing DP will develop strategies unique to the individual discipline. Hence, rather than imitating other professions, it is essential that radiation therapists engage evidence-based approaches that will generate empirical evidence to model radiation therapy-specific DP approaches.

Consensus statement on an updated core communication curriculum for UK undergraduate medical education

OBJECTIVES

Clinical communication is a core component of undergraduate medical training. A consensus statement on the essential elements of the communication curriculum was co-produced in 2008 by the communication leads of UK medical schools. This paper discusses the relational, contextual and technological changes which have affected clinical communication since then and presents an updated curriculum for communication in undergraduate medicine.

METHOD

The consensus was developed through an iterative consultation process with the communication leads who represent their medical schools on the UK Council of Clinical Communication in Undergraduate Medical Education.

RESULTS

The updated curriculum defines the underpinning values, core components and skills required within the context of contemporary medical care. It incorporates the evolving relational issues associated with the more prominent role of the patient in the consultation, reflected through legal precedent and changing societal expectations. The impact on clinical communication of the increased focus on patient safety, the professional duty of candour and digital medicine are discussed.

CONCLUSION

Changes in the way medicine is practised should lead rapidly to adjustments to the content of curricula.

PRACTICE IMPLICATIONS

The updated curriculum provides a model of best practice to help medical schools develop their teaching and argue for resources.