Deliberate practice and acquisition of expert performance: a general overview

How to attain expertise in clinical communication?

Several factors complicate the attainment of expertise in clinical communication. Medical curricula and postgraduate training insufficiently provide the required learning conditions of deliberate practice to overcome these obstacles. In this paper we provide recommendations for learning objectives and teaching methods for the attainment of professional expertise in patient education. Firstly, we propose to use functional learning objectives derived from the goals and strategies of clinical communication. Secondly, we recommend using teaching and assessment methods which: (1) contain stimulating learning tasks with opportunities for immediate feedback, reflection and corrections, and (2) give ample opportunity for repetition, gradual refinements and practice in challenging situations. Video-on-the-job fits these requirements and can be used to improve the competency in patient education of residents and medical staff in clinical practice. However, video-on-the-job can only be successful if the working environment supports the teaching and learning of communication and if medical staff which supervises the residents, is motivated to improve their own communication and didactic skills.

Inconsistency of residents' communication performance in challenging consultations

OBJECTIVE

Communication performance inconsistency between consultations is usually regarded as a measurement error that jeopardizes the reliability of assessments. However, inconsistency is an important phenomenon, since it indicates that physicians' communication may be below standard in some consultations.

METHODS

Fifty residents performed two challenging consultations. Residents' communication competency was assessed with the CELI instrument. Residents' background in communication skills training (CST) was also established. We used multilevel analysis to explore communication performance inconsistency between the two consultations. We also established the relationships between inconsistency and average performance quality, the type of consultation, and CST background.

RESULTS

Inconsistency accounted for 45.5% of variance in residents' communication performance. Inconsistency was dependent on the type of consultation. The effect of CST background training on performance quality was case specific. Inconsistency and average performance quality were related for those consultation combinations dissimilar in goals, structure, and required skills. CST background had no effect on inconsistency.

CONCLUSION

Physician communication performance should be of high quality, but also consistent regardless of the type and complexity of the consultation.

PRACTICE IMPLICATIONS

In order to improve performance quality and reduce performance inconsistency, communication education should offer ample opportunities to practice a wide variety of challenging consultations.

Teaching in the ICU

Teaching in the fast-paced, high-pressure environment of the ICU can be very demanding. Thus, the educator-intensivist must learn teaching strategies that are time-efficient, simple, and successful. In this article, we provide an overview of the current and relevant teaching theories and highlight potential obstacles and limitations to teaching in the ICU. In the second part, we discuss a sample of simple approaches to optimize the ICU-rotation curriculum as well as effective techniques to improve teaching, while not compromising quality of care.

Automatic supervision of gestures to guide novice surgeons during training

BACKGROUND

Virtual surgery simulators enable surgeons to learn by themselves, shortening their learning curves. Virtual simulators offer an objective evaluation of the surgeon's skills at the end of each training session. The considered evaluation parameters are based on the analysis of the surgeon's gestures performed throughout the training session. Currently, this information is usually known by surgeons only at the end of the training session, but very limited during the training performance. In this paper, we present a novel method for automatic and interactive evaluation of the surgeon's skills that is able to supervise inexperienced surgeons during their training session with surgical simulators.

METHODS

The method is based on the assumption that the sequence of gestures carried out by an expert surgeon in the simulator can be translated into a sequence (a character string) that should be reproduced by a novice surgeon during a training session. In this work, a string-matching algorithm has been modified to calculate the alignment and distance between the sequences of both expert and novice during the training performance.

RESULTS

The results have shown that it is possible to distinguish between different skill levels at all times during the surgical training session.

CONCLUSIONS

The main contribution of this paper is a method where the difference between an expert's sequence of gestures and a novice's ongoing sequence is used to guide inexperienced surgeons. This is possible by indicating to novices the gesture corrections to be applied during surgical training as continuous expert supervision would do.

Utilizing a novel tool for the comprehensive assessment of resident operative performance

PURPOSE

A mechanism for more effective and comprehensive assessment of surgical residents' performance in the operating room (OR) is needed, especially in light of the new requirements issued by the American Board of Surgery. Furthermore, there is an increased awareness that assessments need to be more meaningful by including not only procedure-specific and general technical skills, but also nontechnical skills (NOTECHS), such as teamwork and communication skills. Our aims were to develop a methodology and create a tool that comprehensively assesses residents' operative performance.

METHODS

A procedure-specific technical skill assessment for laparoscopic colon resections was created through use of task analysis. Components of previously validated tools were added to broaden the assessment to include general technical skills and NOTECHS. Our instrument was then piloted in the OR to measure face and content validity through an iterative process with faculty evaluators. Once the tool was finalized, postgraduate 3 (PG3) and PG5 residents on a 2-month long rotation were assessed by 1 of 4 colorectal surgeons immediately after completing a case together. Construct validity was measured by evaluating the difference in scores between PG3 and PG5 residents' performance as well as the change in scores over the course of the rotation.

