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

A Computer-Assisted Training Approach for Performing and Charting Periodontal Examinations: A Retrospective Study

The aim of this study was to retrospectively investigate the development of a model-based, computer-assisted training approach for performing and charting periodontal examinations in a dental clinic in Germany. The study was initiated in summer semester 2013 and repeated in two consecutive semesters (S1: 44 students, S2: 48 students, and S3: 61 students) because technical features were introduced (S2: feedback and time control; S3: input control). In each semester, new dental students who had never performed periodontal examinations participated. Students were divided into two groups and received intense training at different time points. Agreement levels were calculated at baseline, after the first group received training, and after the second group received training. Comparisons were also made among the semesters. All 153 enrolled students in the three semesters participated. The results showed that probing depth accuracy significantly decreased in S1 from baseline to training completion (79.9% to 74.5%), and the probing depth accuracy significantly increased in S2 (76.1% to 78.9%) and S3 (77.2% to 82.3%). The students who received intense training at a late stage of the tutorial showed greater improvement, especially in the case of S3. Small changes in accuracy were observed for recession (S1: 94.5% to 96.1%; S2: 93.8% to 93.9%; S3: 95.4% to 96.6%). Accuracy for furcation involvement improved significantly in S1 (46.1% to 52.0%), S2 (46.8% to 59.7%), and S3 (44.2% to 58.3%); the improvements occurred when the students received intense training. The time taken for periodontal examination decreased significantly for S2 (23.6 to 14.2 min) and S3 (25.7 to 13.9 min). This study found that when feedback was provided, the students' periodontal examinations improved in accuracy and duration.

How the Start into the Clinical Elective Year Could be Improved: Qualitative Results and Recommendations from Student Interviews

Background: Entering the Clinical Elective Year (CEY) is a challenging transition phase for undergraduate medical students. Students become members of a professional team, thereby taking over certain tasks, which are executed more or less independently. Factors which facilitate (or impede) this transition in the perception of students are not well described. We therefore wanted to explore, what students perceived to be helpful during the first phase of the CEY and possibly derive respective recommendations. Methods: We conducted semi-structured interviews with 5th year medical students after they had completed the first two months of their CEY. Students were asked which problems they had faced and how they felt prepared for the CEY. Interviews were audio-recorded, transcribed, and analysed by qualitative content analysis. Results: From 34 interviews, we included 28 into analysis. Overall, 24 students were satisfied or very satisfied with their start into the CEY. Satisfaction was expressed with respect to workplace experiences, learning progress, responsibilities and team integration. Especially, students appreciated if they were integrated as active members of the team, were given responsibility for certain units of work, and received well-structured formal teaching and supervision. Students had divergent opinions about the quality of teaching and supervision, about their own achievements, and the recognition they received. Students recommended improvements in respect to formal teaching and supervision by clinical supervisors, preparation of the CEY by university, and supporting structures in the hosting institution. Conclusion: Students in this study were generally satisfied with the first two months of their CEY. Facilitating factors were active and responsible involvement into routine patient care, and high quality formal teaching and supervision. Findings may inform universities, teaching hospitals, and students how to better shape the first phase of the CEY.

Automaticity of Force Application During Simulated Brain Tumor Resection: Testing the Fitts and Posner Model

OBJECTIVE

The Fitts and Posner model of motor learning hypothesized that with deliberate practice, learners progress through stages to an autonomous phase of motor ability. To test this model, we assessed the automaticity of neurosurgeons, senior residents, and junior residents when operating on 2 identical tumors using the NeuroVR virtual reality simulation platform.

DESIGN

Participants resected 9 identical simulated tumors on 2 occasions (total = 18 resections). These resections were separated by the removal of a variable number of tumors with different visual and haptic complexities to mirror neurosurgical practice. Consistency of force application was used as a metric to assess automaticity and was defined as applying forces 1 standard deviation above or below a specific mean force application. Amount and specific location of force application during second identical tumor resection was compared to that used for the initial tumor.

SETTING

This study was conducted at the McGill Neurosurgical Simulation Research and Training Center, Montreal Neurologic Institute and Hospital, Montreal, Canada.

PARTICIPANTS

Nine neurosurgeons, 10 senior residents, and 8 junior residents.

RESULTS

Neurosurgeons display statistically significant increased consistency of force application when compared to resident groups when results from all tumor resections were assessed. Assessing individual tumor types demonstrates significant differences between the neurosurgeon and resident groups when resecting hard stiffness similar-to-background (white) tumors and medium-stiffness tumors. No statistical difference in consistency of force application was found when junior and senior residents were compared.

