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

Comprehensive training curricula for minimally invasive surgery

BACKGROUND

The unique skill set required for minimally invasive surgery has in part contributed to a certain portion of surgical residency training transitioning from the operating room to the surgical skills laboratory. Simulation lends itself well as a method to shorten the learning curve for minimally invasive surgery by allowing trainees to practice the unique motor skills required for this type of surgery in a safe, structured environment. Although a significant amount of important work has been done to validate simulators as viable systems for teaching technical skills outside the operating room, the next step is to integrate simulation training into a comprehensive curriculum.

OBJECTIVES

This narrative review aims to synthesize the evidence and educational theories underlining curricula development for technical skills both in a broad context and specifically as it pertains to minimally invasive surgery.

FINDINGS

The review highlights the critical aspects of simulation training, such as the effective provision of feedback, deliberate practice, training to proficiency, the opportunity to practice at varying levels of difficulty, and the inclusion of both cognitive teaching and hands-on training. In addition, frameworks for integrating simulation training into a comprehensive curriculum are described. Finally, existing curricula on both laparoscopic box trainers and virtual reality simulators are critically evaluated.

Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders

This article reports on the development and evaluation of a Web-based application that provides instruction and hands-on practice in managing electrolyte and acid-base disorders. Our teaching approach, which focuses on concepts rather than details, encourages quantitative analysis and a logical problem-solving approach. Identifying any dangers to the patient is a vital first step. Concepts such as an "appropriate response" to a given perturbation and the need for electroneutrality in body fluids are used repeatedly. Our Electrolyte Workshop was developed using Flash and followed an iterative design process. Two case-based tutorials were built in this first phase, with one tutorial including an interactive treatment simulation. Users select from a menu of therapies and see the impact of their choices on the patient. Appropriate text messages are displayed, and changes in body compartment sizes, brain size, and plasma sodium concentrations are illustrated via Flash animation. Challenges encountered included a shortage of skilled Flash developers, budgetary constraints, and challenges in communication between the authors and the developers. The application was evaluated via user testing by residents and specialists in internal medicine. Satisfaction was measured with a questionnaire based on the System Usability Scale. The mean System Usability Scale score was 78.4 ± 13.8, indicating a good level of usability. Participants rated the content as being scientifically sound; they liked the teaching approach and felt that concepts were conveyed clearly. They indicated that the application held their interest, that it increased their understanding of hyponatremia, and that they would recommend this learning resource to others.

Role-modelling in the operating room: medical student observations of exemplary behaviour

CONTEXT

Training future doctors to develop an appropriate professional persona is an important goal of medical student education and residency training. Most medical education research paradigms on professionalism have focused largely on lapses (e.g. yelling as an example of communication failure) and tend to emphasise behaviour that should be avoided. The assumption is that, if left unchecked, students will see these negative behaviours exhibited by their role models and possibly emulate them, allowing the potential reinforcement of the inappropriate behaviours.

OBJECTIVES

Identifying and characterising exemplary, or positive, behaviours can be similarly valuable to both medical students and residents as tangible examples of behaviours to strive towards. The goal of the present research was to determine and thematically define the exemplary professional actions that medical students observe in the intense and patient-focused environment of the operating room (OR).

METHODS

Using qualitative methodology of content analysis and theme identification, we systematically documented the type of exemplary professional behaviours reported by medical students (n=263) when observing health care teams on an anaesthesia rotation in the OR.

RESULTS

The analysis generated a taxonomy of exemplary OR behaviour that included six overarching themes (e.g. teamwork), 15 sub-themes (e.g. collegial) and numerous exemplars (e.g. showed mutual respect). These themes and sub-themes were then conceptually 'matched'--through the use of antonyms --to complement an existing framework focused on medical student reports of professional lapses witnessed during medical school.

CONCLUSIONS

Year 3 medical students in the USA reported observing very positive, exemplary health care provider interactions that were diverse in focus. Themes were identified regarding the OR team members' interactions with patients (calm, communication, comforting), with one another (teamwork, respect) and with the medical students (teaching). This classification of exemplary OR behaviour contributes to our understanding of how professional behaviour is viewed and potentially emulated by medical students on surgical rotations.

Sim one, do one, teach one: considerations in designing training curricula for surgical simulation

Although there is considerable interest in the use of simulation for the acquisition of fundamental surgical skills through goal-directed practice in a safe environment, there is little evidence guiding educators on how best to implement simulation within surgical skills curricula. This article reviews the application of the expert performance model in surgery and the role of simulation in surgical skills acquisition. The focus is on implementation of deliberate practice, highlighting the principles of part-task training, proficiency-based training and overtraining. With resident and educator time at a premium, the identification of an optimally effective and efficient training strategy has significant implications for how surgical skills training is incorporated into residency programs, which is critical in today's environment.

The value of training in communication skills for continuing medical education

OBJECTIVE

Question arises as to what extent communication skills are considered in continuing medical education (CME).

METHODS

Analysis for CME-courses in communication skills in the area of the Chamber of Physicians North Rhine (ÄkNo), Germany. Supply Arm(A): CME events (n = 19,320) certified in 2007 were evaluated. Demand Arm(B): course participation of 850 family physicians in the period 2002-2007 was analyzed (n = 37,724). Tests were calculated to the level 0.05 using Mann-Whitney U-test.

