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

Evidence-based practice behaviours: a comparison amongst occupational therapy students and clinicians

BACKGROUND

Occupational therapy graduates are expected to demonstrate entry-level competencies in evidence-based practice. To support students during the course of professional education in developing the knowledge, skills, and attitudes for integrating scientific findings into clinical practice, educators must identify the process by which these competencies are developed.

PURPOSE

To identify the differences in evidence-based practice decisions amongst occupational therapy students and experienced clinicians.

METHODS

Using a vignette depicting an older client with a history of falls, participants' evidence-based practice decisions were compared to a reference model.

RESULTS

In the initial steps of the process, knowledge of evidence-based practice concepts appeared to be dependent upon formal instruction, whereas expert-like behaviours in the integration of evidence for decision-making seemed to be a function of clinical experience.

IMPLICATIONS

Academic and clinical educators can use identified gaps in knowledge and synthesis of concepts to update the evidence-based practice content in occupational therapy curricula and fieldwork.

Student uncertainties drive teaching during case presentations: more so with SNAPPS

PURPOSE

To compare the nature of uncertainties expressed by medical students using the six-step SNAPPS technique for case presentations (Summarize history and findings; N>arrow the differential; Analyze the differential; Probe preceptors about uncertainties; Plan management; Select case-related issues for self-study) versus those expressed by students doing customary presentations and to elucidate how preceptors respond.

METHOD

The authors performed a secondary analysis in 2009 of data from a 2004-2005 randomized study, comparing SNAPPS users' case presentations with other students' presentations. Authors coded transcriptions of audiotaped presentations to family medicine preceptors for type of student uncertainties, nature of preceptor responses, alignment of preceptor responses with uncertainty types, and expansion of preceptors' responses beyond addressing uncertainties.

RESULTS

The analysis included 19 SNAPPS and 41 comparison presentations. SNAPPS students expressed uncertainties in all case presentations, nearly twice as many as the comparison group (χ1df = 12.89, P = .0001). Most SNAPPS users' uncertainties (24/44 [55%]) focused on diagnostic reasoning compared with 9/38 (24%) for comparison students' (χ1df = 8.08, P = .004). Uncertainties about clinical findings and medications/management did not differ significantly between groups. Preceptors responded with teaching aligned with the uncertainties and expanded 24/66 (36%) of their comments.

CONCLUSION

Students can drive the content of the teaching they receive based on uncertainties they express to preceptors during case presentations. Preceptors are ready to teach at "the drop of a question" and align their teaching with the content of students' questions; these learning moments-in context and just-in-time-can be created by students.

Content and conceptual frameworks of preceptor feedback related to residents' educational needs

PURPOSE

The development of clinical expertise depends not only on frequent practice opportunities but also on receiving quality feedback, especially regarding difficult aspects of learning. The purpose of this study was to investigate the content and conceptual frameworks of preceptor feedback to residents during case presentations.

METHOD

The authors conducted a qualitative and correlational study in which 25 clinical preceptors from one Canadian medical school's internal medicine and family medicine residency programs responded to six written, case-based vignettes depicting residents seeking help regarding a variety of educational issues. Preceptors were asked probing follow-up questions about their responses. The authors analyzed response content, conceptual frameworks used in formulating responses, and the correlation between the two.

RESULTS

Overall, the preceptors generated 806 responses, representing 96 distinct topics. The five topics mentioned most frequently related to reading suggestions, leading diagnosis, contrasting clinical findings, patient follow-up, and resident's concerns/feelings about the case. Seventy-three percent of the topics were specific to one or two vignettes. The preceptors used 18 distinct conceptual frameworks in formulating responses (e.g., analytical versus nonanalytical reasoning, problem representation, therapeutic alliance, patient-centered approach). Use of conceptual frameworks was positively associated with greater diversity of responses (r = 0.43, P = .03).

CONCLUSIONS

The vignettes stimulated rich and extensive lists of topics and conceptual frameworks. These findings represent but one step in the exploration of the content and conceptual frameworks of preceptor feedback and of the interrelatedness of feedback content and process, which have important implications for teaching and faculty development.