CONCLUSION

"Experts" display significantly more automaticity when operating on identical simulated tumors separated by a series of different tumors using the NeuroVR platform. These results support the Fitts and Posner model of motor learning and are consistent with the concept that automaticity improves after completing residency training. The potential educational application of our findings is outlined related to neurosurgical resident training.

Simulation-based training in laparoscopic urology - Pros and cons

Surgery is traditionally taught by using Halsteadian principle, which includes “see one, do one, teach one”. This principle relies on sheer volume of surgical exposure rather than a specific course structure. Simulation in minimally invasive surgery allows the learner to practice new motor skills in a safe and stress free environment outside the operating room, thereby decreasing the learning curve.

A non-structured exhaustive MEDLINE search was done using MeSH words: “Simulation, Urological Training, Training Models, Laparoscopy Urology, Laparoscopic Skill, Endotrainer, Surgical Simulators, Simulator Validation”. The “ Pros and Cons of simulation based training in laparoscopic urology” were studied.

Results were discussed along the following lines : 1. How does skill acquisition occur? 2. Factors affecting simulator-based training. 3. Description of types of simulators and models. 4. Validating a simulator. 5. Task analysis after training on a simulator. 6. How effectively does simulation based training, translate into improved surgical performance in real time?

Pros: Simulators have the ability to teach a novice basic psychomotor skills. Supervision and feedback enhance learning in a simulation-based training. They are supplements to and not a substitution for traditional method of teaching. These models can be used as a part of most of the surgical training curriculum.

Cons: Cost and availability are the key issues. The cost will determine the availability of the simulators at a center and the availability in turn would determine whether a trainee will get the opportunity to use the simulator. Also, teacher training is an important aspect which would help teachers to understand the importance of simulation in student training. The domains in which it would improve and the extent to which simulation will improve surgical skills is dependent on various factors. Most simulators cannot train a surgeon to deal with anatomical and physiological variations. At present, it is not possible to re-validate all the surgeons in terms of their surgical skills, using simulators.

Hands-off Ultrasound Technique: Utilizing Simultaneous Modeling to Enhance Ultrasound Training

Image acquisition can be a challenging component of obtaining ultrasound proficiency. To assist with obtaining the correct image, instructors may take the transducer away or guide the learner's hand. However, this passive form of learning has been suggested to be much less valuable, as it removes learner autonomy and somatosensory cueing. This paper describes the hands-off ultrasound technique, a simultaneous modeling teaching strategy using multimodal feedback to improve ultrasound image acquisition.

Simulation and Deliberate Practice in a Porcine Model for Congenital Heart Surgery Training

BACKGROUND

Surgeons in training for congenital cardiac surgery face considerable challenges owing to procedure complexity, closely scrutinized outcomes, and a steep learning curve. Simulation methods have been initiated in other surgical specialties, but have yet to be established for congenital cardiac surgery trainees. The purpose of this study was to assess high-fidelity simulation as a method to train and improve skills of resident trainees learning critical components of index congenital cardiac surgical procedures.

METHODS

Using 5 neonatal piglets over a period of 2.5 days, the following procedures were simulated: Norwood procedure, arterial switch operation, neonatal Ross procedure, tetralogy of Fallot repair, systemic to pulmonary artery shunt procedures, transmediastinal coarctation repair, atrial septal defect repair, ventricular septal defect repair, and right ventricular to pulmonary artery conduit. Anastomoses were tested with saline, all procedures were timed and video recorded, and resident trainee techniques and skills were critiqued by the instructor.

RESULTS

All aspects of the procedures were simulated with minimal modifications. Anastomoses were tested, and the procedure successfully replicated without the pressures of operative time. Operative techniques involving suture placement in neonatal tissue, depth perception, and patch size estimation were corrected in real time, resulting in observed improvement of surgical skills. Video review allowed for further pedagogic value through examination and documentation of competency.

CONCLUSIONS

This neonatal porcine simulation model allows surgical trainees in congenital heart surgery to make and correct mistakes in a safe and controlled learning environment without compromising patient safety, thereby fostering surgeon competence and confidence.

Landmark lecture on surgery: paediatric cardiothoracic surgery - training the next generation of congenital heart surgeons

Introduction Recent changes in surgical education have had an impact on our congenital training programmes. The mandate of the 8-hour workweek, a rapidly expanding knowledge base, and a host of other mandates has had an impact on the readiness of the fellows who are entering congenital programmes. To understand these issues completely, we interviewed the top congenital experts in the United States of America. The purpose of this paper is to share their insight and offer suggestions to address these challenges.

METHODS

We used a qualitative thematic analysis approach and performed phone interviews with the top five congenital experts in the United States of America.