RESULTS

(A) 388 (2.0%) events were concerned with the topic communications. 59.3% involved active cooperation of the participants. 0.5% events devoted more than 50% of their duration to the topic communication. Proportions in the subjects of internal medicine, general medicine and pediatrics amounted to 0.2%. (B) 803 (2.1%) events with a focus on communication were identified. Women took part in significantly more events than men (p<0.002) and selected more interactive courses.

CONCLUSION

Content on communication training was small. Increasing experience does not automatically improve communication skills but an extent of deliberate praxis seems to be necessary and must be sought and developed.

PRACTICE IMPLICATIONS

Communication skills are still insufficiently provided in CME-courses and should be more directed to focus as treatment strategies and scientifically investigated for outcome improvements.

Use of a continuing medical education course to improve fellows' knowledge and skills in esophageal disorders

Advanced esophageal endoscopic procedures such as stricture dilation, hemostasis tools, and stent placement as well as high-resolution manometry (HRM) interpretation are necessary skills for gastroenterology fellows to obtain during their training. Becoming proficient in these skills may be challenging in light of higher complication rates compared with diagnostic procedures and infrequent opportunities to practice these skills. Our aim was to determine if intensive training during a continuing medical education (CME) course boosts the knowledge and skills of gastroenterology fellows in esophageal diagnostic test interpretation and performance of therapeutic procedures. This was a pretest-posttest design without a control group of a simulation-based, educational intervention in esophageal stricture balloon dilation and HRM interpretation. The participants were 24 gastroenterology fellows from 21 accredited US training programs. This was an intensive CME course held in Las Vegas, Nevada from August 7 to August 9, 2009. The research procedure had two phases. First, the subjects were measured at baseline (pretest) for their knowledge and procedural skill. Second, the fellows received 6 hours of education sessions featuring didactic content, instruction in HRM indications and interpretation, and deliberate practice using an esophageal stricture dilation model. After the intervention, all of the fellows were retested (posttest). A 17-item checklist was developed for the esophageal balloon dilation procedure using relevant sources, expert opinion, and rigorous step-by-step procedures. Nineteen representative HRM swallow studies were obtained from Northwestern's motility lab and formed the pretest and posttest in HRM interpretation. Mean scores on the dilation checklist improved 81% from 39.4% (standard deviation [SD]= 33.4%) at pretest to 71.3% (SD = 29.5%) after simulation training (P < 0.001). HRM mean examination scores increased from 27.2% (SD = 16.4%) to 46.5% (SD = 15.8%), representing a 71% improvement (P < 0.001). Pearson's correlations indicated there was no correlation between pretest performance, medical knowledge measured by United States Medical Licensing Examination examinations, prior clinical experience, or procedural self-confidence and posttest performance of esophageal dilation or HRM interpretation. The education program was rated highly. This study demonstrated that a CME course significantly enhanced the technical skills and knowledge of gastroenterology fellows in esophageal balloon dilation and HRM interpretation. CME courses such as this may be a valuable adjunct to standard fellowship training in gastroenterology.

The process of problem-based learning: what works and why

OBJECTIVES

In this review, we portray the process of problem-based learning (PBL) as a cognitive endeavour whereby the learner constructs mental models relevant to problems. Two hypotheses are proposed to explain how learning is driven in PBL; an activation-elaboration hypothesis and a situational interest hypothesis.

METHODS

Research relevant to these hypotheses is discussed. In addition, research studying the effects of various support strategies used in PBL is reviewed. Finally, we summarise a number of recent studies in which a new 'micro-analytical' methodology was used to trace the process of PBL in the natural classroom setting.

CONCLUSIONS

We conclude that there is considerable support for the idea that PBL works because it encourages the activation of prior knowledge in the small-group setting and provides opportunities for elaboration on that knowledge. These activities facilitate the comprehension of new information related to the problem and enhance its long-term memorability. In addition, there is evidence that problems arouse situational interest that drives learning. Flexible scaffolding provided by cognitively and socially congruent tutors also seems to be reasonably effective, as opposed to 'hard' scaffolding represented by, for instance, worksheets or questions added to problems. Small-group work protects against dropout and encourages students to study regularly. Initially, students do not study much beyond the learning issues generated; the development of personal agency in self-study needs time to develop. The extent of learning in PBL results from neither group collaboration only (the social constructivist point of view) nor individual knowledge acquisition only; both activities contribute equally to learning in PBL.

Why we need open simulation to train surgeons in an era of work-hour restrictions

Surgical training in the USA and Europe has undergone radical changes with respect to working patterns, culture and limitation on working hours in recent years. Many surgeons who trained prior to the Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions have expressed concern that surgeons currently exiting from training may not have had the same operative experience as in the pre-ACGME era. These concerns are particularly relevant in vascular surgery with the prevalence of endovascular therapies reducing the exposure of trainees to more traditional open vascular operations. Simulation has been used in many non-medical fields for technical skill acquisition prior to real-life performance and in recent years has been identified as a useful tool in surgical training. This article highlights the growing need for open vascular simulation as exposure to complex open vascular operations diminishes. The culture of, ‘see one, do one, teach one’ is fast becoming replaced by ‘do many on a simulator, attain competency then perform under supervision in the operating room’. This will only be successfully achieved by the widespread incorporation of open vascular simulation into current vascular training programs if work hours remain limited and endovascular modalities continue to replace traditional open operations.