Evolution of the Pediatric Advanced Life Support course: enhanced learning with a new debriefing tool and Web-based module for Pediatric Advanced Life Support instructors

OBJECTIVE

To describe the history of the Pediatric Advanced Life Support course and outline the new developments in instructor training that will impact the way debriefing is conducted during Pediatric Advanced Life Support courses.

OUTLINE

The Pediatric Advanced Life Support course, first released by the American Heart Association in 1988, has seen substantial growth and change over the past few decades. Over that time, Pediatric Advanced Life Support has become the standard for resuscitation training for pediatric healthcare providers in North America. The incorporation of high-fidelity simulation-based learning into the most recent version of Pediatric Advanced Life Support has helped to enhance the realism of scenarios and cases, but has also placed more emphasis on the importance of post scenario debriefing. We developed two new resources: an online debriefing module designed to introduce a new model of debriefing and a debriefing tool for real-time use during Pediatric Advanced Life Support courses, to enhance and standardize the quality of debriefing by Pediatric Advanced Life Support instructors. In this article, we review the history of Pediatric Advanced Life Support and Pediatric Advanced Life Support instructor training and discuss the development and implementation of the new debriefing module and debriefing tool for Pediatric Advanced Life Support instructors.

CONCLUSION

The incorporation of the debriefing module and debriefing tool into the 2011 Pediatric Advanced Life Support instructor materials will help both new and existing Pediatric Advanced Life Support instructors develop and enhance their debriefing skills with the intention of improving the acquisition of knowledge and skills for Pediatric Advanced Life Support students.

Remote evaluation of laparoscopic performance using the global operative assessment of laparoscopic skills

BACKGROUND

Although numerous assessment tools currently exist to evaluate laparoscopic surgical skills, no studies have demonstrated the reliability of such tools when used with telementoring technology. This study aimed to determine the reliability of the Global Operative Assessment of Laparoscopic Skills (GOALS) rating scale for assessing laparoscopic skills remotely and to identify how factors unique to remote assessment such as bandwidth and image quality influence its reliability.

METHODS

Four trained observers evaluated 19 participants for their technical performance during a laparoscopic cholecystectomy using the GOALS assessment tool. One observer assessed the study participants directly in the operating room, whereas the three remaining observers were randomly assigned and blinded to a high- (1.5 Mbps), medium- (256 kbps), or low- (64.4 kbps) bandwidth restriction and observed remotely via Skype. The Maryland Visual Comfort Scale was used to evaluate the video quality of the respective connections.

RESULTS

The intraclass correlation coefficient (ICC) calculated for the total GOALS score demonstrated a statistically significant correlation of high, medium, and low bandwidths respectively with ICC 0.693 (95 % confidence interval [CI], 0.226-0.883), 0.518 (95 % CI 0.089-0.783), and 0.499 (95 % CI 0.025-0.781). There was a statistically significant difference in the overall perceived visual quality between the high/low (Z = -3.222; P = 0.001) and the medium/low (Z = -3.567; P < 0.001) bandwidth comparison but no difference between the high/medium bandwidths (Z = -0.610; P = 0.542).

CONCLUSION

The data suggest that the GOALS assessment tool retains its reliability for intraoperative assessment of laparoscopic skills when used remotely. This is a key requirement in telesimulation programs allowing for structured feedback between the mentor and the mentee. This study quantifies the effect that bandwidth has on the reliability of remote assessment, demonstrating that higher bandwidths improve the utility of these tools.

Assessment for simulation learning outcomes: a comparison of knowledge and self-reported confidence with observed clinical performance

BACKGROUND

With extensive use of simulation in nursing education, researchers around the world are evaluating learning outcomes from simulation. Numerous studies reported the use of knowledge tests and self-reported measures to evaluate simulation outcomes.

AIM

To determine whether self-reported confidence and knowledge measures are indicators of clinical performance observed in a simulation-based assessment.

METHOD

Thirty-one third year nursing students were randomized into intervention and control group. The intervention group received a six hour simulation-based programme in care of a patient with physiological deterioration. Pre and post-tests using knowledge test, confidence scale and simulation-based assessment were conducted immediately before and after the simulation program.