RESULTS

Experts unanimously felt that duty-hour restrictions have negatively affected congenital training programmes in the following ways: current fellows do not seem as conditioned as fellows in the past, patient handoffs are not consistent with excellent performance, the mentor-mentee relationship has been affected by duty-hour restrictions, and fellows may be less prepared for real-world practice. Three positive themes emerged in response to duty-hour restrictions: fellows appear to be doing less menial task work, fellows are now better rested for learning, and we are attracting more individuals into the speciality. Experts agreed that congenital fellowships should be increased to 2 years. There was support for both the traditional and integrated residency pathways. Discussion We are in a new era of education and must work together to overcome the challenges that have arisen in recent years.

The Effectiveness of Bioskills Training for Simulated Open Lumbar Laminectomy

STUDY DESIGN

Randomized, prospective study within an orthopedic surgery resident program at a large urban academic medical center.

OBJECTIVES

To develop an inexpensive, user-friendly, and reproducible lumbar laminectomy bioskills training module and evaluation protocol that can be readily implemented into residency training programs to augment the clinical education of orthopedic and neurosurgical physicians-in-training.

METHODS

Twenty participants comprising senior medical students and orthopedic surgical residents. Participants were randomized to control (n = 9) or intervention (n = 11) groups controlling for level of experience (medical students, junior resident, or senior resident). The intervention group underwent a 40-minute bioskills training module, while the control group spent the same time with self-directed study. Pre- and posttest performance was self-reported by each participant (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 Decompression Score metrics.

RESULTS

When compared with the control group, the intervention group yielded a significant mean improvement in OSATS (P = .022) and PPDIS (P = .0001) scores. The Objective Decompression Scores improved in the intervention group with a trend toward significance (P = .058).

CONCLUSIONS

We conclude that a concise lumbar laminectomy bioskills training session can be a useful educational tool for to augment clinical education. Although no direct clinical correlation can be concluded from this study, the improvement in trainee's technical and procedural skills suggests that Sawbones training modules can be an efficient and effective tool for teaching fundamental spine surgical skills outside of the operating room.

European status on temporal bone training: a questionnaire study

PURPOSE

In otorhinolaryngology training, introduction to temporal bone surgery through hands-on practice on cadaveric human temporal bones is the gold-standard training method before commencing supervised surgery. During the recent decades, the availability of such specimens and the necessary laboratory facilities for training seems to be decreasing. Alternatives to traditional training can consist of drilling artificial models made of plaster or plastic but also virtual reality (VR) simulation. Nevertheless, the integration and availability of these alternatives into specialist training programs remain unknown.

METHODS

We conducted a questionnaire study mapping current status on temporal bone training and included responses from 113 departments from 23 countries throughout Europe.

RESULTS

In general, temporal bone training during residency in ORL is organized as in-house training, or as participation in national or international temporal bone courses or some combination hereof. There are considerable differences in the availability of training facilities for temporal bone surgery and the number of drillings each ORL trainee can perform. Cadaveric dissection is still the most commonly used training modality.

CONCLUSIONS

VR simulation and artificial models are reported to be used at many leading training departments already. Decreasing availability of cadavers, lower costs of VR simulation and artificial models, in addition to established evidence for a positive effect on the trainees' competency, were reported as the main reasons. Most remaining departments expect to implement VR simulation and artificial models for temporal bone training into their residency programs in the near future.

Evaluation of learning curves for ovariohysterectomy of dogs and cats and castration of dogs

OBJECTIVE To define learning curves for fourth-year veterinary students performing ovariohysterectomy procedures in dogs and cats and castration in dogs. DESIGN Retrospective study. SAMPLE 3,196 ovariohysterectomies or castrations performed in dogs and cats by 88 veterinary students during a spay-neuter surgery and animal shelter rotation (n = 3,056) or by 1 experienced general practitioner (n = 140). PROCEDURES Data collected from medical records included patient signalment, type and duration of procedure, and sequence (by date and time) of the procedure within a list of procedures of the same type generated for each student. For each procedure type, geometric mean surgery time and 95% confidence intervals were determined for each number of surgeries completed by ≥ 10 students. Median surgery times for the same procedure types were determined for the experienced practitioner. The learning curve for each procedure was modeled with nonlinear (3-factor exponential equation with a nonzero asymptote) and linear regression. For each procedure, the asymptote (optimal surgery time) for students was compared with the experienced practitioner's median surgery time. RESULTS 2,945 surgeries (mean, 33/student) performed by ≥ 10 students were analyzed. Surgery time decreased in a nonlinear manner as student experience increased for castration of adult or pediatric dogs and ovariohysterectomy of pediatric dogs and adult or pediatric cats. Surgery time decreased in a linear manner as experience increased for ovariohysterectomy of adult dogs. CONCLUSIONS AND CLINICAL RELEVANCE To the authors' knowledge, this was the first study to map surgery times for common surgical procedures consecutively performed by veterinary students. Results clearly indicated the value of repetition to improve surgical skills (as measured by surgery time) during a 3-week period.

