Deliberate practice and acquisition of expert performance: a general overview

Replicating an established open skills curriculum: are the same results obtained in a different setting?

INTRODUCTION

The aim of this study was to ascertain whether the University of Texas, Southwestern (UTSW) open skills curriculum (Goova et al.(13)) could be successfully implemented in the University of Minnesota (UMN) multisite training program. We posed 4 questions: (1) Is the curriculum feasible? (2) Did residents' skills improve? (3) Did UMN residents achieve the same level as UTSW residents? (4) What factors were associated with posttest success?

METHODS

Postgraduate year-1 residents (n = 22) were enrolled in the curriculum, which included orientation, access to video instruction, 3 months of independent practice using portable kits and practice logbooks, presurveys and postsurveys, and pretesting and posttesting. Evaluation was based on UTSW proficiency measures (time, errors, and total proficiency score). Descriptive statistics, paired sample t tests, analysis of variance, and bivariate correlations were calculated. Results were compared with Goova.

RESULTS

Startup costs at UMN were $9804 vs $776 at UTSW. Our curriculum required 51 direct faculty hours vs 376 at UTSW. UMN trainees' skills improved significantly (mean score = 973 [standard deviation = 267] at baseline vs 1325 [standard deviation = 215] at posttest), but they achieved proficiency in only 38.6% of tasks at posttest, compared with 88.7% by UTSW trainees. Best predictors of UMN posttest proficiency score were (1) categorical vs preliminary resident status (p < 0.001), (2) pretest proficiency score (r = 0.510, p = 0.008), and (3) self-assessed baseline proficiency (r = 0.415, p = 0.027). Participation in skills laboratories during clerkship or fourth year medical school, estimated number of cases (surgeon or first assistant), and number of practice repetitions recorded in booklets were not predictive of the posttest score.

CONCLUSIONS

The UTSW open skills curriculum is feasible and effective in a new setting. Differences from UTSW-published success rates may be related to their superior onsite monitoring of practice and a policy requiring residents to achieve proficiency for each task before posttesting.

A mixed-reality part-task trainer for subclavian venous access

INTRODUCTION

Mixed-reality (MR) procedural simulators combine virtual and physical components and visualization software that can be used for debriefing and offer an alternative to learn subclavian central venous access (SCVA). We present a SCVA MR simulator, a part-task trainer, which can assist in the training of medical personnel.

METHODS

Sixty-five participants were involved in the following: (1) a simulation trial 1; (2) a teaching intervention followed by trial 2 (with the simulator's visualization software); and (3) trial 3, a final simulation assessment. The main test parameters were time to complete SCVA and the SCVA score, a composite of efficiency and safety metrics generated by the simulator's scoring algorithm. Residents and faculty completed questionnaires presimulation and postsimulation that assessed their confidence in obtaining access and learner satisfaction questions, for example, realism of the simulator.

RESULTS

The average SCVA score was improved by 24.5 (n=65). Repeated-measures analysis of variance showed significant reductions in average time (F=31.94, P<0.0001), number of attempts (F=10.56, P<0.0001), and score (F=18.59, P<0.0001). After the teaching intervention and practice with the MR simulator, the results no longer showed a difference in performance between the faculty and residents. On a 5-point scale (5=strongly agree), participants agreed that the SCVA simulator was realistic (M=4.3) and strongly agreed that it should be used as an educational tool (M=4.9).

CONCLUSIONS

An SCVA mixed simulator offers a realistic representation of subclavian central venous access and offers new debriefing capabilities.

Agreement of experts and non-experts in a desktop exercise evaluating exposure to asthmagens in the cotton and textile, and other industries

In the absence of personal exposure measurements, expert assessment, generally on a case-by-case basis, is often used to estimate exposures. However, the decision processes of individual experts when making assessments are unknown, making it difficult to assess the quality of these assessments or to compare different assessments to each other. We conducted a study in primarily the textile and cotton industries, but also in baking, metal work, and agriculture industries in which we assessed agreement between experts assessing intensity and probability of exposure in the absence of exposure measurements to compare how well their performance compares to agreement of non-desktop-based exercises reported in literature. In addition, agreement was compared with that of non-experts undertaking the same exercise, and results were further stratified to assess the impact of factors expected of affected assessments. Intraclass correlation coefficients of absolute agreement (ICC1) and consistency (ICC3) between raters were calculated. Sensitivity and specificity were estimated using a probabilistic simulation methodology developed previously. Fourteen occupational hygienists and exposure assessors with complete data for all 48 job descriptions and 8 non-experts participated. Although confidence intervals about correlation-coefficient differences are not reported, the individual limits were found to be so broad as to suggest that no statistically significant comparisons can be made. Nevertheless, preliminary observations are presented here as suggested by the computed means. Absolute agreement between expert raters was fair-good, but was somewhat better for intensity (ICC1 = 0.61) than for probability (ICC1 = 0.44) of exposure and was better for experts than non-experts. Estimated sensitivity was 0.95 and specificity 0.82 for intensity, and 0.91 and 0.78 for probability of exposure, respectively. Stratification for factors hypothesized to affect agreement did not show statistically significant differences, but consistent patterns of point estimates indicated that agreement between raters (both expert on non-experts) dropped for medium levels of information compared with little or extensive information. Inclusion of a photo or video generally improved agreement between experts but not between non-experts, whereas the year of the job description had no influence on the assessments. These data indicate that the desktop exposure assessment exercise was of similar quality to previously reported levels of agreement. Agreements between experts' assessments were independent of the time period of the job and can be improved by inclusion of visual material. Agreement between experts as well as the non-experts does not increase with the detail of provided job information.