RESULTS

The intervention group had a significantly higher post-test mean score than the control group for knowledge and clinical performances. Both groups demonstrated a significant improvement on post-test scores from pre-test scores for self-confidence with no significant differences detected among the two groups. Correlation tests indicated no significant correlation between self-confidence and clinical performance, and between knowledge and clinical performance.

CONCLUSION

The study did not provide evidence to support the validity of the knowledge test and self-confidence measures for predicting clinical performance. Most importantly, it revealed potential danger of a simulation-based assessment that could lead toward overestimation of self-confidence.

Virtual reality simulator training of laparoscopic cholecystectomies - a systematic review

BACKGROUND AND AIMS

Simulators are widely used in occupations where practice in authentic environments would involve high human or economic risks. Surgical procedures can be simulated by increasingly complex and expensive techniques. This review gives an update on computer-based virtual reality (VR) simulators in training for laparoscopic cholecystectomies.

MATERIALS AND METHODS

From leading databases (Medline, Cochrane, Embase), randomised or controlled trials and the latest systematic reviews were systematically searched and reviewed. Twelve randomised trials involving simulators were identified and analysed, as well as four controlled studies. Furthermore, seven studies comparing black boxes and simulators were included.

RESULTS

The results indicated any kind of simulator training (black box, VR) to be beneficial at novice level. After VR training, novice surgeons seemed to be able to perform their first live cholecystectomies with fewer errors, and in one trial the positive effect remained during the first ten cholecystectomies. No clinical follow-up data were found. Optimal learning requires skills training to be conducted as part of a systematic training program. No data on the cost-benefit of simulators were found, the price of a VR simulator begins at EUR 60 000.

CONCLUSIONS

Theoretical background to learning and limited research data support the use of simulators in the early phases of surgical training. The cost of buying and using simulators is justified if the risk of injuries and complications to patients can be reduced. Developing surgical skills requires repeated training. In order to achieve optimal learning a validated training program is needed.

Simulation in clinical teaching and learning

Simulation-based education (SBE) is a rapidly developing method of supplementing and enhancing the clinical education of medical students. Clinical situations are simulated for teaching and learning purposes, creating opportunities for deliberate practice of new skills without involving real patients. Simulation takes many forms, from simple skills training models to computerised full-body mannequins, so that the needs of learners at each stage of their education can be targeted. Emerging evidence supports the value of simulation as an educational technique; to be effective it needs to be integrated into the curriculum in a way that promotes transfer of the skills learnt to clinical practice. Currently, SBE initiatives in Australia are fragmented and depend on local enthusiasts; Health Workforce Australia is driving initiatives to develop a more coordinated national approach to optimise the benefits of simulation.

Simulation-based education with mastery learning improves residents' lumbar puncture skills

OBJECTIVE

To evaluate the effect of simulation-based mastery learning (SBML) on internal medicine residents' lumbar puncture (LP) skills, assess neurology residents' acquired LP skills from traditional clinical education, and compare the results of SBML to traditional clinical education.

METHODS

This study was a pretest-posttest design with a comparison group. Fifty-eight postgraduate year (PGY) 1 internal medicine residents received an SBML intervention in LP. Residents completed a baseline skill assessment (pretest) using a 21-item LP checklist. After a 3-hour session featuring deliberate practice and feedback, residents completed a posttest and were expected to meet or exceed a minimum passing score (MPS) set by an expert panel. Simulator-trained residents' pretest and posttest scores were compared to assess the impact of the intervention. Thirty-six PGY2, 3, and 4 neurology residents from 3 medical centers completed the same simulated LP assessment without SBML. SBML posttest scores were compared to neurology residents' baseline scores.

RESULTS

PGY1 internal medicine residents improved from a mean of 46.3% to 95.7% after SBML (p < 0.001) and all met the MPS at final posttest. The performance of traditionally trained neurology residents was significantly lower than simulator-trained residents (mean 65.4%, p < 0.001) and only 6% met the MPS.

CONCLUSIONS

Residents who completed SBML showed significant improvement in LP procedural skills. Few neurology residents were competent to perform a simulated LP despite clinical experience with the procedure.