Review article: Critical Care Airway Management eLearning modules

The Australasian College for Emergency Medicine (ACEM) has recently launched the Critical Care Airway Management eLearning modules to support emergency medicine trainees in developing their airway management skills in the ED. A team of emergency physicians and trainees worked collaboratively to develop the eLearning resources ensuring extensive stakeholder consultation. A comprehensive resource manual was written to provide learners with knowledge that underpins the modules. ACEM provided project coordination as well as administrative and technical team support to the production. Although specifically developed with early ACEM trainees in mind, it is envisaged the resources will be useful for all emergency clinicians. The project was funded by the Australian Commonwealth Department of Health.

Easy-to-learn cardiopulmonary resuscitation training programme: a randomised controlled trial on laypeople's resuscitation performance

INTRODUCTION

Simplifying the learning of cardiopulmonary resuscitation (CPR) is advocated to improve skill acquisition and retention. A simplified CPR training programme focusing on continuous chest compression, with a simple landmark tracing technique, was introduced to laypeople. The study aimed to examine the effectiveness of the simplified CPR training in improving lay rescuers' CPR performance as compared to standard CPR.

METHODS

A total of 85 laypeople (aged 21-60 years) were recruited and randomly assigned to undertake either a two-hour simplified or standard CPR training session. They were tested two months after the training on a simulated cardiac arrest scenario. Participants' performance on the sequence of CPR steps was observed and evaluated using a validated CPR algorithm checklist. The quality of chest compression and ventilation was assessed from the recording manikins.

RESULTS

The simplified CPR group performed significantly better on the CPR algorithm when compared to the standard CPR group (p < 0.01). No significant difference was found between the groups in time taken to initiate CPR. However, a significantly higher number of compressions and proportion of adequate compressions was demonstrated by the simplified group than the standard group (p < 0.01). Hands-off time was significantly shorter in the simplified CPR group than in the standard CPR group (p < 0.001).

CONCLUSION

Simplifying the learning of CPR by focusing on continuous chest compressions, with simple hand placement for chest compression, could lead to better acquisition and retention of CPR algorithms, and better quality of chest compressions than standard CPR.

Robotic Mitral Valve Repair

Objective

Adoption of robotic mitral valve surgery has been slow, likely in part because of its perceived technical complexity and a poorly understood learning curve. We sought to correlate changes in technical performance and outcome with surgeon experience in the “learning curve” part of our series.

Methods

From 2006 to 2011, two surgeons undertook robotically assisted mitral valve repair in 458 patients (intent-to-treat); 404 procedures were completed entirely robotically (as-treated). Learning curves were constructed by modeling surgical sequence number semiparametrically with flexible penalized spline smoothing best-fit curves.

Results

Operative efficiency, reflecting technical performance, improved for (1) operating room time for case 1 to cases 200 (early experience) and 400 (later experience), from 414 to 364 to 321 minutes (12% and 22% decrease, respectively), (2) cardiopulmonary bypass time, from 148 to 102 to 91 minutes (31% and 39% decrease), and (3) myocardial ischemic time, from 119 to 75 to 68 minutes (37% and 43% decrease). Composite postoperative complications, reflecting safety, decreased from 17% to 6% to 2% (63% and 85% decrease). Intensive care unit stay decreased from 32 to 28 to 24 hours (13% and 25% decrease). Postoperative stay fell from 5.2 to 4.5 to 3.8 days (13% and 27% decrease). There were no in-hospital deaths. Predischarge mitral regurgitation of less than 2+, reflecting effectiveness, was achieved in 395 (97.8%), without correlation to experience; return-to-work times did not change substantially with experience.

Conclusions

Technical efficiency of robotic mitral valve repair improves with experience and permits its safe and effective conduct.

Systematic Review of Patient-Specific Surgical Simulation: Toward Advancing Medical Education

OBJECTIVE

Simulation-based education has been shown to be an effective tool to teach foundational technical skills in various surgical specialties. However, most of the current simulations are limited to generic scenarios and do not allow continuation of the learning curve beyond basic technical skills to prepare for more advanced expertise, such as patient-specific surgical planning. The objective of this study was to evaluate the current medical literature with respect to the utilization and educational value of patient-specific simulations for surgical training.