RESULTS

Sixty-three assessments were performed. All evaluations were completed within 48 hours of the operation. There was a statistically significant difference between the PG3 and PG5 scores on procedure-specific performance, general technical skills, NOTECHS, and overall performance. Over the course of the rotation, a statistically significant improvement was found in residents' scores on the procedure-specific portion of the assessment but not on the general surgical skills or NOTECHS.

CONCLUSION

This is a feasible, valid, and reliable assessment tool for the comprehensive evaluation of resident performance in the OR. We plan to use this tool to assess resident operative skill development and to improve direct resident feedback.

The roles of deliberate practice and innate ability in developing expertise: evidence and implications

CONTEXT

Medical education research focuses extensively on experience and deliberate practice (DP) as key factors in the development of expert performance. The research on DP minimises the role of individual ability in expert performance. This claim ignores a large body of research supporting the importance of innate individual cognitive differences. We review the relationship between DP and an innate individual ability, working memory (WM) capacity, to illustrate how both DP and individual ability predict expert performance.

METHODS

This narrative review examines the relationship between DP and WM in accounting for expert performance. Studies examining DP, WM and individual differences were identified through a targeted search.

RESULTS

Although all studies support extensive DP as a factor in explaining expertise, much research suggests individual cognitive differences, such as WM capacity, predict expert performance after controlling for DP. The extent to which this occurs may be influenced by the nature of the task under study and the cognitive processes used by experts. The importance of WM capacity is greater for tasks that are non-routine or functionally complex. Clinical reasoning displays evidence of this task-dependent importance of individual ability.

CONCLUSIONS

No single factor is both necessary and sufficient in explaining expertise, and individual abilities such as WM can be important. These individual abilities are likely to contribute to expert performance in clinical settings. Medical education research and practice should identify the individual differences in novices and experts that are important to clinical performance.

The value of preoperative planning

"Better to throw your disasters into the waste paper basket than to consign your patients to the scrap heap" has been a proverb of Jeff Mast, one of the greatest fracture and deformity surgeons in the history of our specialty. Stated slightly more scientifically, one of the major values of simulation is that it allows one to make mistakes in a consequence-free environment. Preoperative planning is the focus of this article. The primary goal is not to provide you with a recipe of how to steps. Rather, the primary goal of this article is to explain why preoperative planning should be standard, to clarify what should be included, and to provide examples of what can happen when planning is ignored. At the end of this, we should all feel the need to approach fracture care more intellectually with forethought, both in our own practices and in our educational system.

Educational strategies for improving clinical reasoning

Clinical reasoning serves as a crucial skill for all physicians regardless of their area of expertise. Helping trainees develop effective and appropriate clinical reasoning abilities is a central aim of medical education. Teaching clinical reasoning however can be a very difficult challenge for practicing physicians. Better understanding of the different cognitive processes involved in physician clinical reasoning provides a foundation from which to guide learner development of effective reasoning skills, while pairing assessment of learner reasoning abilities with understanding of different improvement strategies offers the opportunity to maximize educational efforts for learners. Clinical reasoning errors often can occur as a result of one of four problems in trainees as well as practicing physicians; inadequate knowledge, faulty data gathering, faulty data processing, or faulty metacognition. Educators are encouraged to consider at which point a given learner's reasoning is breaking down. Experimentation with different strategies for improving clinical reasoning can help address learner struggles in each of these domains. In this chapter, various strategies for improving reasoning related to knowledge acquisition, data gathering, data processing, and clinician metacognition will be discussed. Understanding and gaining experience using the different educational strategies will provide practicing physicians with a toolbox of techniques for helping learners improve their reasoning abilities.

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.

Complexity of physiological responses decreases in high-stress musical performance

For musicians, performing in front of an audience can cause considerable apprehension; indeed, performance anxiety is felt throughout the profession, with wide ranging symptoms arising irrespective of age, skill level and amount of practice. A key indicator of stress is frequency-specific fluctuations in the dynamics of heart rate known as heart rate variability (HRV). Recent developments in sensor technology have made possible the measurement of physiological parameters reflecting HRV non-invasively and outside of the laboratory, opening research avenues for real-time performer feedback to help improve stress management. However, the study of stress using standard algorithms has led to conflicting and inconsistent results. Here, we present an innovative and rigorous approach which combines: (i) a controlled and repeatable experiment in which the physiological response of an expert musician was evaluated in a low-stress performance and a high-stress recital for an audience of 400 people, (ii) a piece of music with varying physical and cognitive demands, and (iii) dynamic stress level assessment with standard and state-of-the-art HRV analysis algorithms such as those within the domain of complexity science which account for higher order stress signatures. We show that this offers new scope for interpreting the autonomic nervous system response to stress in real-world scenarios, with the evolution of stress levels being consistent with the difficulty of the music being played, superimposed on the stress caused by performing in front of an audience. For an emerging class of algorithms that can analyse HRV independent of absolute data scaling, it is shown that complexity science performs a more accurate assessment of average stress levels, thus providing greater insight into the degree of physiological change experienced by musicians when performing in public.