The dynamic audio-motor system in pianists

This paper reports a preliminary study based on the theoretical assumption that continuous closed-loop audio-motor control could be disadvantageous for pianists. It is argued that the functional relationship between the intracerebral electrical activations in the auditory and premotor cortex should be rhythmically decreased and increased. To test this hypothesis, intracerebral electrical activations for the auditory and premotor cortex were estimated using scalp EEG and standardized low-resolution electrical tomography (sLORETA). The extracted times series were subjected to a Granger causality analysis, revealing a causal relationship from the auditory cortex to the premotor cortex that was considerably stronger during piano playing and weaker during rest. Importantly, this relationship varied rhythmically during the course of piano playing, with lags (obtained with cross-correlations) between 666 ms and 820 milliseconds. This study thus delivers evidence that the functional coupling between the auditory and premotor cortex varies during piano playing.

Improving residents' code status discussion skills: a randomized trial

BACKGROUND

Inpatient Code Status Discussions (CSDs) are commonly facilitated by resident physicians, despite inadequate training. We studied the efficacy of a CSD communication skills training intervention for internal medicine residents.

METHODS

This was a prospective, randomized controlled trial of a multimodality communication skills educational intervention for postgraduate year (PGY) 1 residents. Intervention group residents completed a 2 hour teaching session with deliberate practice of communication skills, online modules, self-reflection, and a booster training session in addition to assigned clinical rotations. Control group residents completed clinical rotations alone. CSD skills of residents in both groups were assessed 2 months after the intervention using an 18 item behavioral checklist during a standardized patient encounter. Average scores for intervention and control group residents were calculated and between-group differences on the CSD skills assessment were evaluated using two-tailed independent sample t tests.

RESULTS

Intervention group residents displayed higher overall scores on the simulated CSD (75.1% versus 53.2%, p<0.0001) than control group residents. The intervention group also displayed a greater number of key CSD communication behaviors and facilitated significantly longer conversations. The training, evaluation, and feedback sessions were rated highly.

CONCLUSION

A focused, multimodality curriculum can improve resident performance of simulated CSDs. Skill improvement lasted for at least 2 months after the intervention. Further studies are needed to assess skill retention and to set minimum performance standards.

Practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning?

BACKGROUND

Teaching practical skills is a core component of undergraduate and postgraduate surgical education. It is crucial to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. This review explores the role of educational theory in promoting effective learning in practical skills teaching.

METHODS

Peer-reviewed publications, books, and online resources from national bodies (eg, the UK General Medical Council) were reviewed.

RESULTS

This review highlights several aspects of surgical education, modeling them on current educational theory. These include the following: (1) acquisition and retention of motor skills (Miller's triangle; Fitts' and Posner's theory), (2) development of expertise after repeated practice and regular reinforcement (Ericsson's theory), (3) importance of the availability of expert assistance (Vygotsky's theory), (4) learning within communities of practice (Lave and Wenger's theory), (5) importance of feedback in learning practical skills (Boud, Schon, and Endes' theories), and (6) affective component of learning.

CONCLUSIONS

It is hoped that new approaches to practical skills teaching are designed in light of our understanding of educational theory.

Information Distortion in Physicians’ Diagnostic Judgments

Background: Information distortion suggests that people change the evaluation of new information to support an emerging belief. The present study was designed to measure the extent to which physicians distort incoming medical information to support an emerging diagnosis. Design: Data were collected via an anonymous questionnaire. The experimental group (102 physicians) read 3 patient scenarios, each with 2 competing diagnoses. Physicians first read information that favored 1 of the 2 diagnoses (the “steer”). They then rated a series of neutral cues that favored neither diagnosis. At each cue presentation, respondents rated the extent to which cues favored either diagnosis and updated the strength of their diagnostic belief. After the neutral cues in the third scenario, respondents rated cues that opposed the initial steer. A control group (36 physicians) rated all the cues in random order and not within scenarios, thus providing unbiased baseline ratings for calculating distortion in the experimental group. Results: Distortion was statistically significant ( P < 0.001) and was associated with the strength of belief in the leading diagnosis. Physicians with over 10 years in practice distorted less than their less experienced counterparts ([Formula: see text] = 1.04 v. [Formula: see text] = 1.78, P < 0.05). Having developed an initial diagnostic leaning consistent with the steer, 56% of physicians remained committed to it after receiving the conflicting cues. Distortion was strongly associated with commitment to the steer (odds ratio, 1.4; 95% confidence interval, 1.03–1.79; P = 0.03). Limitations: Physicians did not elicit information; therefore, the authors cannot estimate the size of distortion in tasks involving information search. Conclusions: Distortion could partly explain commitment of physicians to an early diagnosis. Both distortion and strength of initial diagnostic belief seem to decline after 10 years in family medicine.