Improving ward round skills

BACKGROUND

Ward rounds represent an important task in clinical settings. Despite their importance, students show substantial deficits in ward round competencies (e.g. physical examination, drug prescription, documentation). Previously reported teaching methods such as ward round training with standardized patients or educational wards, however, are time-consuming and expensive.

AIMS

To assess the effects of a structured on-ward supervision program for final-year students with specially trained supervising doctors focusing on ward round competencies.

METHOD

A total of 36 medical students were randomly assigned to an intervention group (IG) and a control group (CG). During an eight-week-long training course, the intervention group (IG; n = 18) received structured ward round training while the control group (CG; n = 18) received on-ward training regarding how to take patient histories and perform physical examinations. Ward round competencies were assessed using simulated ward round scenarios with objective checklist ratings and standardized patient ratings.

RESULTS

The IG achieved significantly more predefined learning goals compared to the CG. Standardized patient ratings did not differ significantly between groups.

CONCLUSIONS

RESULTS provide evidence that the presented program is a feasible and efficient tool for teaching ward round skills at the bedside. Further research should focus on cost effectiveness compared to alternative models.

The Milestones Passport: A Learner-Centered Application of the Milestone Framework to Prompt Real-Time Feedback in the Emergency Department

BACKGROUND

In July 2013, emergency medicine residency programs implemented the Milestone assessment as part of the Next Accreditation System.

OBJECTIVE

We hypothesized that applying the Milestone framework to real-time feedback in the emergency department (ED) could affect current feedback processes and culture. We describe the development and implementation of a Milestone-based, learner-centered intervention designed to prompt real-time feedback in the ED.

METHODS

We developed and implemented the Milestones Passport, a feedback intervention incorporating subcompetencies, in our residency program in July 2013. Our primary outcomes were feasibility, including faculty and staff time and costs, number of documented feedback encounters in the first 2 months of implementation, and user-reported time required to complete the intervention. We also assessed learner and faculty acceptability.

RESULTS

Development and implementation of the Milestones Passport required 10 hours of program coordinator time, 120 hours of software developer time, and 20 hours of faculty time. Twenty-eight residents and 34 faculty members generated 257 Milestones Passport feedback encounters. Most residents and faculty reported that the encounters required fewer than 5 minutes to complete, and 48% (12 of 25) of the residents and 68% (19 of 28) of faculty reported satisfaction with the Milestones Passport intervention. Faculty satisfaction with overall feedback in the ED improved after the intervention (93% versus 54%, P  =  .003), whereas resident satisfaction with feedback did not change significantly.

CONCLUSIONS

The Milestones Passport feedback intervention was feasible and acceptable to users; however, learner satisfaction with the Milestone assessment in the ED was modest.

Using Simulation Education With Deliberate Practice to Teach Leadership and Resource Management Skills to Senior Resident Code Leaders

BACKGROUND

Cardiopulmonary arrests are rare, high-stakes events that benefit from using crisis resource management (CRM). Simulation-based education with deliberate practice can promote skill acquisition.

OBJECTIVE

We assessed whether using simulation-based education to teach CRM would lead to improved performance, compared to a lecture format.

METHODS

We tested third-year internal medicine residents in simulated code scenarios. Participants were randomly assigned to simulation-based education with deliberate practice (SIM) group or lecture (LEC) group. We created a checklist of CRM critical actions (which includes announcing the diagnosis, asking for help/suggestions, and assigning tasks), and reviewed videotaped performances, using a checklist of skills and communications patterns to identify CRM skills and communication efforts. Subjects were tested in simulated code scenarios 6 months after the initial assessment.

RESULTS

At baseline, all 52 subjects recognized distress, and 92% (48 of 52) called for help. Seventy-eight percent (41 of 52) did not succeed in resuscitating the simulated patient or demonstrate the CRM skills. After intervention, both groups (n  =  26 per group) improved. All SIM subjects announced the diagnosis compared to 65% LEC subjects (17 of 26, P  =  .01); 77% (20 of 26) SIM and 19% (5 of 26) LEC subjects asked for suggestions (P < .001); and 100% (26 of 26) SIM and 27% (7 of 26) LEC subjects assigned tasks (P < .001).

CONCLUSIONS

The SIM intervention resulted in significantly improved team communication and cardiopulmonary arrest management. During debriefing, participants acknowledged the benefit of the SIM sessions.