A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: the role of deliberate practice

OBJECTIVES

There is mounting evidence supporting the benefit of surgical skills practice in a simulated environment. However, the use of simulation in cardiac surgical training has been limited. The purpose of the current trial was to examine the effect of independent and deliberate simulator practice, during nonclinical time, on the performance of an end-to-side microvascular anastomosis in an in vivo model.

METHODS

This single-blinded, randomized controlled trial received institutional review board approval. Thirty-nine first- and second-year surgical trainees were randomized to an expert-guided tutorial on a procedural trainer or to the expert-guided tutorial combined with self-directed practice on the same procedural trainer. Self-directed practice consisted of 10 anastomoses performed on the procedural trainer: a low-fidelity, commercially available bench model using 4-mm polytetrafluoroethylene graft as simulated blood vessel. Two weeks after the tutorial, subjects performed an end-to-side anastomosis in a live porcine model, under realistic operating room conditions. Assessment of outcomes was performed by 2 blinded, expert observers, uings validated measurements of technical skill. The primary outcome was the score on the Objective Structured Assessment of Technical Skill (OSATS) scale. Secondary outcomes included an anastomosis-specific end-product evaluation and time to completion. Statistical analysis was conducted using nonparametric, univariate techniques.

RESULTS

Compared with residents who received expert-guided simulator training alone, those who in addition practiced on a simulator independently after hours scored significantly higher on the OSATS scale (23.7 ± 4.7 vs 18.5 ± 3.9, P = .003). Residents who practiced independently also scored significantly higher on the end-product evaluation (11.4 ± 3.2 vs 8.9 ± 2.1, P = .02) and performed the anastomosis significantly faster (777 seconds vs 977 seconds, P = .04). Interrater reliability was high between the expert observers (intraclass correlation coefficient = 0.8).

CONCLUSIONS

Residents who had the opportunity for self-directed simulator practice performed an end-to-side anastomosis more adeptly, more quickly, and with a higher quality end product. The results of this randomized trial suggest that independent training on a procedural trainer did transfer to improved performance in an operating room environment. Simulator training should be incorporated into cardiovascular surgical curricula and residents should have access to this modality for independent after-hours practice to improve operating room performance.

Who determines the patient mix of GP trainees? The role of the receptionist

BACKGROUND

During their specialty training, Dutch GP trainees work at a GP under the supervision of a GP trainer. Research suggests that the patient mix of GP trainees differs from that of their trainers. Receptionists assign patients to either the trainee or the trainer, thereby influencing the patient mix of the trainees. The decision to which doctor to assign is complex and depends on the latitude the receptionists have. Their considerations when assigning patients are unknown.

OBJECTIVE

To study receptionists' assigning behaviour.

METHODS

This was a questionnaire survey. To design the questionnaire, topics about assigning behaviour were identified in a focus group. The resulting questionnaire was sent to 478 GP training practices in the Netherlands.

RESULTS

Response rate was 68%. Of the receptionists, 95% asked for the reason for the consultation at least 'sometimes'. Most (86.3%) of the receptionists considered the patient mix of trainees and trainers to be similar. Almost all receptionists (97%) reported 'often' or 'always' assigning 'every possible problem' to the trainee and a similar picture arose regarding specific subpopulations. However, the receptionists reported that they assigned complex and new patients to the trainers more often than to trainees.

CONCLUSION

With some exceptions, receptionists try to assign trainees a varied patient mix.

The impact of a diagnostic reminder system on student clinical reasoning during simulated case studies

INTRODUCTION

Diagnostic reminder systems (DRS) may help students improve their clinical reasoning skill and gain competency in using informatics tools. This study explored the influence of Isabel PRO, a web-based DRS, on student diagnostic reasoning during simulated encounters.

METHODS

Diagnostic reasoning was assessed in 20 fourth-year medical students during four simulated case scenarios. After seeing each case, students submitted diagnostic hypotheses before (Pre-Isabel) and after (Post-Isabel) using Isabel PRO. The quality of the Pre- and Post-Isabel diagnostic hypotheses was assessed and compared to determine the impact of a DRS on student diagnostic reasoning. A follow-up survey and focus group identified student perception toward the use of a DRS in educational settings.

RESULTS

Paired t testing demonstrated that diagnostic accuracy significantly improved after using Isabel PRO (P < 0.05). Students found the software relatively simple to learn, felt that it helped them reflect on diagnostic options that they had not originally considered, and valued the opportunity to use the software in conjunction with simulated cases.

CONCLUSIONS

Despite limited experience, students were able to effectively use a DRS to improve their diagnostic accuracy. Use of a DRS within the context of a patient case represents a distinct clinical skill set requiring appropriate training. Providing learners with gold standard examples of how to best use a specific informatics tool within specific clinical situations is an essential learning component. Simulated case scenarios offer an appropriate platform for introducing diagnostic support tools to learners within a clinical context.

Rescuing A Patient In Deteriorating Situations (RAPIDS): A simulation-based educational program on recognizing, responding and reporting of physiological signs of deterioration

AIM

To describe the development, implementation and evaluation of an undergraduate nursing simulation program for developing nursing students' competency in assessing, managing and reporting of patients with physiological deterioration.