Neuroangiography simulation using a silicone model in the angiography suite improves trainee skills

PURPOSE

Simulation techniques in neurosurgical training are becoming more important. The purpose of this study was to determine whether silicone vascular models used in the angiography suite can render improvement in trainee performance and safety in neuroendovascular procedures.

METHODS

10 residents from neurosurgery and radiology training programs were asked to perform a diagnostic angiogram on a silicone based vascular model (United Biologics, Tustin, USA). This was done in the angiography suite with the full biplane fluoroscopy machine (Siemens, Munich, Germany). On their first attempt, they were coached by a faculty member trained in endovascular neurosurgery; on their second attempt, they received coaching only if the procedure had stalled. Technique was scored on multiple criteria by the faculty, and total time and fluoroscopy time were recorded on both attempts.

RESULTS

In this group of 10 residents, overall procedure time significantly decreased from 51 to 42 min (p=0.01), and total fluoro time significantly decreased from 12 to 9 min (p=0.002) between the first attempt and the second attempt. Technical skill increased significantly in navigation, vessel selection, projection setup, and road map usage.

CONCLUSIONS

Silicone vascular models used in the angiography suite, with the clinical working tools and biplane fluoroscopy, provide a valuable experience for training residents in diagnostic angiography, and improved performance and safety.

Application of the "see one, do one, teach one" concept in surgical training

BACKGROUND

The traditional method of teaching in surgery is known as "see one, do one, teach one." However, many have argued that this method is no longer applicable, mainly because of concerns for patient safety. The purpose of this article is to show that the basis of the traditional teaching method is still valid in surgical training if it is combined with various adult learning principles.

METHODS

The authors reviewed literature regarding the history of the formation of the surgical residency program, adult learning principles, mentoring, and medical simulation. The authors provide examples for how these learning techniques can be incorporated into a surgical resident training program.

RESULTS

The surgical residency program created by Dr. William Halsted remained virtually unchanged until recently with reductions in resident work hours and changes to a competency-based training system. Such changes have reduced the teaching time between attending physicians and residents. Learning principles such as experience, observation, thinking, and action and deliberate practice can be used to train residents. Mentoring is also an important aspect in teaching surgical technique. The authors review the different types of simulators-standardized patients, virtual reality applications, and high-fidelity mannequin simulators-and the advantages and disadvantages of using them.

CONCLUSIONS

The traditional teaching method of "see one, do one, teach one" in surgical residency programs is simple but still applicable. It needs to evolve with current changes in the medical system to adequately train surgical residents and also provide patients with safe, evidence-based care.

International overview of high-level simulation education initiatives in relation to critical care

The use of simulation in health care education has become very topical across all professions and specialties in order to improve patient safety and quality of care. In the last decade, the adoption of more realistic simulation-based teaching methodologies, which serves as a bridge between the acquisition and application of clinical skills, knowledge, and attributes, has been accompanied by the development of a multitude of international and national simulation societies. These serve as important exchange fora for educators, clinicians, researchers, and engineers who desire to learn and share their experience and knowledge around simulation-based education. Several countries have derived their own strategy in order to promote the use of such training methodology. Current key national strategies will be presented in this paper alongside a discussion of their expected impact. Various approaches have been adopted and each has their own place and the potential to be adopted by other nations depending on their political, economic or even geographic context. Within the critical care arena, simulation has generated considerable interest and there is a growing evidence base for its use as a learning and teaching strategy within this environment. A number of critical care-related associations and societies are now recognizing simulation as an appropriate pedagogical approach and acknowledging its potential to improve patient care and clinical outcomes. Its implementation should be carefully considered to ensure that developments are based on current best educational practice to maximize the efficiency of these educational interventions.

Teaching ultrasound in a curricular course according to certified EFSUMB standards during undergraduate medical education: a prospective study

BACKGROUND

As a non-invasive and readily available diagnostic tool, ultrasound is one of the most important imaging techniques in medicine. Ultrasound is usually trained during residency preferable according to German Society of Ultrasound in Medicine (DEGUM) standards. Our curriculum calls for undergraduate training in ultrasound of medical students in their 4th year of undergraduate education. An explorative pilot study evaluated the acceptance of this teaching method, and compared it to other practical activities in medical education at Muenster University.

METHODS

240 medical students in their 4th year of undergraduate medical education participated in the training and completed a pre- and post-questionnaire for self-assessment of technical knowledge, self-assurance of the procedure, and motivation in performing ultrasound using a Likert scale. Moreover, students were asked about their interest in pursuing a career in internal medicine. To compare this training to other educational activities a standardized online evaluation tool was used. A direct observation of procedural skills assessment (DOPS) for the first time applied on ultrasound aimed to independently assess the success of our teaching method.