Retrospective adjustment of self-assessed medical competencies - noteworthy in the evaluation of postgraduate practical training courses

Aim: The efficacy of postgraduate practical training courses is frequently evaluated by self-assessment instruments. The present study analyses the effect of a basic course in laparoscopic surgery on self-assessed medical competencies.

Methods: The 3-day course included teaching of knowledge and training of practical skills. In relation to course evaluation, a questionnaire for self-assessment was applied

at the beginning of the course ('pre-course'),

at the end of the course ('post-course') and

at the end of the course to reassess pre-course competencies ('retrospective pre-course').

Results: 89 out of 110 participants (81%) attending 10 courses completed all the questionnaires; 83% were postgraduate trainees in surgery and 82% were inexperienced as an independent surgeon. At the beginning of the course most trainees rated themselves as 'moderately competent' or 'fully competent' with respect to the various task levels as well as to specific areas of medical competencies. At the end of the course however pronounced retrospective revisions of self-assessment to lower ratings became apparent. Statistically significant differences were seen for the task 'performing surgical procedures under supervision' and for most of the practical skills trained during the course (p <0.01). In contrast, no significant differences were observed for knowledge taught during the course as well as for 'ability to work in a team' and 'ability to concentrate', which were not foci of the course.

Conclusions: Surgeons with little experience change their self-assessment of pre-course competencies to a lower level after participation in a practical postgraduate training course. Evaluations comparing 'pre-course' and 'post-course' ratings only – without 'retrospective pre-course' ratings – may underestimate the training effects. This phenomenon needs to be taken into account when evaluations are dependent exclusively on self-assessment instruments.

The Impact of the European Working Time Regulations on Orthopaedic Trainee Operative Experience

Trauma and orthopaedic surgery (T&O) has the largest number of trainees of any individual surgical specialty in the UK. It is a craft-based specialty, with 'hands-on' training, based on an apprenticeship model involving operative and procedural skills. In 1992 Kenneth Calman, then Chief Medical Officer, set up a working group to reform the specialist curriculum, placing more emphasis on structured teaching, supervised learning and surgical experience.

Why simulation-based team training has not been used effectively and what can be done about it

Advanced medical education simulators are broadly used today to train both technical/procedural and team-based skills. While there is convincing evidence of the benefits of training technical skills, this is not the case for team-based skills. Research on medical expertise could drive the creation of a new regime of simulation-based team training. The new regime includes first the understanding of complex systems such as the hospital and the operating room; then the performance of work-place assessment; thirdly, the deliberate training of weaknesses and team performance skills; and lastly the understanding of the underlying mechanisms of team competence. A new regime of deliberate training proposed by the author, which would need to be evaluated and validated, could elucidate the underlying mechanisms of team competence while providing evidence of the effect of simulation-based team training.

Innovative simulation strategies in education

The use of simulation in the undergraduate nursing curriculum is gaining popularity and is becoming a foundation of many nursing programs. The purpose of this paper is to highlight a new simulation teaching strategy, virtual reality (VR) simulation, which capitalizes on the technological skills of the new generation student. This small-scale pilot study focused on improving interpersonal skills in senior level nursing students using VR simulation. In this study, a repeated-measure design was used to evaluate the effectiveness of VR simulation on improving student's performance over a series of two VR scenarios. Using the Emergency Medicine Crisis Resource Management (EMCRM) tool, student performance was evaluated. Overall, the total EMCRM score improved but not significantly. The subscale areas of communication (P = .047, 95% CI: - 1.06, -.007) and professional behavior (P = .003, 95% CI: - 1.12, -.303) did show a significant improvement between the two scenario exposures. Findings from this study show the potential for virtual reality simulations to have an impact on nursing student performance.