METHOD

A full-scale simulation program was developed and implemented in a pre-registered nursing curriculum. A randomized controlled study was performed with 31 third year nursing students. After a baseline evaluation of all participants in a simulated environment, the intervention group underwent four simulation scenarios in a 6h education session. All participants were then re-tested. The baseline and post-test simulation performances were scored using a validated tool. The students completed a survey to evaluate their learning experiences.

RESULTS

The clinical performances mean scores for assessment and management of deteriorating patients improved significantly after the training program compared to baseline scores (t=9.26; p<0.0001) and to post-test mean scores of the control group (F=77.28; p<0.0001). The post-test mean scores of the intervention group in reporting deterioration was significantly higher than the baseline mean scores (t=4.24; p<0.01) and the post-test means scores of the control group (F=8.98; p<0.01). The participants were satisfied with their simulation experiences, rated positively on features of the simulation and valued the program in developing their self-confidence.

CONCLUSION

The nursing students' competency in assessing, managing and reporting of deteriorating patient can be enhanced through a systematic development and implementation of a simulation-based educational program that utilized mnemonics to help students to remember key tasks.

Workplace-based assessment: effects of rater expertise

Traditional psychometric approaches towards assessment tend to focus exclusively on quantitative properties of assessment outcomes. This may limit more meaningful educational approaches towards workplace-based assessment (WBA). Cognition-based models of WBA argue that assessment outcomes are determined by cognitive processes by raters which are very similar to reasoning, judgment and decision making in professional domains such as medicine. The present study explores cognitive processes that underlie judgment and decision making by raters when observing performance in the clinical workplace. It specifically focuses on how differences in rating experience influence information processing by raters. Verbal protocol analysis was used to investigate how experienced and non-experienced raters select and use observational data to arrive at judgments and decisions about trainees' performance in the clinical workplace. Differences between experienced and non-experienced raters were assessed with respect to time spent on information analysis and representation of trainee performance; performance scores; and information processing--using qualitative-based quantitative analysis of verbal data. Results showed expert-novice differences in time needed for representation of trainee performance, depending on complexity of the rating task. Experts paid more attention to situation-specific cues in the assessment context and they generated (significantly) more interpretations and fewer literal descriptions of observed behaviors. There were no significant differences in rating scores. Overall, our findings seemed to be consistent with other findings on expertise research, supporting theories underlying cognition-based models of assessment in the clinical workplace. Implications for WBA are discussed.

Noblesse oblige - the pediatric surgeon (h)as the key to quality control and improvement. The Fred MacLoed Lecture

The trust crisis in health care demands action by health care professionals. Trust is based on quality, candor, and accountability. The pediatric surgeon, as the expert in the field, should be in control of quality management. By improving quality, the trust in the health care system can be restored. Quality is defined as being on target with minimal variation. To assess these targets, performance indicators have been developed by the Association of Pediatric Surgeons in The Netherlands for 7 neonatal conditions. Variation can be distinguished as special-cause and common-cause variation using the control chart method of Walter Shewhart. The various activities in this field that have been developed and are ongoing in The Netherlands are presented.

Simulation in emergency medicine training

Simulation provides a range of educational tools that have increasingly been incorporated into emergency medicine (EM) curricula. Standardized patients and some partial task trainers, such as intubation heads, have been used for decades. More recently, a growing number of computer-screen simulations, high-fidelity mannequins, and virtual-reality simulators have expanded the number of procedures and conditions, which can be effectively simulated.The Accreditation Council for Graduate Medical Education transitioned to a competency-based assessment of residency programs in 2001 and included simulation as a method for incorporating the 6 core competencies into graduate medical education curricula. Over the past decade, numerous peer-reviewed publications have promoted simulation as an effective educational tool for each of the core competencies.The advanced technology used to operate many current simulators can erroneously become the focus of efforts to create a simulation-based curriculum. Simulation can most effectively be incorporated into EM curricula through the use of time-proven concepts, which start with defining the targeted learners, assessing their general and specific educational needs, defining learning objectives, and selecting the best educational strategy for achieving each objective. In many, but not all, instances, simulation can be the best tool for achieving EM learning objectives.

Development of professional expertise in optometry

BACKGROUND

Development of professional expertise is the gradual transition from novice to expert within a profession. Studies on expertise in the profession of optometry have never been published. However, many studies have been performed in other health professions (e.g., nursing, medicine, physical therapy, occupational therapy).

METHODS

This report is an overview of the development of professional expertise that will highlight some applications for optometry.

RESULTS

A 5-level scale of professional expertise development, divided into 2 parts, is described. The first part is the progression of students during their professional studies (novice, intermediate, competent). The second part is the professional development occurring during the practice years (advanced, expert). Personal and collective efforts are required to foster the progression toward expertise. Great interest for the profession, motivation, and deliberate practice are individual attitudes that help this progression. The "optometric community of practice," by means of university (professional) training, continuing education, and collaboration between colleagues, also contributes to this process.

CONCLUSION

Professional development is an integral part of the Optometric Oath. Each clinical case is a potential learning experience contributing to one's professional development. Optometrists' attitudes are predominant factors in the progression from one level to another.

Early use of magnetic endoscopic imaging by novice colonoscopists: improved performance without increase in workload

BACKGROUND

Magnetic endoscopic imaging represents a recent advance in colonoscopy training. This technique provides adjunct information to the endoscopist, specifically with regard to colonoscope loop formation.