A simulation model for improving learner and health outcomes

Simulation has become a necessary and integral part of education for prelicensure and ongoing education of health care practitioners. To guide this process, the Simulation Model for Improving Learner and Health Outcomes (SMILHO) model provides a framework to design the experience from a science of learning approach and links it to learner and health outcomes to add to the knowledge base. Much work has been done in this area, and the SMILHO model will support the future work needed to continue to create effective simulation-based learning experiences and move research from knowledge and skill evaluation to learner and health outcomes.

Excellence in clinical teaching: knowledge transformation and development required

CONTEXT

Clinical teachers in medicine face the daunting task of mastering the many domains of knowledge needed for practice and teaching. The breadth and complexity of this knowledge continue to increase, as does the difficulty of transforming the knowledge into concepts that are understandable to learners. Properly targeted faculty development has the potential to expedite the knowledge transformation process for clinical teachers.

METHODS

Based on my own research in clinical teaching and faculty development, as well as the work of others, I describe the unique forms of clinical teacher knowledge, the transformation of that knowledge for teaching purposes and implications for faculty development.

RESULTS

The following forms of knowledge for clinical teaching in medicine need to be mastered and transformed: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and learners, and (iv) knowledge integrated into teaching scripts. This knowledge is employed and conveyed through the parallel processes of clinical reasoning and clinical instructional reasoning. Faculty development can facilitate this knowledge transformation process by: (i) examining, deconstructing and practising new teaching scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching.

CONCLUSIONS

To become an excellent clinical teacher in medicine requires the transformation of multiple forms of knowledge for teaching purposes. These domains of knowledge allow clinical teachers to provide tailored instruction to learners at varying levels in the context of fast-paced and demanding clinical practice. Faculty development can facilitate this knowledge transformation process.

Simulation in laparoscopic surgery

Nowadays surgical trainees are faced with a more reduced surgical practice, due to legal limitations and work hourly constraints. Also, currently surgeons are expected to dominate more complex techniques such as laparoscopy. Simulation emerges as a complementary learning tool in laparoscopic surgery, by training in a safe, controlled and standardized environment, without jeopardizing patient' safety. Simulation' objective is that the skills acquired should be transferred to the operating room, allowing reduction of learning curves. The use of simulation has increased worldwide, becoming an important tool in different surgical residency programs and laparoscopic training courses. For several countries, the approval of these training courses are a prerequisite for the acquisition of surgeon title certifications. This article reviews the most important aspects of simulation in laparoscopic surgery, including the most used simulators and training programs, as well as the learning methodologies and the different key ways to assess learning in simulation.

Simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia

Introduction. Properly performing a subarachnoid block (SAB) is a competency expected of anesthesiology residents. We aimed to determine if adding simulation-based deliberate practice to a base curriculum improved performance of a SAB. Methods. 21 anesthesia residents were enrolled. After baseline assessment of SAB on a task-trainer, all residents participated in a base curriculum. Residents were then randomized so that half received additional deliberate practice including repetition and expert-guided, real-time feedback. All residents were then retested for technique. SABs on all residents' next three patients were evaluated in the operating room (OR). Results. Before completing the base curriculum, the control group completed 81% of a 16-item performance checklist on the task-trainer and this increased to 91% after finishing the base curriculum (P < 0.02). The intervention group also increased the percentage of checklist tasks properly completed from 73% to 98%, which was a greater increase than observed in the control group (P < 0.03). The OR time required to perform SAB was not different between groups. Conclusions. The base curriculum significantly improved resident SAB performance. Deliberate practice training added a significant, independent, incremental benefit. The clinical impact of the deliberate practice intervention in the OR on patient care is unclear.

Characteristics of high-level youth soccer players: variation by playing position

The present study aimed to investigate positional differences in 744 high-level soccer players, aged 8 to 18 years. Players were assigned to six age groups (U9-U19) and divided into four playing positions (goalkeeper (GK), defender (DEF), midfielder (MF) and attacker (ATT)). MANOVA and effect sizes were used to examine anthropometrical and functional characteristics between all positions in all age groups. The main findings of the study were that GKs and DEFs were the tallest and heaviest compared with MFs and ATTs in all age groups. Further, between U9-U15, no significant differences in functional characteristics were found, except for dribbling skill, which MFs performed the best. In the U17-U19 age groups, ATTs seemed to be the most explosive (with GKs), the fastest and the more agile field players. These results suggest that inherent physical capacities (i.e., speed, power, agility) might select players in or reject players from an attacking position, which is still possible from U15-U17. Apparently, players with excellent dribbling skills at younger age are more likely to be selected to play as a MF, although, one might conclude that the typical physical characteristics for different positions at senior level are not yet fully developed among young soccer players between 8 and 14 years.