RESULTS

There was a significant increase in technical knowledge and self-assurance (p < 0.001) of the students' self-assessments. The clinical relevance and self-motivation of the teaching were evaluated positively. The students' DOPS results demonstrated proficiency in the understanding of anatomic structures shown in ultrasonographic images, including terminology, machine settings, and transducer frequencies.

CONCLUSIONS

Training ultrasound according to certified DEGUM standards was successful and should be offered in undergraduate medical education. The evaluation of the course affirmed the necessity, quality and clinical relevance of the course with a top ranking score of hands-on training courses within the educational activities of the Medical Faculty of Muenster.

How do attendings perceive housestaff autonomy? Attending experience, hospitalists, and trends over time

BACKGROUND

Graduated supervision is necessary for residents to progress to independence, but it is unclear what factors influence attendings' perception of housestaff autonomy.

OBJECTIVE

To determine if attending characteristics and secular trends are associated with variation in attendings' perception of housestaff autonomy.

DESIGN

Secondary data analysis of monthly survey data collected from 2001 to 2008.

SETTING/PARTICIPANTS

Attending hospitalists and nonhospitalists on teaching internal medicine services at an academic tertiary care center.

MEASUREMENTS

Attendings' perception of intern decision making and resident autonomy.

RESULTS

Response rate was 70% (514/738). Compared with early-career attendings, experienced attendings perceived more intern involvement in decision making (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.17-3.97, P=0.013). Hospitalists perceived less intern involvement in decision making (OR: 0.19, 95% CI: 0.06-0.58, P=0.004) and resident autonomy (OR: 0.27, 95% CI: 0.11-0.66, P=0.004) compared with nonhospitalists. A significant interaction existed between hospitalists and experience; experienced hospitalists perceived more intern decision making (OR: 7.36, 95% CI: 1.86-29.1, P=0.004) and resident autonomy (OR: 5.85, 95% CI: 1.75-19.6, P=0.004) compared with early-career hospitalists. With respect to secular trends, spring season of the academic year was associated with greater perception of intern decision making compared with other seasons (OR: 1.94, 95% CI: 1.18-3.19, P=0.009). The 2003 resident duty-hours restrictions were associated with decreased perception of intern decision making (OR: 0.51, 95% CI: 0.29-0.87, P=0.014) and resident autonomy (OR: 0.49, 95% CI: 0.28-0.86, P=0.012).

CONCLUSIONS

Perception of housestaff autonomy varies with attending characteristics and time trends. Hospitalists perceive autonomy and clinical decision making differently, depending on their attending experience.

Teaching and assessing procedural skills: a qualitative study

BACKGROUND

Graduating Internal Medicine residents must possess sufficient skills to perform a variety of medical procedures. Little is known about resident experiences of acquiring procedural skills proficiency, of practicing these techniques, or of being assessed on their proficiency. The purpose of this study was to qualitatively investigate resident 1) experiences of the acquisition of procedural skills and 2) perceptions of procedural skills assessment methods available to them.

METHODS

Focus groups were conducted in the weeks following an assessment of procedural skills incorporated into an objective structured clinical examination (OSCE). Using fundamental qualitative description, emergent themes were identified and analyzed.

RESULTS

Residents perceived procedural skills assessment on the OSCE as a useful formative tool for direct observation and immediate feedback. This positive reaction was regularly expressed in conjunction with a frustration with available assessment systems. Participants reported that proficiency was acquired through resident directed learning with no formal mechanism to ensure acquisition or maintenance of skills.

CONCLUSIONS

The acquisition and assessment of procedural skills in Internal Medicine programs should move toward a more structured system of teaching, deliberate practice and objective assessment. We propose that directed, self-guided learning might meet these needs.

Validating a global rating scale to monitor individual resident learning curves during arthroscopic knee meniscal repair

PURPOSE

To determine whether a global rating scale (GRS) with construct validity can also be used to assess the learning curve of individual orthopaedic trainees during simulated arthroscopic knee meniscal repair.

METHODS

An established arthroscopic GRS was used to evaluate the technical skill of 19 orthopaedic residents performing a standardized arthroscopic meniscal repair in a bioskills laboratory. The residents had diagnostic knee arthroscopy experience but no experience with arthroscopic meniscal repair. Residents were videotaped performing an arthroscopic meniscal repair on 12 separate occasions. Their performance was assessed by use of the GRS and motion analysis objectively measuring the time taken to complete tasks, path length of the subject's hands, and number of hand movements. One author assessed all 228 videos, whereas 2 other authors rated 34 randomly selected videos, testing the interobserver reliability of the GRS. The validity of the GRS was tested against the motion analysis.