OBJECTIVE

To examine the effect of a magnetic endoscopic imager on novice performance and workload in colonoscopy.

METHODS

Twenty complete novices received an introductory teaching session followed by the completion of two procedures on a colonoscopy model. One-half of the participants performed their first procedure with the imager, and the second procedure without, while the other one-half were trained with the inverse sequence. Two main outcome measures were recorded: distance achieved and total workload as measured by the National Aeronautics and Space Administration task load index tool.

RESULTS

A significant improvement was noted between the first and second colonoscopies, with the best performance recorded for participants who performed their first procedure with the imager, and their second without. The imager did not significantly change the total workload.&nbsp;

DISCUSSION

The study participants paid attention to the magnetic endoscopic imager; however, this did not translate into a measurable increase in novice workload. A delayed learning benefit was conferred to the group exposed to the imager on their first colonoscopy, suggesting that, even at an early training stage, the additional imager information entered working memory and was processed in a useful fashion. The introductory teaching strategy used in the present study was successful as judged by the overall distance achieved and performance improvement seen in all study participants.

Training the endoscopy trainer: from general principles to specific concepts

Endoscopy instruction has progressed a great deal in recent years, evolving from the age-old dictum of 'see one, do one' to the current skillful application of sound educational principles. Some of these educational principles are generic and applicable to the teaching of any content at all levels, while others are quite specific to technical skills training. The present review summarizes these important principles under the following headings: creating a learner-centred curriculum; delivering an achievable learning task; and moving from theory to practice. The present article challenges national gastroenterology organizations to embrace these concepts in structured, outcome-based educational programs.

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

CONTEXT

Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physician's most critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward.

PURPOSE

This paper aims at exploring a comprehensive approach: the "dual-process theory", a model developed by cognitive psychologists over the last few years.

DISCUSSION

After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians' intuition and the high level of interaction between analytical and non-analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical education will be discussed.

Use of performance curves in estimating number of procedures required to achieve proficiency in coronary angiography

BACKGROUND

Current guidelines in cardiology training programs recommend 100-300 coronary angiography procedures for certification. We aimed to assess the number of procedures needed to reach sufficient proficiency.

METHODS

Procedure time, fluoroscopy time, dose area product (DAP), and contrast media volume were used as indicators of quality of performance. We analyzed data from 4,200 coronary angiographies. Performance curves of seven trainees were compared with recommended reference levels and to those of seven interventional cardiologists.

RESULTS

On average, the number of procedures needed for trainees to reach recommended reference levels was estimated as 226 and 353, for DAP and use of contrast media, respectively. After 300 procedures, trainees' procedure time, fluoroscopy time, DAP, and contrast media volume were significantly higher compared with experts' performance, P < 0.001 for all parameters. To approach the experts' level of DAP and contrast media use, trainees need 394 and 588 procedures, respectively. Performance curves showed large individual differences in the development of competence.

CONCLUSION

On average, trainees needed 300 procedures to reach sufficient level of proficiency, and this is in accordance with current guidelines. However, because of large individual differences, performance curves might be useful in monitoring individual trainees' progress and ensure documentation of sufficient competence when dealing with patients at risk.

Standards of resuscitation during inter-hospital transportation: the effects of structured team briefing or guideline review - a randomised, controlled simulation study of two micro-interventions

Background

Junior physicians are sometimes sent in ambulances with critically ill patients who require urgent transfer to another hospital. Unfamiliar surroundings and personnel, time pressure, and lack of experience may imply a risk of insufficient treatment during transportation as this can cause the physician to loose the expected overview of the situation. While health care professionals are expected to follow complex algorithms when resuscitating, stress can compromise both solo-performance and teamwork.

Aim

To examine whether inter-hospital resuscitation improved with a structured team briefing between physician and ambulance crew in preparation for transfer vs. review of resuscitation guidelines. The effect parameters were physician team leadership (requesting help, delegating tasks), time to resuscitation key elements (chest compressions, defibrillation, ventilations, medication, or a combination of these termed "the first meaningful action"), and hands-off ratio.

Methods

Participants: 46 physicians graduated within 5 years. Design: A simulation intervention study with a control group and two interventions (structured team briefing or review of guidelines). Scenario: Cardiac arrest during simulated inter-hospital transfer.

Results

Forty-six candidates participated: 16 (control), 13 (review), and 17 (team briefing). Reviewing guidelines delayed requesting help to 162 seconds, compared to 21 seconds in control and team briefing groups (p = 0.021). Help was not requested in 15% of cases; never requesting help was associated with an increased hands-off ratio, from 39% if the driver's assistance was requested to 54% if not (p < 0.01). No statistically significant differences were found between groups regarding time to first chest compression, defibrillation, ventilation, drug administration, or the combined "time to first meaningful action".

Conclusion

Neither review nor team briefing improved the time to resuscitation key elements. Review led to an eight-fold increase in the delay to requesting help. The association between never requesting help and an increased hands-off ratio underpins the importance of prioritising available resources. Other medical and non-medical domains have benefited from the use of guidelines reviews and structured team briefings. Reviewing guidelines may compromise the ability to focus on aspects such as team leading and delegating tasks and warrants the need for further studies focusing on how to avoid this cognitive impairment.