As accessible as a book on a library shelf: the imperative of routine simulation in modern health care

Technology-enhanced patient simulation has emerged as an important new modality for teaching and learning in medicine. In particular, immersive simulation platforms that replicate the clinical environment promise to revolutionize medical education by enabling an enhanced level of safety, standardization, and efficiency across health-care training. Such an experiential approach seems unique in reliably catalyzing a level of emotional engagement that fosters immediate and indelible learning and allows for increasingly reliable levels of performance evaluation-all in a completely risk-free environment. As such, medical simulation is poised to emerge as a critical component of training and certification throughout health care, promising to fundamentally enhance quality and safety across disciplines. To encourage routine simulation-based practice as part of its core quality and safety mission, Massachusetts General Hospital now incorporates simulation resources within its historic medical library (est. 1847), located at the center of the campus. In this new model, learners go to the library not only to read about a patient's illness, but also to take care of their "patient." Such an approach redefines and advances the central role of the library on the campus and ensures that simulation-based practice is centrally available as part of everyday hospital operations. This article describes the reasons for identifying simulation as an institutional priority leading up to the Massachusetts General Hospital Bicentennial Celebration (1811-2011) and for creating a simulation-based learning laboratory within a hospital library.

The role of collaborative interactivity in the observational practice of clinical skills

CONTEXT

  Video-based observational practice can extend simulation-based learning outside the training space. This study explores the value of collaborative feedback provided during observational practice to the acquisition of clinical skills.

METHODS

  Nursing students viewed a video demonstrating the proper ventrogluteal injection technique before performing a videotaped pre-test trial on a simulator. They were then assigned randomly to one of three observational practice groups: a group that observed the expert demonstration (EO group); a group that viewed the expert demonstration, self-assessed their individual pre-test and contrasted their self-assessments with expert feedback (ESO group), and a group that observed the expert demonstration, self-assessed and contrasted their assessments with those of an expert, and formed a community that engaged in peer-to-peer feedback (ESPO group). The observation of all videos, the provision of assessments and all networking occurred via an Internet-mediated network. After 2 weeks, participants returned for post-tests and transfer tests.

RESULTS

  The pre-test-post-test analyses revealed significant interactions (global rating scale: F((2,22)) =4.00 [p =0.033]; checklist: F((2,22)) =4.31 [p =0.026]), which indicated that post-test performance in the ESPO group was significantly better than pre-test performance. The transfer analyses revealed main effects for both the global rating scale (F((2,23)) =6.73; p =0.005) and validated checklist (F((2,23)) =7.04; p =0.004) measures. Participants in the ESPO group performed better on the transfer test than those in the EO group.

CONCLUSIONS

  The results suggest that video-based observational practice can be effective in extending simulation-based learning, but its effectiveness is mediated by the amount of time the learner spends engaged in the practice and the type of learning activities the learner performs in the observational practice environment. We speculate that increasing collaborative interactivity supports observational learning by increasing the extent to which the educational environment can accommodate learners' specific needs.

Effectiveness of IV cannulation skills laboratory training and its transfer into clinical practice: a randomized, controlled trial

Background

The effectiveness of skills laboratory training is widely recognized. Yet, the transfer of procedural skills acquired in skills laboratories into clinical practice has rarely been investigated. We conducted a prospective, randomised, double-blind, controlled trial to evaluate, if students having trained intravenous (IV) cannulation in a skills laboratory are rated as more professional regarding technical and communication skills compared to students who underwent bedside teaching when assessed objectively by independent video assessors and subjectively by patients.