RESULTS

Objective assessment with motion analysis defined the surgeon's learning curve, showing significant improvement by each subject over 12 episodes (P < .0001). The GRS also showed a similar learning curve with significant improvements in performance (P < .0001). The median GRS score improved from 15 of 34 (interquartile range, 14 to 17) at baseline to 22 of 34 (interquartile range, 19 to 23) in the final period. There was a moderate correlation (P < .0001, Spearman test) between the GRS and motion analysis parameters (r = -0.58 for time, r = -0.58 for path length, and r = -0.51 for hand movements). The inter-rater reliability among 3 trained assessors using the GRS was excellent (Cronbach α = 0.88).

CONCLUSIONS

When compared with motion analysis, an established arthroscopic GRS, with construct validity, also offers a moderately feasible method to monitor the learning curve of individual residents during simulated knee meniscal repair.

CLINICAL RELEVANCE

An arthroscopic GRS can be used for monitoring skill improvement during knee meniscal repair and has the potential for use as a training and assessment tool in the real operating room.

Teaching medical students a clinical approach to altered mental status: simulation enhances traditional curriculum

INTRODUCTION

Simulation-based medical education (SBME) is increasingly being utilized for teaching clinical skills in undergraduate medical education. Studies have evaluated the impact of adding SBME to third- and fourth-year curriculum; however, very little research has assessed its efficacy for teaching clinical skills in pre-clerkship coursework. To measure the impact of a simulation exercise during a pre-clinical curriculum, a simulation session was added to a pre-clerkship course at our medical school where the clinical approach to altered mental status (AMS) is traditionally taught using a lecture and an interactive case-based session in a small group format. The objective was to measure simulation's impact on students' knowledge acquisition, comfort, and perceived competence with regards to the AMS patient.

METHODS

AMS simulation exercises were added to the lecture and small group case sessions in June 2010 and 2011. Simulation sessions consisted of two clinical cases using a high-fidelity full-body simulator followed by a faculty debriefing after each case. Student participation in a simulation session was voluntary. Students who did and did not participate in a simulation session completed a post-test to assess knowledge and a survey to understand comfort and perceived competence in their approach to AMS.

RESULTS

A total of 154 students completed the post-test and survey and 65 (42%) attended a simulation session. Post-test scores were higher in students who attended a simulation session compared to those who did not (p<0.001). Students who participated in a simulation session were more comfortable in their overall approach to treating AMS patients (p=0.05). They were also more likely to state that they could articulate a differential diagnosis (p=0.03), know what initial diagnostic tests are needed (p=0.01), and understand what interventions are useful in the first few minutes (p=0.003). Students who participated in a simulation session were more likely to find the overall AMS curriculum useful (p<0.001).

CONCLUSION

Students who participated in a simulation exercise performed better on a knowledge-based test and reported increased comfort and perceived competence in their clinical approach to AMS. SBME shows significant promise for teaching clinical skills to medical students during pre-clinical curriculum.

Depicting adverse events in cardiac theatre: the preliminary conception of the RECORD model

Human error is a byproduct of the human activity and may results in random unintended events; they may have major consequences when it comes to delivery of medicine. Furthermore the causes of error in surgical practice are multifaceted and complex. This article aims to raise awareness for safety measures in the cardiac surgical room and briefly "touch upon" the human factors that could lead to adverse outcomes. Finally, we describe a model that would enable us to depict and study adverse events in the operating theatre.

A theoretical framework for simulation in nursing: answering Schiavenato's call

The aim of this article was to provide a response that supports and extends Schiavenato's call for a theoretically guided approach to simulation use in nursing education.We propose that a theoretical framework for simulation In nursing must first include, as a basis, a theoretical understanding of human performance and how it is enhanced.This understanding will, in turn, allow theorists to provide a framework regarding the utility, application, and design of the training environment, including internal and external validity. The expert performance approach, a technique that recently has been termed Expert-Performance-based Training (ExPerT), is introduced as a guiding frame work for addressing these training needs. We also describe how the theory of deliberate practice within the framework of ExPerT can be useful for developing effective training methods in health care domains and highlight examples of how deliberate practice has been successfully applied to the training of psychomotor and cognitive skills.

A qualitative analysis of faculty motivation to participate in otolaryngology simulation boot camps

OBJECTIVES/HYPOTHESIS

To characterize factors that motivate faculty to participate in Simulation-Based Boot Camps (SBBC); to assess whether prior exposure to Simulation-Based Medical Education (SBME) or duration (years) of faculty practice affects this motivation.

STUDY DESIGN

Qualitative content analysis of semi-structured interviews of faculty.