Exploring deliberate practice in medicine: how do physicians learn in the workplace?

Medical professionals need to keep on learning as part of their everyday work to deliver high-quality health care. Although the importance of physicians' learning is widely recognized, few studies have investigated how they learn in the workplace. Based on insights from deliberate practice research, this study examined the activities physicians engage in during their work that might further their professional development. As deliberate practice requires a focused effort to improve performance, the study also examined the goals underlying this behaviour. Semi-structured interviews were conducted with 50 internal medicine physicians: 19 residents, 18 internists working at a university hospital, and 13 working at a non-university hospital. The results showed that learning in medical practice was very much embedded in clinical work. Most relevant learning activities were directly related to patient care rather than motivated by competence improvement goals. Advice and feedback were sought when necessary to provide this care. Performance standards were tied to patients' conditions. The patients encountered and the discussions with colleagues about patients were valued most for professional development, while teaching and updating activities were also valued in this respect. In conclusion, physicians' learning is largely guided by practical experience rather than deliberately sought. When professionals interact in diagnosing and treating patients to achieve high-quality care, their experiences contribute to expertise development. However, much could be gained from managing learning opportunities more explicitly. We offer suggestions for increasing the focus on learning in medical practice and further research.

Clinical observed performance evaluation: a prospective study in final year students of surgery

We report a prospective study of clinical observed performance evaluation (COPE) for 197 medical students in the pre-qualification year of clinical education. Psychometric quality was the main endpoint. Students were assessed in groups of 5 in 40-min patient encounters, with each student the focus of evaluation for 8 min. Each student had a series of assessments in a 25-week teaching programme. Over time, several clinicians from a pool of 16 surgical consultants and registrars evaluated each student by direct observation. A structured rating form was used for assessment data. Variance component analysis (VCA), internal consistency and inter-rater agreement were used to estimate reliability. The predictive and convergent validity of COPE in relation to summative OSCE, long case, and overall final examination was estimated. Median number of COPE assessments per student was 7. Generalisability of a mean score over 7 COPE assessments was 0.66, equal to that of an 8 × 7.5 min station final OSCE. Internal consistency was 0.88-0.97 and inter-rater agreement 0.82. Significant correlations were observed with OSCE performance (R = 0.55 disattenuated) and long case (R = 0.47 disattenuated). Convergent validity was 0.81 by VCA. Overall final examination performance was linearly related to mean COPE score with standard error 3.7%. COPE permitted efficient serial assessment of a large cohort of final year students in a real world setting. Its psychometric quality compared well with conventional assessments and with other direct observation instruments as reported in the literature. Effect on learning, and translation to clinical care, are directions for future research.

Use of unannounced spaced telephone testing to improve retention of knowledge after life-support courses

BACKGROUND

Life-support courses improve knowledge and skills but attrition of factual knowledge is considerable. There is evidence that retention can be improved by spaced testing.

AIM

To investigate the effect of spaced testing on retention of knowledge after a life-support course.

METHOD

In a prospective-controlled trial using stratified randomization, 19 final-year medical students followed a half-day life-support course involving an identical written pre-test and end-of-course test consisting of a factual and a clinical case-based test (CCT). They were subsequently assigned to an intervention and a control group matched for the end-of-course test scores. The intervention group was given four unannounced spaced CCTs intermediate tests over 2 months. The control group took one intermediate test at 6 weeks. All students took a final retention test identical to the pre-test at 2 months.

RESULTS

Test performance improved equally in both groups immediately after the course. Students in the intervention group retained factual information significantly better than those in the control group. There was no difference in performance on the CCTs.

CONCLUSION

Unannounced spaced testing seems to have a positive effect on retention of factual knowledge after life-support courses. There was no evidence of an effect on clinical problem-solving ability.

What patients value when oncologists give news of cancer recurrence: commentary on specific moments in audio-recorded conversations

PURPOSE

Recommendations for communicating bad or serious news are based on limited evidence. This study was designed to understand patient perspectives on what patients value when oncologists communicate news of cancer recurrence.

STUDY DESIGN AND METHODS

Participants were 23 patients treated for a gastrointestinal cancer at a tertiary U.S. cancer center within the past 2 years, who had semistructured qualitative interviews in which they listened to audio recordings of an oncology fellow discussing news of cancer recurrence with a standardized patient. Participants paused the audio recording to comment on what they liked or disliked about the oncologist's communication.

RESULT

Three themes were identified that refine existing approaches to discussing serious news. The first theme, recognition, described how the oncologist responded to the gravity of the news of cancer recurrence for the patient. Participants saw the need for recognition throughout the encounter and not just after the news was given. The second theme, guiding, describes what participants wanted after hearing the news, which was for the oncologist to draw on her biomedical expertise to frame the news and plan next steps. The third theme, responsiveness, referred to the oncologist's ability to sense the need for recognition or guidance and to move fluidly between them.

CONCLUSION

This study suggests that oncologists giving news of cancer recurrence could think of the communication as going back and forth between recognition and guidance and could ask themselves: "Have I demonstrated that I recognize the patient's experience hearing the news?" and "Have I provided guidance to the next steps?"