METHODS

We performed a systematic review of the literature using Pubmed, Embase, and Scopus focusing on themes of simulation, patient-specific, surgical procedure, and education. The study included randomized controlled trials, cohort studies, and case-control studies published between 2005 and 2016. Two independent reviewers (W.H.R. and N.D) conducted the study appraisal, data abstraction, and quality assessment of the studies.

RESULTS

The search identified 13 studies that met the inclusion criteria; 7 studies employed computer simulations and 6 studies used 3-dimensional (3D) synthetic models. A number of surgical specialties evaluated patient-specific simulation, including neurosurgery, vascular surgery, orthopedic surgery, and interventional radiology. However, most studies were small in size and primarily aimed at feasibility assessments and early validation.

CONCLUSIONS

Early evidence has shown feasibility and utility of patient-specific simulation for surgical education. With further development of this technology, simulation-based education may be able to support training of higher-level competencies outside the clinical settingto aid learners in their development of surgical skills.

Personalized Video Feedback and Repeated Task Practice Improve Laparoscopic Knot-Tying Skills: Two Controlled Trials

PURPOSE

Compare the effect of personalized feedback (PF) vs. task demonstration (TD), both delivered via video, on laparoscopic knot-tying skills and perceived workload; and evaluate the effect of repeated practice.

METHOD

General surgery interns and research fellows completed four repetitions of a simulated laparoscopic knot-tying task at one-month intervals. Midway between repetitions, participants received via e-mail either a TD video (demonstration by an expert) or a PF video (video of their own performance with voiceover from a blinded senior surgeon). Each participant received at least one video per format, with sequence randomly assigned. Outcomes included performance scores and NASA Task Load Index (NASA-TLX) scores. To evaluate the effectiveness of repeated practice, scores from these trainees on a separate delayed retention test were compared against historical controls who did not have scheduled repetitions.

RESULTS

Twenty-one trainees completed the randomized study. Mean change in performance scores was significantly greater for those receiving PF (difference = 23.1 of 150 [95% confidence interval (CI): 0, 46.2], P = .05). Perceived workload was also significantly reduced (difference = -3.0 of 20 [95% CI: -5.8, -0.3], P = .04). Compared with historical controls (N = 93), the 21 with scheduled repeated practice had higher scores on the laparoscopic knot-tying assessment two weeks after the final repetition (difference = 1.5 of 10 [95% CI: 0.2, 2.8], P = .02).

CONCLUSIONS

Personalized video feedback improves trainees' procedural performance and perceived workload compared with a task demonstration video. Brief monthly practice sessions support skill acquisition and retention.

Programmatic Assessment of Professionalism in Psychiatry Education: A Literature Review and Implementation Guide

Programmatic assessment is being adopted as a preferred method of assessment in postgraduate medical education in Australia. Programmatic assessment of professionalism is likely to receive increasing attention. This paper reviews the literature regarding the assessment of professionalism in psychiatry. A search using the terms 'professionalism AND psychiatry' was conducted in the ERIC database. Only original articles relevant to professionalism education and assessment in psychiatry were selected, rather than theoretical or review papers that applied research from other fields of medicine to psychiatry. Articles regarding the need for professionalism education in psychiatry were included as they provided a rationale for curriculum development in this field as a precursor to assessment. Key findings from the literature were summarised in light of the author's own experience as an educator and assessor of both medical students and trainees in psychiatry, and incorporated into a guide to implementing programmatic assessment of professionalism in psychiatry. Within psychiatry, the specific evidence base for use of particular tools in assessing professionalism is limited. However, used in conjunction with psychiatrists' views about what is important in professionalism education, as well as knowledge from other medical disciplines regarding professionalism assessment tools, this evidence can inform implementation of programmatic assessment of professionalism in undergraduate, postgraduate and continuing professional development settings. Given the emergent nature of such assessment initiatives, they should be subjected to rigorous evaluation.

Otologic Skills Training

This article presents a summary of the current simulation training for otologic skills. There is a wide variety of educational approaches, assessment tools, and simulators in use, including simple low-cost task trainers to complex computer-based virtual reality systems. A systematic approach to otologic skills training using adult learning theory concepts, such as repeated and distributed practice, self-directed learning, and mastery learning, is necessary for these educational interventions to be effective. Future directions include development of measures of performance to assess efficacy of simulation training interventions and, for complex procedures, improvement in fidelity based on educational goals.