Effective teaching and feedback strategies in the or and beyond

Maintaining a standard of excellence for graduating surgical residents requires a comprehensive and consistent approach to surgical education. The omnipresent and increasing barriers to education must also be recognized and addressed. The implementation of effective teaching strategies is largely dependent on the resources available at each institution and the vision of education. Unfortunately, allocating time for surgeons to teach both inside and outside the operating room has become a foreign concept to administration. Furthermore, the reduction in case numbers performed by trainees now demands "quality over quantity" to ensure success. Quality teaching moments will only be realized when emphasis is placed on preparation, useful instruction during the procedure, and postoperative feedback. Ideal preparation entails a detailed discussion between the trainee and surgeon about the specific learning goals for the case. During the procedure, the faculty surgeon must strive to maximize the experience through effective communication while performing an efficient and safe operation. Numerous validated objective assessment tools exist for postprocedure evaluation but are grossly underutilized. Surgical education must thoughtfully be approached with the same fervor and detail as patient care. As faculty, it is our responsibility to train the next generation of surgeons and therefore "every case must count."

Spontaneously spotting and applying shortcuts in arithmetic-a primary school perspective on expertise

One crucial feature of expertise is the ability to spontaneously recognize where and when knowledge can be applied to simplify task processing. Mental arithmetic is one domain in which people should start to develop such expert knowledge in primary school by integrating conceptual knowledge about mathematical principles and procedural knowledge about shortcuts. If successful, knowledge integration should lead to transfer between procedurally different shortcuts that are based on the same mathematical principle and therefore likely are both associated to the respective conceptual knowledge. Taking commutativity principle as a model case, we tested this conjecture in two experiments with primary school children. In Experiment 1, we obtained eye tracking data suggesting that students indeed engaged in search processes when confronted with mental arithmetic problems to which a formerly feasible shortcut no longer applied. In Experiment 2, children who were first provided material allowing for one commutativity-based shortcut later profited from material allowing for a different shortcut based on the same principle. This was not the case for a control group, who had first worked on material that allowed for a shortcut not based on commutativity. The results suggest that spontaneous shortcut usage triggers knowledge about different shortcuts based on the same principle. This is in line with the notion of adaptive expertise linking conceptual and procedural knowledge.

Continuous professional development for GPs: experience from Denmark

BACKGROUND AND OBJECTIVES

Continuous professional development (CPD) for Danish general practitioners (GPs) is voluntary and based on funded accredited activities. There is an ongoing discussion on how to improve this current system by introducing mandatory elements. To inform this debate, we set out to identify GPs' current use of CPD and to explore the motives behind their choices.

METHODS

A mixed-methods study with a combined qualitative and quantitative approach was used. In 2012, two focus group interviews were conducted, followed up the same year by an online questionnaire sent to 1079 randomly chosen Danish GPs.

RESULTS

Focus groups: CPD activities are chosen based on personal needs analysis, and in order to be professionally updated, to meet engaged colleagues and to prevent burnout. GPs also attend CPD to assess their own pre-existing level of competence. CPD activities need to be experienced as being both meaningful and relevant in order to have an impact. Questionnaire: The response rate was 686/1079 (63%). GPs spend on average 10.5 days per year on accredited, voluntary CPD activities. Workplace-related CPD activities and practice-based small group learning played a significant role. The main motivation for choice of CPD activities included academic interest, experience of patient-related problems in their own surgeries and medical topics where the GPs felt insufficiently confident.

CONCLUSIONS

Danish GPs are frequent users of voluntary accredited CPD. Their CPD choices are motivated by topics strengthening their professional capacity and preventing burnout. There would seem to be no need for a mandatory system.

[Does simulator-based team training improve patient safety?]

Patient safety became paramount in medicine as well as in emergency medicine after it was recognized that preventable, adverse events significantly contributed to morbidity and mortality during hospital stay. The underlying errors cannot usually be explained by medical technical inadequacies only but are more due to difficulties in the transition of theoretical knowledge into tasks under the conditions of clinical reality. Crew Resource Management and Human Factors which determine safety and efficiency of humans in complex situations are suitable to control such sources of error. Simulation significantly improved safety in high reliability organizations, such as the aerospace industry.Thus, simulator-based team training has also been proposed for medical areas. As such training is consuming in cost, time and human resources, the question of the cost-benefit ratio obviously arises. This review outlines the effects of simulator-based team training on patient safety. Such course formats are not only capable of creating awareness and improvements in safety culture but also improve technical team performance and emphasize team performance as a clinical competence. A few studies even indicated improvement of patient-centered outcome, such as a reduced rate of adverse events but further studies are required in this respect. In summary, simulator-based team training should be accepted as a suitable strategy to improve patient safety.

The role of simulation in developing surgical skills

Surgical training has followed the master-apprentice model for centuries but is currently undergoing a paradigm shift. The traditional model is inefficient with no guarantee of case mix, quality, or quantity. There is a growing focus on competency-based medical education in response to restrictions on doctors' working hours and the traditional mantra of "see one, do one, teach one" is being increasingly questioned. The medical profession is subject to more scrutiny than ever before and is facing mounting financial, clinical, and political pressures. Simulation may be a means of addressing these challenges. It provides a way for trainees to practice technical tasks in a protected environment without putting patients at risk and helps to shorten the learning curve. The evidence for simulation-based training in orthopedic surgery using synthetic models, cadavers, and virtual reality simulators is constantly developing, though further work is needed to ensure the transfer of skills to the operating theatre.