Teaching clinical examination using peer-assisted learning amongst graduate-entry students

BACKGROUND

We ran a peer-assisted learning programme for teaching clinical examination amongst graduate-entry medical students. We had three objectives: (1) to provide a forum for using peer-assisted learning to deliver the medical schools' clinical examination curriculum using the techniques of deliberate practice; (2) to obtain feedback on the programme using the nominal group technique; (3) to use the feedback to provide a means of improving the programme in subsequent years.

METHODS

The syllabus was based on the medical school's first year curriculum for clinical examination, and was drawn-up by one of the faculty members. The peer tutors were given a large degree of autonomy to run the programme as they thought best. At the end of the programme we used the nominal group technique to generate feedback.

RESULTS

Final-year graduate-entry students are capable of organising a high-quality peer-assisted learning programme to teach clinical examination based on the medical school's curriculum.

DISCUSSION

The nominal group technique provided an excellent method of generating structured feedback from the peer tutees, which required minimal resources and only a few hours of input from a neutral facilitator. The feedback session generated 14 specific suggestions for improving the programme in future years. These suggestions will be passed on to the peer tutors for next year, and in this way the feedback cycle is engrained in the programme.

A novel educational tool for teaching diagnostic reasoning and laboratory data interpretation to veterinary (and medical) students

The Diagnostic Pathfinder was designed to help students learn diagnostic problem solving by supporting them in explaining relationships among history and physical examination findings, data abnormalities, and the underlying mechanisms of disease. The Pathfinder has been used to teach diagnostic problem solving to veterinary students since 2001 and is currently in use at 10 colleges of veterinary medicine. This article describes how the Pathfinder works and summarizes results from studies exploring the effect of Pathfinder use on learning and satisfaction. Pathfinder characteristics are described in terms of their influence on cognitive load, and strategies are provided for effective implementation.

GOALS-incisional hernia: a valid assessment of simulated laparoscopic incisional hernia repair

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid and reliable measure of basic, non-procedure-specific laparoscopic skills. GOALS-incisional hernia (GOALS-IH) was developed to evaluate performance of laparoscopic incisional hernia repair (LIHR). The purpose of this study was to assess the validity and reliability of GOALS-IH during LIHR simulation. GOALS-IH assesses 7 domains with a maximum score of 35. A total of 12 experienced surgeons and 10 novices performed LIHR on the Surgical Abdominal Wall simulator. Performance was assessed by a trained observer and by self-assessment using GOALS-IH, basic GOALS and a visual analog scale (VAS) for overall competence. Both interrater reliability and internal consistency were high (.76 and .95 respectively). Experienced surgeons had higher mean GOALS-IH scores than novices (32.3 ± 2 versus 22.7 ± 5). There was excellent correlation between GOALS-IH and other measures of performance (GOALS r = .93 and VAS r = .93). GOALS-IH is easy to use, valid and reliable for assessment of simulated LIHR.

Objective assessment of operator performance during ultrasound-guided procedures

PURPOSE

Simulation permits objective assessment of operator performance in a controlled and safe environment. Image-guided procedures often require accurate needle placement, and we designed a system to monitor how ultrasound guidance is used to monitor needle advancement toward a target. The results were correlated with other estimates of operator skill.

METHODS

The simulator consisted of a tissue phantom, ultrasound unit, and electromagnetic tracking system. Operators were asked to guide a needle toward a visible point target. Performance was video-recorded and synchronized with the electromagnetic tracking data. A series of algorithms based on motor control theory and human information processing were used to convert raw tracking data into different performance indices. Scoring algorithms converted the tracking data into efficiency, quality, task difficulty, and targeting scores that were aggregated to create performance indices. After initial feasibility testing, a standardized assessment was developed. Operators (N = 12) with a broad spectrum of skill and experience were enrolled and tested. Overall scores were based on performance during ten simulated procedures. Prior clinical experience was used to independently estimate operator skill.

RESULTS

When summed, the performance indices correlated well with estimated skill. Operators with minimal or no prior experience scored markedly lower than experienced operators. The overall score tended to increase according to operator's clinical experience. Operator experience was linked to decreased variation in multiple aspects of performance. The aggregated results of multiple trials provided the best correlation between estimated skill and performance. A metric for the operator's ability to maintain the needle aimed at the target discriminated between operators with different levels of experience.

CONCLUSIONS

This study used a highly focused task model, standardized assessment, and objective data analysis to assess performance during simulated ultrasound-guided needle placement. The performance indices were closely related to operator experience.

A structured career-immersion experience in the third year of residency training

This is the second in a series of 4 articles that highlight the projects that were chosen for implementation by the Initiative for Innovation in Pediatric Education (IIPE) review committee in response to the 2009 call for letters of intent. The authors describe their progress to date in implementing a training experience that allows residents the opportunity to engage in a longitudinal clinical experience that is aligned with their ultimate career choice. Mentors play a critical role in this immersion experience.

Repetitive pediatric simulation resuscitation training

OBJECTIVE

The objective of the study was to compare the effectiveness of repetitive pediatric simulation (RPS) training (scenario-debriefing-scenario) to standard pediatric simulation (STN) training (scenario-debriefing).