The Holistic Processing Account of Visual Expertise in Medical Image Perception: A Review

In the field of medical image perception, the holistic processing perspective contends that experts can rapidly extract global information about the image, which can be used to guide their subsequent search of the image (Swensson, 1980; Nodine and Kundel, 1987; Kundel et al., 2007). In this review, we discuss the empirical evidence supporting three different predictions that can be derived from the holistic processing perspective: Expertise in medical image perception is domain-specific, experts use parafoveal and/or peripheral vision to process large regions of the image in parallel, and experts benefit from a rapid initial glimpse of an image. In addition, we discuss a pivotal recent study (Litchfield and Donovan, 2016) that seems to contradict the assumption that experts benefit from a rapid initial glimpse of the image. To reconcile this finding with the existing literature, we suggest that global processing may serve multiple functions that extend beyond the initial glimpse of the image. Finally, we discuss future research directions, and we highlight the connections between the holistic processing account and similar theoretical perspectives and findings from other domains of visual expertise.

Preparing for the American Board of Surgery Flexible Endoscopy Curriculum: Development of multi-institutional proficiency-based training standards and pilot testing of a simulation-based mastery learning curriculum for the Endoscopy Training System

BACKGROUND

The Fundamentals of Endoscopic Surgery (FES) exam is required for American Board of Surgery certification. The purpose of this study was to develop performance standards for a simulation-based mastery learning (SBML) curriculum for the FES performance exam using the Endoscopy Training System (ETS).

METHODS

Experienced endoscopists from multiple institutions and specialties performed each ETS task (scope manipulation (SM), tool targeting (TT), retroflexion (RF), loop management (LM), and mucosal inspection (MI)) with scores used to develop performance standards for a SBML training curriculum. Trainees completed the curriculum to determine feasibility, and effect on FES performance.

RESULTS

Task specific training standards were determined (SM-121sec, TT-243sec, RF-159sec, LM-261sec, MI-180-480sec, 7 polyps). Trainees required 29.5 ± 3.7 training trials over 2.75 ± 0.5 training sessions to complete the SBML curriculum. Despite high baseline FES performance, scores improved (pre 73.4 ± 7, post 78.1 ± 5.2; effect size = 0.76, p > 0.1), but this was not statistically discernable.

CONCLUSIONS

This SBML curriculum was feasible and improved FES scores in a group of high performers. This curriculum should be applied to novice endoscopists to determine effectiveness for FES exam preparation.

Primary palliative care for heart failure: what is it? How do we implement it?

Heart failure (HF) is a chronic and progressive illness, which affects a growing number of adults, and is associated with a high morbidity and mortality, as well as significant physical and psychological symptom burden on both patients with HF and their families. Palliative care is the multidisciplinary specialty focused on optimizing quality of life and reducing suffering for patients and families facing serious illness, regardless of prognosis. Palliative care can be delivered as (1) specialist palliative care in which a palliative care specialist with subspecialty palliative care training consults or co-manages patients to address palliative needs alongside clinicians who manage the underlying illness or (2) as primary palliative care in which the primary clinician (such as the internist, cardiologist, cardiology nurse, or HF specialist) caring for the patient with HF provides the essential palliative domains. In this paper, we describe the key domains of primary palliative care for patients with HF and offer some specific ways in which primary palliative care and specialist palliative care can be offered in this population. Although there is little research on HF primary palliative care, primary palliative care in HF offers a key opportunity to ensure that this population receives high-quality palliative care in spite of the growing numbers of patients with HF as well as the limited number of specialist palliative care providers.

Personalized Learning in Medical Education: Designing a User Interface for a Dynamic Haptic Robotic Trainer for Central Venous Catheterization

While Virtual Reality (VR) has emerged as a viable method for training new medical residents, it has not yet reached all areas of training. One area lacking such development is surgical residency programs where there are large learning curves associated with skill development. In order to address this gap, a Dynamic Haptic Robotic Trainer (DHRT) was developed to help train surgical residents in the placement of ultrasound guided Internal Jugular Central Venous Catheters and to incorporate personalized learning. In order to accomplish this, a 2-part study was conducted to: (1) systematically analyze the feedback given to 18 third year medical students by trained professionals to identify the items necessary for a personalized learning system and (2) develop and experimentally test the usability of the personalized learning interface within the DHRT system. The results can be used to inform the design of VR and personalized learning systems within the medical community.

Development of a Dermatology Diagnostic Techniques Teaching Session: A Nine-Step Approach

Creating effective learning experiences for veterinary clinical skills and procedures can be a challenging task. Drawing from both medical and veterinary education literature and personal experiences as practicing veterinarians and educators, the authors share nine key steps that describe the development process of a pre-clinical veterinary clinical skills teaching session. Relevant research and pedagogical principles supporting the effectiveness of the proposed nine-step process were identified and discussed. The aims of this article were to describe the development of a dermatology techniques teaching session and to provide the reader with a structured approach that can be used as a template to design or audit other clinical skills teaching sessions.