Methodology and Principal Findings

84 volunteer first-year medical students were randomly assigned to one of two groups. Three drop-outs occurred. The intervention group (IG; n = 41) trained IV cannulation in a skills laboratory receiving instruction after Peyton's ‘Four-Step Approach’. The control group (CG; n = 40) received a bedside teaching session with volunteer students acting as patients. Afterwards, performance of IV cannulation of both groups in a clinical setting with students acting as patients was video-recorded. Two independent, blinded video assessors scored students' performance using binary checklists (BC) and the Integrated Procedural Protocol Instrument (IPPI). Patients assessed students' performance with the Communication Assessment Tool (CAT) and a modified IPPI. IG required significantly shorter time needed for the performance on a patient (IG: 595.4 SD(188.1)s; CG: 692.7 SD(247.8)s; 95%CI 23.5 s to 45.1 s; p = 0.049) and completed significantly more single steps of the procedure correctly (IG: 64% SD(14) for BC items; CG: 53% SD(18); 95%CI 10.25% to 11.75%; p = 0.004). IG also scored significantly better on IPPI ratings (median: IG: 3.1; CG: 3.6; p = 0.015;). Rated by patients, students' performance and patient-physician communication did not significantly differ between groups.

Conclusions

Transfer of IV cannulation-related skills acquired in a skills laboratory is superior to bedside teaching when rated by independent video raters by means of IPPI and BC. It enables students to perform IV cannulation more professionally on volunteer students acting as patients.

Simulation-based education with mastery learning improves paracentesis skills

BACKGROUND

Paracentesis is a commonly performed bedside procedure that has the potential for serious complications. Therefore, simulation-based education for paracentesis is valuable for clinicians.

OBJECTIVE

To assess internal medicine residents' procedural skills before and after simulation-based mastery learning on a paracentesis simulator.

METHODS

A team with expertise in simulation and procedural skills developed and created a high fidelity, ultrasound-compatible paracentesis simulator. Fifty-eight first-year internal medicine residents completed a mastery learning-based intervention using the paracentesis simulator. Residents underwent baseline skill assessment (pretest) using a 25-item checklist. Residents completed a posttest after a 3-hour education session featuring a demonstration of the procedure, deliberate practice, ultrasound training, and feedback. All residents were expected to meet or exceed a minimum passing score (MPS) at posttest, the key feature of mastery learning. We compared pretest and posttest checklist scores to evaluate the effect of the educational intervention. Residents rated the training sessions.

RESULTS

Residents' paracentesis skills improved from an average pretest score of 33.0% (SD  =  15.2%) to 92.7% (SD  =  5.4%) at posttest (P < .001). After the training intervention, all residents met or exceeded the MPS. The training sessions and realism of the simulation were rated highly by learners.

CONCLUSION

This study demonstrates the ability of a paracentesis simulator to significantly improve procedural competence.

Boot cAMP: educational outcomes after 4 successive years of preparatory simulation-based training at onset of internship

PURPOSE

Preparatory training for new trainees beginning residency has been used by a variety of programs across the country. To improve the clinical orientation process for our new postgraduate year (PGY)-1 residents, we developed an intensive preparatory training curriculum inclusive of cognitive and procedural skills, training activities considered essential for early PGY-1 clinical management. We define our surgical PGY-1 Boot Camp as preparatory simulation-based training implemented at the onset of internship for introduction of skills necessary for basic surgical patient problem assessment and management. This orientation process includes exposure to simulated patient care encounters and technical skills training essential to new resident education. We report educational results of 4 successive years of Boot Camp training. Results were analyzed to determine if performance evidenced at onset of training was predictive of later educational outcomes.