METHODS

Pediatric and emergency medicine residents prospectively participated in simulated pediatric resuscitation training sessions in an in situ simulation room. Residents anonymously reported their knowledge, skills, and confidence after each session. Four learners and 2 faculty preceptors (1 pediatric emergency medicine attending physician and 1 pediatric emergency medicine fellow) participated in each session. Scenarios were performed on a high-fidelity simulator (SimBaby; Laerdal Medical, Stavanger, Norway), and video debriefing was used for all training sessions. Standard pediatric simulation was used in the initial 6 months of the study, whereas RPS was used in the second 6 months of the study.

RESULTS

One hundred fifteen subjects completed simulation sessions during the study period. The RPS group reported higher overall debriefing quality and were more likely to report that the simulation session was an excellent method of teaching. The RPS group reported greater improvement in knowledge and skills than did the STN group. Similar scores were reported for confidence, overall performance, stress levels, and realism of the simulator in both the STN and RPS groups.

CONCLUSIONS

Feedback is a key feature of effective medical simulation. Repetitive pediatric simulation provides learners with a discrete opportunity to apply the knowledge and skills discussed during debriefing in an immediate second simulation session and thereby complete Kolb's experiential learning cycle. In this study, the RPS debriefing format was associated with higher self-reported knowledge and skills. The RPS group reported more positive attitudes toward simulation than the STN group.

Musculoskeletal examination teaching by patients versus physicians: how are they different? Neither better nor worse, but complementary

BACKGROUND

Musculoskeletal (MSK) complaints comprise 12-20% of primary healthcare; however, practicing physicians' MSK physical examination (PE) skills are weak. Further, there is a shortage of specialists able to effectively teach this subject. Previous evaluations of patient educators have yielded mixed results.

AIMS

The aim of this study is to document how teaching by patient educators and physician tutors in MSK PE skills differs.

METHODS

A qualitative researcher observed, video-recorded, and took notes during preclerkship MSK PE teaching sessions given by patient educators or physician tutors. The researcher identified themes which were evaluated by collective case study methods.

RESULTS

Two patient educator and four physician groups were evaluated. The patient educators were more consistent regarding content and style than the physicians. There appeared to be a continuum in teaching organization from patient educator to novice physician tutors to experienced physician tutors. The patient educators consistently covered all major joints (physicians did not); physicians were more likely to request verbalization of actions, relate findings to history, receive questions, and use opportunistic teaching moments.

CONCLUSIONS

Understanding preclerkship MSK teaching by patient educators compared to physician tutors is necessary for appropriate targeting of the existing Patient Partners® in Arthritis patient educator program and to guide the development of future MSK teaching initiatives.

Building expertise using the deliberate practice curriculum-planning model

This article reviews critical shortcomings of the current system for the education of physicians. The authors propose and describe a deliberate practice curriculum-planning model for educating healthcare professionals to respond to the demands of modern healthcare. The model integrates contemporary educational philosophies, creating the curricular framework outlined as follows: (1) determine the overall competencies expected of learners at graduation from the program; (2) for program components, develop outcome-based objectives that stem from the overall competencies; (3) to fulfill the objectives, design appropriate content using a variety of learner-centered instructional methods; (4) stimulate acquisition of knowledge, skills, and attitudes through practice accompanied by formative assessment, reflection, and mentoring; (5) establish milestones for summative assessment accompanied by feedback, reflection, and mentoring.

Medical students as teachers: how preclinical teaching opportunities can create an early awareness of the role of physician as teacher

BACKGROUND

As future physicians, questions about when medical students realize they will have to teach remain under-explored.

AIM

To understand when students serving in pre-clinical teaching roles make the connection between teaching and being a physician.

METHODS

Medical students involved in a peer instruction program included: (1) archived first-year student interview candidate data (n = 60/150); (2) focus groups of first-year students selected as instructors (n = 16/60); and (3) focus groups of second-year students (n = 16/24) who taught for the program. A modified extended-term mixed-method research design involved data from the pre-hire interviews and post-hire focus group.

RESULTS

Prior to teaching, none of the first year interviewees made an explicit connection between teaching and being a physician. The new instructors selected to teach minimally made a connection and only after prompting. The majority of the experienced instructors did make the connection; however, and did so spontaneously.

CONCLUSION

It was only after they taught medicine-related material that students saw the benefits of teaching as a way of preparing for becoming a physician and not merely as a way to review or help their peers.

Making a difference in curriculum reform and decision-making processes

CONTEXT

Although firmly grounded in Flexner's legacy of ideas, today's medical curriculum, as both an entity and a process, has become more and more complex. The curriculum as an entity is portrayed according to five key elements: the expected competencies and roles; the learners at the centre of the enterprise; assessment linking competencies and learners; the conditions and resources for learning; and a multifaceted socio-politico-cultural context in which the learning occurs. Significant developments have also occurred in the disciplines of curriculum studies, cognitive psychology and organisational change over the past century, as well as in institutional best practices, that help us to better understand and plan curricular innovations.

DISCUSSION

Practical advice is offered to help curriculum developers in designing or reforming the medical curriculum. The key points of this are: (i) while focusing reform and innovation on specific elements of the curriculum, consider how those elements affect other elements and vice versa, in positive and negative ways; (ii) while grounding the reform or innovation in sound conceptual frameworks, seize any opportunities to formulate a research agenda that can build upon and advance our understanding of curricular innovations, and, (iii) moving beyond considering the curriculum as an entity, use deliberative and leadership processes that can lead to enduring curriculum reform.