Experts bodies, experts minds: How physical and mental training shape the brain

Skill learning is the improvement in perceptual, cognitive, or motor performance following practice. Expert performance levels can be achieved with well-organized knowledge, using sophisticated and specific mental representations and cognitive processing, applying automatic sequences quickly and efficiently, being able to deal with large amounts of information, and many other challenging task demands and situations that otherwise paralyze the performance of novices. The neural reorganizations that occur with expertise reflect the optimization of the neurocognitive resources to deal with the complex computational load needed to achieve peak performance. As such, capitalizing on neuronal plasticity, brain modifications take place over time-practice and during the consolidation process. One major challenge is to investigate the neural substrates and cognitive mechanisms engaged in expertise, and to define “expertise” from its neural and cognitive underpinnings. Recent insights showed that many brain structures are recruited during task performance, but only activity in regions related to domain-specific knowledge distinguishes experts from novices. The present review focuses on three expertise domains placed across a motor to mental gradient of skill learning: sequential motor skill, mental simulation of the movement (motor imagery), and meditation as a paradigmatic example of “pure” mental training. We first describe results on each specific domain from the initial skill acquisition to expert performance, including recent results on the corresponding underlying neural mechanisms. We then discuss differences and similarities between these domains with the aim to identify the highlights of the neurocognitive processes underpinning expertise, and conclude with suggestions for future research.

What's your best time? Chronometry in the learning of medical procedures

OBJECTIVES

Most medical procedures have a time element. It is uncommon, however, to explicitly use chronometry, the measurement of time, in the learning of these procedures. This study considered whether instructional designs that include chronometry could improve deliberate practice and be used in meaningful formative assessments.

METHODS

A selective review of the medical education literature was undertaken to identify how chronometry was used in a broad sampling of medical education research in the learning of medical procedures. We identified prior publications in which time measurement was used either directly as a pedagogic intervention or as an assessment method in a medical school programme.

RESULTS

Our review suggests a number of desirable features of chronometry. For the individual learner, procedural time measurements can demonstrate both improving ability and increasing consistency. Chronometry can enhance instructional designs involving deliberate practice by facilitating overlearning (i.e. learning that goes beyond minimum competence), increasing the challenge level and enhancing self-regulation of learning (e.g. self-competition). Breaking down chronometric data into meaningful interval or split times might further inform instructional designs.

CONCLUSIONS

Chronometry has the potential to contribute to instructional designs and assessment methods in medical procedures training. However, more research is needed to elucidate its full potential and describe possible negative consequences of this widely available but underutilised educational tool.

Evidence-based microsurgical skill-acquisition series part 1: validated microsurgical models--a systematic review

OBJECTIVES

The purpose of this study is to (1) systematically review all the literature pertaining to microsurgical training models and to (2) determine which of these are specific to and validated for microsurgery training.

DESIGN

PubMed, MEDLINE (OVID/EBSCO), Google Scholar, and Cochrane Central Register of Controlled Trials were searched using preset terms. The last search date was in July 2012. Articles of all languages, years of publication, sample sizes, and model types pertaining to microsurgery were included. The eligibility criteria included the use of a microsurgical training model on a subject group with statistical analysis and measures of validation. Two assessors independently reviewed the articles and their references.

RESULTS

Of the 238 articles reviewed, 9 articles met the criteria. Those excluded were predominantly model descriptions that had not been validated in a set of learners. The 9 models whose performances were assessed in a group of learners included an online curriculum, nonliving prosthetics and biologics, and the live rat femoral artery model. Each model was evaluated for content, construct, face, and criterion (concurrent and predictive) validity, as well as selection and observation/expectant bias. Content, construct, concurrent, and face validities were consistently demonstrated for all 9 models. Selection bias was also reliably well controlled with random allocation of participants to each study group. Observation/expectant bias was controlled in 6 of the 8 papers. Predictive validity, an arguably more difficult factor to measure, was only present in 1 article.

CONCLUSIONS

Despite a plethora of papers describing microsurgical learning tools, only 9 were discovered that provided validation of the proposed method of microsurgical skills acquisition. This review depicts the need for basic, yet well-designed studies that substantiate the effectiveness of microsurgical training models by using a subject group and demonstrating a statistical improvement with employment of the model. Ease of access, cost, and assessment tools used also require attention.

The development of a virtual simulator for training neurosurgeons to perform and perfect endoscopic endonasal transsphenoidal surgery

BACKGROUND

A virtual reality (VR) neurosurgical simulator with haptic feedback may provide the best model for training and perfecting surgical techniques for transsphenoidal approaches to the sella turcica and cranial base. Currently there are 2 commercially available simulators: NeuroTouch (Cranio and Endo) developed by the National Research Council of Canada in collaboration with surgeons at teaching hospitals in Canada, and the Immersive Touch. Work in progress on other simulators at additional institutions is currently unpublished.