METHODS

Learners were PGY-1 residents, in both categorical and preliminary positions, at our medium-sized surgical residency program. Over a 4-year period, from July 2007 to July 2010, all 30 PGY-1 residents starting surgical residency at our institution underwent specific preparatory didactic and skills training over a 9-week period. This consisted of mandatory weekly 1-hour and 3-hour sessions in the Simulation Center, representing a 4-fold increase in time in simulation laboratory training compared with the remainder of the year. Training occurred in 8 procedural skills areas (instrument use, knot-tying, suturing, laparoscopic skills, airway management, cardiopulmonary resuscitation, central venous catheter, and chest tube insertion) and in simulated patient care (shock, surgical emergencies, and respiratory, cardiac, and trauma management) using a variety of high- and low-tech simulation platforms. Faculty and senior residents served as instructors. All educational activities were structured to include preparatory materials, pretraining briefing sessions, and immediate in-training or post-training review and debriefing. Baseline cognitive skills were assessed with written tests on basic patient management. Post-Boot Camp tests similarly evaluated cognitive skills. Technical skills were assessed using a variety of task-specific instruments, and expressed as a mean score for all activities for each resident. All measurements were expressed as percent (%) best possible score. Cognitive and technical performance in Boot Camp was compared with subsequent clinical and core curriculum evaluations including weekly quiz scores, annual American Board of Surgery In-Training Examination (ABSITE) scores, program in-training evaluations (New Innovations, Uniontown, Ohio), and operative assessment instrument scores (OP-Rate, Baystate Medical Center, Springfield, Massachusetts) for the remainder of the PGY-1 year.

RESULTS

Performance data were available for 30 PGY-1 residents over 4 years. Baseline cognitive skills were lower for the first year of Boot Camp as compared with subsequent years (71 ± 13, 83 ± 9, 84 ± 11, and 86 ± 6, respectively; p = 0.028, analysis of variance; ANOVA). Performance improved between pretests and final testing (81 ± 11 vs 89 ± 7; p < 0.001 paired t test). There was statistically significant correlation between Boot Camp final cognitive test results and American Board of Surgery In-Training Examination scores (p = 0.01; n = 22), but not quite significant for weekly curriculum quiz scores (p = 0.055; n = 22) and New Innovations cognitive assessments (p = 0.09; n = 25). Statistically significant correlation was also noted between Boot Camp mean overall skills and New Innovations technical skills assessments (p = 0.002; n = 25) and OP-Rate assessments (p = 0.01; n = 12).

CONCLUSIONS

Individual simulation-based Boot Camp performance scores for cognitive and procedural skills assessments in PGY-1 residents correlate with subjective and objective clinical performance evaluations. This concurrent correlation with multiple traditional evaluation methods used to express competency in our residency program supports the use of Boot Camp performance measures as needs assessment tools as well as adjuncts to cumulative resident evaluation data.

Medical education: past, present and future

This article reviews changes in undergraduate and postgraduate medical education since the Flexner report of 1910. I argue that many of the changes in the twentieth century could be viewed as 'post-Flexnerian', and related to the integration of biomedical science in the preclinical medical curriculum. I then go on to argue that recent changes in the health care systems worldwide will force a critical re-examination of our approach to clinical education-a 'post-Oslerian' era. I suggest that one approach would be to decouple clinical education from clinical care, to some degree, and supplement with curricula designed around careful sequencing of simulated cases.

Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes

Self-appraisal has repeatedly been shown to be inadequate as a mechanism for performance improvement. This has placed greater emphasis on understanding the processes through which self-perception and external feedback interact to influence professional development. As feedback is inevitably interpreted through the lens of one's self-perceptions it is important to understand how learners interpret, accept, and use feedback (or not) and the factors that influence those interpretations. 134 participants from 8 health professional training/continuing competence programs were recruited to participate in focus groups. Analyses were designed to (a) elicit understandings of the processes used by learners and physicians to interpret, accept and use (or not) data to inform their perceptions of their clinical performance, and (b) further understand the factors (internal and external) believed to influence interpretation of feedback. Multiple influences appear to impact upon the interpretation and uptake of feedback. These include confidence, experience, and fear of not appearing knowledgeable. Importantly, however, each could have a paradoxical effect of both increasing and decreasing receptivity. Less prevalent but nonetheless important themes suggested mechanisms through which cognitive reasoning processes might impede growth from formative feedback. Many studies have examined the effectiveness of feedback through variable interventions focused on feedback delivery. This study suggests that it is equally important to consider feedback from the perspective of how it is received. The interplay observed between fear, confidence, and reasoning processes reinforces the notion that there is no simple recipe for the delivery of effective feedback. These factors should be taken into account when trying to understand (a) why self-appraisal can be flawed, (b) why appropriate external feedback is vital (yet can be ineffective), and (c) why we may need to disentangle the goals of performance improvement from the goals of improving self-assessment.