Pursuing Improvement in Clinical Reasoning: Development of the Clinical Coaching Interactions Inventory

BACKGROUND

Clinical coaching has been identified as a signature pedagogy in nursing education. Recent findings indicate that clinical coaching interactions in the clinical learning environment fail to engage students in the higher order thinking skills believed to promote clinical reasoning.

METHOD

The Clinical Coaching Interactions Inventory (CCII) was based on evidence of supervisor questioning techniques, the Tanner clinical judgment model, Bloom's Taxonomy, and simulation evaluation tools. Content validity was established with expert assessment, student testing for clarity, and calculation of scale-content validity index/average (S-CVI/Ave). Reliability was established with Kuder-Richardson Formula 20 (KR-20).

RESULTS

CVI (S-CVI/Ave) was .91, and KR-20 was .70. The CCII identified differences in clinical coaching behaviors in university faculty supervisors and staff nurse preceptor supervisors.

CONCLUSION

The CCII advances the measurement of clinical coaching interactions from qualitative to quantitative. Ultimately, results from use of this inventory may facilitate the design of prelicensure clinical coaching strategies that promote the improvement of students' clinical reasoning skill. [J Nurs Educ. 2016;55(9):495-504.].

Effect of students' determination of testing time on their test performance

This article investigates whether giving students control over preparing for and the moment of taking a test affects their test results in comparison with when the school is in control of the amount of training followed by a predetermined test moment. The students participated in training for manual dexterity. After the training, the students performed a test. The results of the test were stored in a database. Students from the group with freedom to select the moment of the test performed much better than those in the other group who did not have the freedom to select the moment for the test, with significantly fewer students requiring three attempts to pass the test. The fact that students when given the responsibility to develop manual skills performed better than when guided by the policy of the school is hopeful in the sense that students can learn in an early stage of their study to take responsibility for learning.

The SGIM TEACH Program: A Curriculum for Teachers of Clinical Medicine

BACKGROUND

Demand for faculty with teaching expertise is increasing as medical education is becoming well established as a career pathway. Junior faculty may be expected to take on teaching responsibilities with minimal training in teaching skills.

AIM

To address the faculty development needs of junior clinician-educators with teaching responsibilities and those changing their career focus to include teaching.

SETTING

Sessions at two Society of General Internal Medicine (SGIM) annual meetings combined with local coaching and online learning during the intervening year.

PARTICIPANTS

Eighty-nine faculty scholars in four consecutive annual cohorts from 2013 to 2016.

PROGRAM DESCRIPTION

Scholars participate in a full-day core teaching course as well as selective workshops at the annual meetings. Between meetings they receive direct observation and feedback on their teaching from a local coach and participate in an online discussion group.

PROGRAM EVALUATION

Sessions were evaluated using a post-session survey. Overall content rating was 4.48 (out of 5). Eighty-nine percent of participants completed all requirements. Of these, 100% agreed that they had gained valuable knowledge and skills.

DISCUSSION

The TEACH certificate program provides inexperienced faculty teachers an opportunity to develop core skills. Satisfaction is high. Future research should focus on the impact that this and similar programs have on teaching skills.

A primer on the statistical modelling of learning curves in health professions education

Learning curves are a useful way of representing the rate of learning over time. Features include an index of baseline performance (y-intercept), the efficiency of learning over time (slope parameter) and the maximal theoretical performance achievable (upper asymptote). Each of these parameters can be statistically modelled on an individual and group basis with the resulting estimates being useful to both learners and educators for feedback and educational quality improvement. In this primer, we review various descriptive and modelling techniques appropriate to learning curves including smoothing, regression modelling and application of the Thurstone model. Using an example dataset we demonstrate each technique as it specifically applies to learning curves and point out limitations.

Design-Based Comparison of Spine Surgery Simulators: Optimizing Educational Features of Surgical Simulators

BACKGROUND

Simulation-based education has made its entry into surgical residency training, particularly as an adjunct to hands-on clinical experience. However, one of the ongoing challenges to wide adoption is the capacity of simulators to incorporate educational features required for effective learning. The aim of this study was to identify strengths and limitations of spine simulators to characterize design elements that are essential in enhancing resident education.

METHODS

We performed a mixed qualitative and quantitative cohort study with a focused survey and interviews of stakeholders in spine surgery pertaining to their experiences on 3 spine simulators. Ten participants were recruited spanning all levels of training and expertise until qualitative analysis reached saturation of themes. Participants were asked to perform lumbar pedicle screw insertion on 3 simulators. Afterward, a 10-item survey was administrated and a focused interview was conducted to explore topics pertaining to the design features of the simulators.