OBJECTIVE

This article describes a newly developed application of the NeuroTouch simulator that facilitates the performance and assessment of technical skills for endoscopic endonasal transsphenoidal surgical procedures as well as plans for collecting metrics during its early use.

METHODS

The main components of the NeuroTouch-Endo VR neurosurgical simulator are a stereovision system, bimanual haptic tool manipulators, and high-end computers. The software engine continues to evolve, allowing additional surgical tasks to be performed in the VR environment. Device utility for efficient practice and performance metrics continue to be developed by its originators in collaboration with neurosurgeons at several teaching hospitals in the United States. Training tasks are being developed for teaching 1- and 2-nostril endonasal transsphenoidal approaches. Practice sessions benefit from anatomic labeling of normal structures along the surgical approach and inclusion (for avoidance) of critical structures, such as the internal carotid arteries and optic nerves.

CONCLUSION

The simulation software for NeuroTouch-Endo VR simulation of transsphenoidal surgery provides an opportunity for beta testing, validation, and evaluation of performance metrics for use in neurosurgical residency training.

ABBREVIATIONS

CTA, cognitive task analysisVR, virtual reality.

What factors determine academic achievement in high achieving undergraduate medical students? A qualitative study

BACKGROUND

Medical students' academic achievement is affected by many factors such as motivational beliefs and emotions. Although students with high intellectual capacity are selected to study medicine, their academic performance varies widely.

OBJECTIVES

The aim of this study is to explore the high achieving students' perceptions of factors contributing to academic achievement.

MATERIALS AND METHODS

Focus group discussions (FGD) were carried out with 10 male and 9 female high achieving (scores more than 85% in all tests) students, from the second, third, fourth and fifth academic years. During the FGDs, the students were encouraged to reflect on their learning strategies and activities. The discussion was audio-recorded, transcribed and analysed qualitatively.

RESULTS

Factors influencing high academic achievement include: attendance to lectures, early revision, prioritization of learning needs, deep learning, learning in small groups, mind mapping, learning in skills lab, learning with patients, learning from mistakes, time management, and family support. Internal motivation and expected examination results are important drivers of high academic performance. Management of non-academic issues like sleep deprivation, homesickness, language barriers, and stress is also important for academic success.

CONCLUSION

Addressing these factors, which might be unique for a given student community, in a systematic manner would be helpful to improve students' performance.

Individualized deliberate practice on a virtual reality simulator improves technical performance of surgical novices in the operating room: a randomized controlled trial

OBJECTIVE

The purpose of this study was to investigate whether individualized deliberate practice on a virtual reality (VR) simulator results in improved technical performance in the operating room.

BACKGROUND

Training on VR simulators has been shown to improve technical performance in the operating room (OR). Currently described VR curricula consist of trainees practicing the same tasks until expert proficiency is reached. It has yet to be investigated whether the individualized deliberate practice, where curricula tasks vary depending on prior levels of technical proficiency, would translate into the OR.

METHODS

This single-blinded prospective trial randomized 16 novice surgical residents to a deliberate practice (DP) group and a conventional residency training group. Both groups performed a laparoscopic cholecystectomy in the OR that was video-recorded. Technical performance of DP group residents in the OR was assessed using 3 validated assessment tools. A score of less than 60% on any component of the assessment tool resulted in the trainee practicing a specific task on the VR simulator. The DP group practiced on the simulator as per their individualized schedule. Both groups then performed another laparoscopic cholecystectomy. A blinded expert assessed the OR recordings using a validated global rating scale.

RESULTS

Although both groups had similar technical abilities preintervention [DP: median score, 13.5 (9.3-15.0); control: median score, 14.5 (9.3-17.8); P = 0.45], the DP residents had a superior technical performance postintervention [DP: median score, 17.0 (15.3-18.5); control: median score, 12.5 (7.5-14.0); P = 0.03]. Of 8 DP residents, 6 practiced 5 basic VR tasks (median 1 trial to pass), and 7 of 8 practiced 2 advanced tasks (median 4 trials to pass).

CONCLUSIONS

A curriculum of deliberate individualized practice on a VR simulator improves technical performance in the OR. This has implications to greatly improve the feasibility of implementing simulation-based curricula in residency training programs, rather then having them being limited to research protocols.

What surgeons can learn from athletes: mental practice in sports and surgery

BACKGROUND

Mental practice has been successfully applied in professional sports for skills acquisition and performance enhancement. The goals of this review are to describe the literature on mental practice within sport psychology and surgery and to explore how the specific principles of mental practice can be applied to the improvement of surgical performance-both in novice and expert surgeons.

METHOD

The authors reviewed the sports psychology, education, and surgery literatures through Medline, PubMed, PsycINFO, and Embase.