METHODS

Interviews of 35 (56%) of 62 eligible faculty including demographic questions, and scripted, open-ended questions addressing motivation. Interviews were recorded, transcribed, de-identified, coded and analyzed using qualitative analysis software. Demographic characteristics were described. Emerging response categories were organized into themes contributing to both satisfaction and dissatisfaction.

RESULTS

Three major themes of faculty motivation emerged: enjoyment of teaching and camaraderie; benefits to residents, patients and themselves; and opportunities to learn or improve their own patient care and teaching techniques. Expense, and time away from work and family, were identified as challenges. Faculty with many versus few years in practice revealed a greater interest in diversity of teaching experiences and techniques. Comparison of faculty with extensive versus limited simulation experience yielded similar motivations.

CONCLUSION

Enjoyment of teaching; benefits to all participants; and opportunities for self-improvement emerged as themes of faculty motivation to participate in SBBC. SBBC have unique characteristics which provide an opportunity to facilitate teaching experiences that motivate faculty.

Defining the purpose of phantom head

Simulation is a vital part of the learning of restorative dentistry. It provides the student with motor and procedural skills that would be impossible to learning in any other way. However, in order to use preclinical simulation most effectively, its limits need to be understood. Discussion of these rarely appears in the literature. This article identifies some of the purposes of simulation found in more general literature on the subject, and applies these to preclinical dentistry. It also describes some of the limits to simulation in the teaching of restorative dentistry.

The objective assessment of experts' and novices' suturing skills using an image analysis program

PURPOSE

To objectively assess suturing performance using an image analysis program and to provide validity evidence for this assessment method by comparing experts' and novices' performance.

METHOD

In 2009, the authors used an image analysis program to extract objective variables from digital images of suturing end products obtained during a previous study involving third-year medical students (novices) and surgical faculty and residents (experts). Variables included number of stitches, stitch length, total bite size, travel, stitch orientation, total bite-size-to-travel ratio, and symmetry across the incision ratio. The authors compared all variables between groups to detect significant differences and two variables (total bite-size-to-travel ratio and symmetry across the incision ratio) to ideal values.

RESULTS

Five experts and 15 novices participated. Experts' and novices' performances differed significantly (P < .05) with large effect sizes attributable to experience (Cohen d > 0.8) for total bite size (P = .009, d = 1.5), travel (P = .045, d = 1.1), total bite-size-to-travel ratio (P < .0001, d = 2.6), stitch orientation (P = .014,d = 1.4), and symmetry across the incision ratio (P = .022, d = 1.3).

CONCLUSIONS

The authors found that a simple computer algorithm can extract variables from digital images of a running suture and rapidly provide quantitative summative assessment feedback. The significant differences found between groups confirm that this system can discriminate between skill levels. This image analysis program represents a viable training tool for objectively assessing trainees' suturing, a foundational skill for many medical specialties.

Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study

Background

Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today’s youth (ie, the digital native generation).

Objective

Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training.

Methods

In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables.

Results

The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use.

Conclusions

By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training.

Simulator training on pulsatile vascular models significantly improves surgical skills and the quality of carotid patch plasty

OBJECTIVE

Vascular surgeons perform numerous highly sophisticated and delicate procedures. Due to restrictions in training time and the advent of endovascular techniques, new concepts including alternative environments for training and assessment of surgical skills are required. Over the past decade, training on simulators and synthetic models has become more sophisticated and lifelike. This study was designed to evaluate the impact of a 3-day intense training course in open vascular surgery on both specific and global vascular surgical skills.

METHODS

Prospective observational cohort analysis with various parameter measurements of both surgical skills and the technical quality of the finished product, performed before and after 3 days of simulator training of 10 participants (seven male and three female) in a vascular surgery training course. The simulator model used was a conventional carotid endarterectomy with a Dacron patch plasty on a lifelike carotid bench model under pulsatile pressure. The primary end points were assessment of any changes in the participants' surgical skills and in the technical quality of their completed carotid patches documented by procedure-based assessment forms. Scores ranging from 1 (inadequate) to 5 (excellent) were compared by a related-sample Wilcoxon signed test. Interobserver reliability was estimated by Cronbach's alpha (CA).

RESULTS

A significant improvement in surgical skills tasks was observed (P < .001). The mean score increased significantly by 21.5% from fair (3.43 ± 0.93) to satisfactory (4.17 ± 0.69; P < .001). The mean score for the quality of the carotid patch increased significantly by 0.96 (27%) from fair (3.55 ± 0.87) to satisfactory (4.51 ± 0.76; P < .01). The median interassessor reliability for the quality of the carotid patch was acceptable (CA = 0.713) and for surgical skills was low (CA = 0.424).

CONCLUSIONS

This study shows that lifelike simulation featuring pulsatile flow can increase surgical skills and technical quality in a highly sophisticated multistep vascular intervention. This training provides comparatively inexpensive and lifelike training possibilities for the adoption and assessment of surgical skills required to perform delicate vascular surgical procedures.