RESULTS

Overall impressions of the simulators were positive with regards to their educational benefit, but our qualitative analysis revealed differing strengths and limitations. Main design strengths of the computer-based simulators were incorporation of procedural guidance and provision of performance feedback. The synthetic model excelled in achieving more realistic haptic feedback and incorporating use of actual surgical tools.

DISCUSSION

Stakeholders from trainees to experts acknowledge the growing role of simulation-based education in spine surgery. However, different simulation modalities have varying design elements that augment learning in distinct ways. Characterization of these design characteristics will allow for standardization of simulation curricula in spinal surgery, optimizing educational benefit.

Framework for Teaching Psychomotor and Procedural Skills in Nursing

The development of psychomotor and procedural skills requires opportunities for repetitive practice combined with specific, informational feedback from the teacher, another expert, or simulator to correct performance errors. Practice enables learners to refine skills and progress through the phases of motor learning: cognitive, associative, and autonomous. Practice should be spaced over time, can occur in dyads, and can rapidly cycle between practicing and receiving feedback and coaching until skills are mastered. The purpose of this article is to examine psychomotor skill learning in nursing and to suggest strategies for nurse educators in teaching motor and procedural skills in nursing programs, as well as in clinical settings. J Contin Educ Nurs. 2016;47(6):278-282.

A Novel Approach to Study Medical Decision Making in the Clinical Setting: The "Own-point-of-view" Perspective

BACKGROUND

Making diagnostic and therapeutic decisions is a critical activity among physicians. It relies on the ability of physicians to use cognitive processes and specific knowledge in the context of a clinical reasoning. This ability is a core competency in physicians, especially in the field of emergency medicine where the rate of diagnostic errors is high. Studies that explore medical decision making in an authentic setting are increasing significantly. They are based on the use of qualitative methods that are applied at two separate times: 1) a video recording of the subject's actual activity in an authentic setting and 2) an interview with the subject, supported by the video recording. Traditionally, activity is recorded from an "external perspective"; i.e., a camera is positioned in the room in which the consultation takes place. This approach has many limits, both technical and with respect to the validity of the data collected.

OBJECTIVES

The article aims at 1) describing how decision making is currently being studied, especially from a qualitative standpoint, and the reasons why new methods are needed, and 2) reporting how we used an original, innovative approach to study decision making in the field of emergency medicine and findings from these studies to guide further the use of this method. The method consists in recording the subject's activity from his own point of view, by fixing a microcamera on his temple or the branch of his glasses. An interview is then held on the basis of this recording, so that the subject being interviewed can relive the situation, to facilitate the explanation of his reasoning with respect to his decisions and actions.

RESULTS

We describe how this method has been used successfully in investigating medical decision making in emergency medicine. We provide details on how to use it optimally, taking into account the constraints associated with the practice of emergency medicine and the benefits in the study of clinical reasoning.

CONCLUSION

The "own-point-of-view" video technique is a promising method to study clinical decision making in emergency medicine. It is a powerful tool to stimulate recall and help physicians make their reasoning explicit, thanks to a greater psychological immersion.

Pediatric Critical Event Debriefing in Emergency Medicine Training: An Opportunity for Educational Improvement

INTRODUCTION

In the emergency department (ED), critical events, including death and severe illness, are not uncommon. Critical events involving children, while less frequent, may be especially distressing. Debriefing following a critical event may serve several purposes: review of team performance, education, identification of errors, emotional support, and planning for future events. Debriefing skills and habits learned during training may be carried forward throughout an emergency physician's career. This study evaluates how educators in emergency medicine (EM) view debriefing after pediatric critical events and identifies barriers to use of debriefing in postgraduate training programs.

METHODS

In this cross-sectional observational study, we surveyed program directors (PDs) from EM residency and pediatric emergency medicine (PEM) fellowship programs via e-mail listserv. A panel of PEM experts and survey methodologists designed the survey, which was reviewed for content validity by an independent panel of EM educators. We obtained data on current debriefing practices following pediatric critical events, PDs' perceptions of ideal debriefing practices, and barriers to implementation. Data were analyzed using descriptive statistics.

RESULTS

A total of 109 PDs completed the survey (45% overall response rate). All respondents feel that debriefing pediatric critical events is useful. The majority of debriefings are initiated and led by emergency physicians as informal meetings shortly following a critical event. Debriefings are most commonly held following a patient death, although PDs feel that debriefings should also occur for other specific patient scenarios (e.g., child abuse). Barriers to debriefing include timing, scheduling, location, discomfort with debriefing, participant buy-in, and leader buy-in.

CONCLUSIONS

Program leaders in both EM and PEM believe that debriefing after pediatric critical events is important for training. Barriers to debriefing specific to the ED setting should be explored to optimize the implementation of this practice.