RESULTS

In sports, mental practice is a valuable tool for optimizing existing motor skill sets once core competencies have been mastered. These techniques have been shown to be more advantageous when used by elite athletes. Within surgery, mental practice studies have focused on skill acquisition among novices with little study of how expert surgeons use it to optimize surgical preparation.

CONCLUSIONS

We propose that performance optimization and skills acquisition should be viewed as 2 separate domains of mental practice. Further understanding of this phenomenon has implications for changing how we teach and train not only novice surgeons but also how experienced surgeons continue to maintain their skills, acquire new ones, and excel in surgery.

Exploring clinical reasoning in novices: a self-regulated learning microanalytic assessment approach

OBJECTIVES

The primary objectives of this study were to examine the regulatory processes of medical students as they completed a diagnostic reasoning task and to examine whether the strategic quality of these regulatory processes were related to short-term and longer-term medical education outcomes.

METHODS

A self-regulated learning (SRL) microanalytic assessment was administered to 71 second-year medical students while they read a clinical case and worked to formulate the most probable diagnosis. Verbal responses to open-ended questions targeting forethought and performance phase processes of a cyclical model of SRL were recorded verbatim and subsequently coded using a framework from prior research. Descriptive statistics and hierarchical linear regression models were used to examine the relationships between the SRL processes and several outcomes.

RESULTS

Most participants (90%) reported focusing on specific diagnostic reasoning strategies during the task (metacognitive monitoring), but only about one-third of students referenced these strategies (e.g. identifying symptoms, integration) in relation to their task goals and plans for completing the task. After accounting for prior undergraduate achievement and verbal reasoning ability, strategic planning explained significant additional variance in course grade (ΔR(2 ) = 0.15, p < 0.01), second-year grade point average (ΔR(2) = 0.14, p < 0.01), United States Medical Licensing Examination Step 1 score (ΔR(2) = 0.08, p < 0.05) and National Board of Medical Examiner subject examination score in internal medicine (ΔR(2) = 0.10, p < 0.05).

CONCLUSIONS

These findings suggest that most students in the formative stages of learning diagnostic reasoning skills are aware of and think about at least one key diagnostic reasoning process or strategy while solving a clinical case, but a substantially smaller percentage set goals or develop plans that incorporate such strategies. Given that students who developed more strategic plans achieved better outcomes, the potential importance of forethought regulatory processes is underscored.

The making of expert clinicians: reflective practice

Debriefing is a rigorous reflection process which helps trainees recognize and resolve clinical and behavioral dilemmas raised by a clinical case. This approach emphasizes eliciting trainees'assumptions about the situation and their reasons for performing as they did (mental models). It analyses their impact on actions, to understand if it is necessary to maintain them or construct new ones that may lead to better performance in the future. It blends evidence and theory from education research, the social and cognitive sciences, and experience drawn from conducting and teaching debriefing to clinicians worldwide, on how to improve professional effectiveness through "reflective practice".

Manual laparoscopic skills development using a low-cost trainer box in Tanzania

OBJECTIVES

To explore the feasibility and effectiveness of guided practice using a low-cost laparoscopic trainer on the development of laparoscopic skills by surgeons in a resource-poor setting.

DESIGN

This was a prospective trial involving a pretest/posttest single-sample design. Study participants completed a background survey and pretest on the 5 McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) tasks using a simulator developed and validated by researchers from the University of California, San Francisco. On completion of a 3-month guided practice course, participants were again tested on the MISTELS tasks and completed an exit survey.

SETTING

The Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania.

PARTICIPANTS

Fourteen Tanzanian surgery residents and specialists completed the study.

RESULTS

Most of the subjects were surgical residents (64.3%). Only 2 participants (14.2%) had previous laparoscopic training, and baseline laparoscopic surgical experience was limited to intraoperative observation only. Study subjects practiced the MISTELS tasks for an average of 8.67 hours (range: 4.75-15.25) over the 3-month course. On the posttest, participants improved significantly in performance of each of the MISTELS tasks (p < 0.001). Total scores on the tasks increased from 24 ± 44 on the pretest to 384 ± 49 on the posttest (p < 0.001). All study participants were satisfied with the course, found the training personally valuable, and felt that their laparoscopic skills had improved on completion of the training.

CONCLUSIONS

We have demonstrated the feasibility and effectiveness of training with a low-cost laparoscopic trainer box in Tanzania. Study participants achieved impressive posttest scores on the 5 MISTELS tasks with minimal baseline laparoscopic exposure. We feel that guided training by an expert was key in ensuring correct technique during practice sessions.

Robotic surgery basic skills training: Evaluation of a pilot multidisciplinary simulation-based curriculum

PURPOSE

Simulation-based training improves clinical skills, while minimizing the impact of the educational process on patient care. We present results of a pilot multidisciplinary, simulation-based robotic surgery basic skills training curriculum (BSTC) for robotic novices.