How is clinical reasoning developed, maintained, and objectively assessed? Views from expert internists and internal medicine interns

INTRODUCTION

There is limited understanding of how clinical reasoning is developed, maintained, and objectively assessed. Using the theoretical lens of deliberate practice, we explored physicians' views on clinical reasoning. We compared responses from internists (faculty) and internal medicine interns, to identify potential qualitative and/or quantitative differences in how clinical reasoning is developed and maintained.

METHODS

Participants' free-text comments regarding how clinical reasoning is developed, maintained, and objectively assessed were analyzed. Three investigators coded responses using a constant-comparative, grounded theory approach. We also compared the frequencies of each theme between the 2 groups.

RESULTS

Twenty-two faculty and 17 interns participated in this study. Faculty and intern themes for how clinical reasoning is developed, maintained, and objectively assessed were similar, but quantitative and qualitative differences emerged. Interrater reliability of themes was high (overall kappa: 0.92; range: 0.88-0.98). Only experts (faculty) mentioned the value of teaching for development and maintenance of clinical reasoning. Interns focused on knowledge acquisition activities and use of online resources. Experts and intern participants both struggled with how to best measure clinical reasoning; direct observation was rarely mentioned as a strategy.

DISCUSSION

Consistent with our theoretical expectations, we found quantitative and qualitative differences in participants' responses, which have implications for teaching and assessment of clinical reasoning. By capturing the types of activities and their relative frequencies within and between these groups, this work adds to the deliberate practice literature.

Education in patient-physician communication: how to improve effectiveness?

OBJECTIVE

Despite educational efforts expertise in communication as required by the CanMEDS competency framework is not achieved by medical students and residents. Several factors complicate the learning of professional communication.

METHODS

We adapted the reflective-impulsive model of social behaviour to explain the complexities of learning professional communication behaviour. We formulated recommendations for the learning objectives and teaching methods of communication education. Our recommendations are based on the reflective-impulsive model and on the model of deliberate practice which complements the reflective-impulsive model. Our recommendations are substantiated by those we found in the literature.

RESULTS

The reflective-impulsive model explains why the results of communication education fall below expectations and how expertise in communication can be attained by deliberate practice. The model of deliberate practice specifies learning conditions which are insufficiently fulfilled in current communication programmes.

CONCLUSION

The implementation of our recommendations would require a great deal of effort. Therefore we doubt whether expertise in professional communication can be fully attained during medical training.

PRACTICE IMPLICATIONS

We propose that the CanMEDS communication competencies not be regarded as endpoints in medical education but as guidelines to improve communication competency through deliberate practice throughout a professional career.

The role of specialisation in the promotion of young football talents: a person-oriented study

This paper investigates the controversial question whether it is more effective to promote specialisation in a specific sport at the beginning of a career or whether to encourage a broad range of sports when promoting competitive sports talents in order for them to achieve a high level of performance in adulthood. The issue of promoting talents depends on human developmental processes and therefore raises developmental scientific questions. Based on recent, dynamic-interactionist concepts of development, we assume a person-oriented approach focussing on the person as a whole rather than individual features. Theoretical considerations lead to four interacting factors being summarised to form a subsystem: childhood training. The relative weights of these factors lead to patterns. By relating these to a performance criterion at the age of peak performance, particularly promising developmental patterns may be identified. One hundred fifty-nine former Swiss football talents were retrospectively interviewed about their career and the data analysed using the LICUR method. Two early career patterns were identified as having a favourable influence on adult performance. Both are characterised by an above-average amount of in-club training. One pattern also exhibits an above-average amount of informal football played outside the club, the other above-average scores for activity in other sports. Hence, comprehensive training and practice inside and outside the club form the basis for subsequent football expertise.

Experience curves as an organizing framework for deliberate practice in emergency medicine learning

Deliberate practice is an important skill-training strategy in emergency medicine (EM) education. Learning curves display the relationship between practice and proficiency. Forgetting curves show the opposite, and demonstrate how skill decays over time when it is not reinforced. Using examples of published studies of deliberate practice in EM we list the properties of learning and forgetting curves and suggest how they can be combined to create experience curves: a longitudinal representation of the relationship between practice, skill acquisition, and decay over time. This framework makes explicit the need to avoid a piecemeal, episodic approach to skill practice and assessment in favor of more emphasis on what can be done to improve durability of competence over time. The authors highlight the implications for both educators and education researchers.

The emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives

Simulation-based educational processes are emerging as key tools for assessing and improving patient safety. Multidisciplinary or interprofessional simulation training can be used to optimize crew resource management and safe communication principles. There is good evidence that simulation training improves self-confidence, knowledge, and individual and team performance on manikins. Emerging evidence supports that procedural simulation, deliberate practice, and debriefing can also improve operational performance in clinical settings and can result in safer patient and population/system outcomes in selected settings. This article highlights emerging evidence that shows how simulation-based interventions and education contribute to safer, more efficient systems of care that save lives.