METHODS

A 4-week, simulation-based, robotic surgery BSTC was offered to the Departments of Surgery and Obstetrics & Gynecology (ObGyn) at the University of Toronto. The course consisted of various instructional strategies: didactic lecture, self-directed online-training modules, introductory hands-on training with the da Vinci robot (dVR) (Intuitive Surgical Inc., Sunnyvale, CA), and dedicated training on the da Vinci Skills Simulator (Intuitive Surgical Inc., Sunnyvale, CA) (dVSS). A third of trainees participated in competency-based dVSS training, all others engaged in traditional time-based training. Pre- and post-course skill testing was conducted on the dVR using 2 standardized skill tasks: ring transfer (RT) and needle passing (NP). Retention of skills was assessed at 5 months post-BSTC.

RESULTS

A total of 37 participants completed training. The mean task completion time and number of errors improved significantly post-course on both RT (180.6 vs. 107.4 sec, p < 0.01 and 3.5 vs. 1.3 sec, p < 0.01, respectively) and NP (197.1 vs. 154.1 sec, p < 0.01 and 4.5 vs. 1.8 sec, p = 0.04, respectively) tasks. No significant difference in performance was seen between specialties. Competency-based training was associated with significantly better post-course performance. The dVSS demonstrated excellent face validity.

CONCLUSIONS

The implementation of a pilot multidisciplinary, simulation-based robotic surgery BSTC revealed significantly improved basic robotic skills among novice trainees, regardless of specialty or level of training. Competency-based training was associated with significantly better acquisition of basic robotic skills.

Connecting the dots: like watching a movie…critically

Acquisition of expertise in the diagnosis and management of patients requires years of practice; exposure to diverse clinical entities is critical as well as the myriad ways in which the same disease can present in a given patient. However, this repeated exposure has to be accompanied by two critical elements; first, the novice needs the guidance of an expert or master to appreciate the nuances and subtleties in making a diagnosis or taking a course of action. Second, and perhaps most importantly, the physician needs to acquire the habit of reflecting on and in actions during the clinical encounter. Unguided repetition during formative years or lack of critical introspection during practice hinders the progression to expertise. In a way, a complex clinical encounter is akin to watching a complex movie; it takes repeated exposure to the movie to understand the subtleties the director is utilizing to understand the plot in its entirety.

Strengthening student communication through pediatric simulated patient encounters

As medical students enter the role of physician, clinical outcomes not only rely on their mastery of clinical knowledge, but also on the effectiveness in which they can communicate with patients and family members. While students typically have numerous opportunities to practice clinical communication with adult patients, such practice in pediatric settings is limited. This study examines if simulated patient (SP) encounters strengthen third-year medical students' communication skills during the pediatrics clerkship. During 2011-2013, three SP encounters (comprising 3 pediatric scenarios) were incorporated into a pediatrics clerkship at one United States medical school to give students a safe venue to practice advanced communication with observation and direct feedback. Third-year medical students engaged in the scenarios and received both written and oral feedback from an evaluator observing the encounter. With IRB approval, students' self-perceived confidence and abilities at performing the advanced communication skills were measured using an eightitem, Likert scale questionnaire administered pre and post the SP encounter. Pre- and post-questionnaires (n=215; response rate, 96%) analyzed using a Wilcoxon-matched pairs signed-rank test demonstrated statistically significant increases in students' perception of their confidence and abilities regarding their performance (P<0.05; Bonferroni correction, P<0.006). There was an increases in student confidence and self-perceived ability in: first, communicating with children and family members of young patients; second, managing confrontational situations involving parents; third, performing a thorough psychosocial history with an adolescent; and fourth, using Evidence Based Medicine to motivate parents.

Necessity is the mother of invention: video recording firsthand perspectives of critical medical procedures to make simulated training more effective

The traditional apprenticeship model for training doctors requires ample opportunities in the clinic for trainees to learn core procedures under the supervision of skilled doctors. In this issue, Kyser and colleagues document that the learning opportunities for residents to master certain core procedures, such as forceps and vacuum deliveries, are insufficient in many teaching hospitals. To address this serious problem, this author argues that learning techniques (i.e., deliberate practice and simulator use) from other domains of expertise, such as chess, music, and sports, must be adapted for use in medicine. For example, medical procedures should be videotaped and indexed for access over the Internet. Trainees then could view recordings of rare emergency procedures and complications and practice their decision-making skills. Evidence suggests that training outside the constraints of the clinic could be more effective in improving performance because trainees are able to engage in deliberate practice and focus on their individual weaknesses in executing procedures and making decisions. For example, with video and simulator training, trainees have the opportunity to repeatedly perform only the parts of a procedure that they find challenging until they have attained a level of acceptable speed and control. More generally, training could be structured around the particular needs of individual learners and scheduled when the learners are rested and able to concentrate fully on learning. Training also should include opportunities for learners to practice repeatedly with different patient descriptions requiring the same or different, yet related, procedures to teach trainees effective discrimination and execution.

Cognitive Processes in Anesthesiology Decision Making

The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.

Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.

Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.