A suggested core content for education scholarship fellowships in emergency medicine

A working group at the 2012 Academic Emergency Medicine consensus conference on education research in emergency medicine (EM) convened to develop a curriculum for dedicated postgraduate fellowships in EM education scholarship. This fellowship is intended to create future education scholars, equipped with the skills to thrive in academic careers. This proceedings article reports on the consensus of a breakout session subgroup tasked with defining a common core content for education scholarship fellowships. The authors propose that the core content of an EM education scholarship fellowship can be categorized in four distinct areas: career development, theories of learning and teaching methods, education research methods, and educational program administration. This core content can be incorporated into curricula for education scholarship fellowships in EM or other fields and can also be adapted for use in general medical education fellowships.

Assessing patient care: summary of the breakout group on assessment of observable learner performance

There is an established expectation that physicians in training demonstrate competence in all aspects of clinical care prior to entering professional practice. Multiple methods have been used to assess competence in patient care, including direct observation, simulation-based assessments, objective structured clinical examinations (OSCEs), global faculty evaluations, 360-degree evaluations, portfolios, self-reflection, clinical performance metrics, and procedure logs. A thorough assessment of competence in patient care requires a mixture of methods, taking into account each method's costs, benefits, and current level of evidence. At the 2012 Academic Emergency Medicine (AEM) consensus conference on educational research, one breakout group reviewed and discussed the evidence supporting various methods of assessing patient care and defined a research agenda for the continued development of specific assessment methods based on current best practices. In this article, the authors review each method's supporting reliability and validity evidence and make specific recommendations for future educational research.

Influence of clinical experience and productivity on emergency medicine faculty teaching scores

BACKGROUND

Commonly cited barriers to effective teaching in emergency medicine include lack of time, competing demands for patient care, and a lack of formal teaching experience. Teaching may be negatively affected by demands for increased clinical productivity, or positively influenced by clinical experience.

OBJECTIVE

To examine the association between faculty teaching scores and clinical productivity, years of clinical experience, and amount of clinical contact with resident physicians.

METHODS

We conducted a retrospective, observational study with existing data on full-time faculty at a high-volume, urban emergency medicine residency training program for academic year 2008-2009. Residents rated faculty on 9 domains of teaching, including willingness to teach, enthusiasm for teaching, medical knowledge, preparation, and communication. Clinical productivity data for relative value units per hour and number of patients per hour, years of clinical experience, and annual clinical hours were obtained from existing databases.

RESULTS

For the 25 core faculty members included in the study, there was no relationship between faculty teaching scores and clinical productivity measures (relative value units per hour: r (2)  =  0.01, P  =  .96, patients per hour: r (2)  =  0.00, P  =  .76), or between teaching scores and total clinical hours with residents (r (2)  =  0.07, P  =  .19). There was a significant negative relationship between years of experience and teaching scores (r (2)  =  0.27, P < .01).

CONCLUSIONS

Our study demonstrated that teaching scores for core emergency medicine faculty did not correlate with clinical productivity or amount of clinical contact with residents. Teaching scores were inversely related to number of years of clinical experience, with more experienced faculty earning the lowest teaching scores. Further study is necessary to determine if there are clinical measures that identify good educators.

Learning through inter- and intradisciplinary problem solving: using cognitive apprenticeship to analyse doctor-to-doctor consultation

Today's healthcare can be characterised by the increasing importance of specialisation that requires cooperation across disciplines and specialities. In view of the number of educational programmes for interdisciplinary cooperation, surprisingly little is known on how learning arises from interdisciplinary work. In order to analyse the learning and teaching practices of interdisciplinary cooperation, a multiple case study research focused on how consults, i.e., doctor-to-doctor consultations between medical doctors from different disciplines were carried out: semi-structured interviews with doctors of all levels of seniority from two hospital sites in Switzerland were conducted. Starting with a priori constructs based on the 'methods' underpinning cognitive apprenticeship (CA), the transcribed interviews were analysed according to the principles of qualitative content analysis. The research contributes to three debates: (1) socio-cognitive and situated learning, (2) intra- and interdisciplinary learning in clinical settings, and (3), more generally, to cooperation and problem solving. Patient cases, which necessitate the cooperation of doctors in consults across boundaries of clinical specialisms, trigger intra- as well as interdisciplinary learning and offer numerous and varied opportunities for learning by requesting doctors as well as for on-call doctors, in particular those in residence. The relevance of consults for learning can also be verified from the perspective of CA which is commonly used by experts, albeit in varying forms, degrees of frequency and quality, and valued by learners. Through data analysis a model for collaborative problem-solving and help-seeking was developed which shows the interplay of pedagogical 'methods' of CA in informal clinical learning contexts.