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

Laparoscopic simulation training with proficiency targets improves practice and performance of novice surgeons

BACKGROUND

This study compares a laparoscopic skill training protocol without proficiency targets to the same protocol with explicit targets and notification of progress.

METHODS

Fourteen surgery interns were randomized into 2 groups. The intervention group received task-specific proficiency criteria to guide practice. The control group did not. After training, participants were evaluated by blinded faculty during laparoscopic cholecystectomy.

RESULTS

The control group met significantly fewer of the 7 LapSim (Surgical Science Sweden AB, Gotëborg) targets (mean = 1.14) than the intervention group (mean = 7.00; P = .001) and significantly fewer of the 5 video trainer targets (mean = .86) than the intervention group (mean = 5.00; P = .001). Ratings of depth perception, bimanual dexterity, efficiency, tissue handling, autonomy, and overall competence were higher for the intervention group. Effect sizes ranged from medium to large (.394-.981), indicating an impact of the proficiency-based training protocol.

CONCLUSIONS

Delineation of proficiency targets with reporting of progress improves interns' practice results, and appears to have a positive effect on their early operating room (OR) performance of laparoscopic cholecystectomy.

The future of emergency medicine: an evolutionary perspective

Emergency medicine (EM) has grown rapidly over the past 50 years, evolving from a specialty defined by its locational identity--a hospital receiving room--to the specialty picked fourth-most-frequently by graduating U.S. medical students and to being the focal point of clinical care and of research on time-sensitive medical conditions. The authors review the forces that led to the growth of EM and those that will shape its future--in particular, cost, quality, and technology. A balancing of cost and quality considerations will likely drive EM education and research endeavors. The future of the field will be determined in part by resolution of the tension between the current inefficient conditions of emergency departments (EDs), which are crowded because of the temporary boarding of admitted patients for whom a bed is not yet ready, and the desired provision of quality care under emergent conditions. That is, patients with stroke, myocardial infarction, sepsis, or severe injuries from trauma require a working diagnosis and interventions that are initiated shortly after presentation, but ED personnel distracted by the demands of caring for boarded patients are unable to deliver optimal ED care. The reduction or elimination of boarding will enhance education and research within EDs and will contribute to an efficient system of high-quality EM services.

Performance goals on simulators boost resident motivation and skills laboratory attendance

OBJECTIVE

To assess the impact of setting simulator training goals on resident motivation and skills laboratory attendance.

DESIGN

Residents followed a proficiency-based laparoscopic curriculum on the 5 Fundamentals of Laparoscopic Surgery and 9 virtual reality tasks. Training goals consisted of the average expert performance on each task + 2 SD (mandatory) and best expert performance (optional). Residents rated the impact of the training goals on their motivation on a 20-point visual analog scale. Performance and attendance data were analyzed and correlated (Spearman's). Data are reported as medians (range).

SETTING

General Surgery residency program at a regional referral Academic Medical Center.

PARTICIPANTS

General surgery residents (n = 15).

RESULTS

During the first 5 months of the curriculum, weekly attendance rate was 51% (range, 8-96). After 153 (range, 21-412) repetitions, resident speed improved by 97% (range, 18-230), errors improved by 17% (range, 0-24), and motion efficiency by 59% (range, 26-114) compared with their baseline. Nine (60%) residents achieved proficiency in 7 (range, 3-14) and the best goals in 3.5 (range, 1-9) tasks; the other 6 residents had attendance rates <30%. Residents rated the impact of setting performance goals on their motivation as 15 (range, 1-18) and setting a best goal as 13 (range, 1-18). Motivation ratings correlated positively with attendance rates, number of repetitions, performance improvement, and achievement of proficiency and best goals (r = 0.59-0.75; p < 0.05) but negatively with postgraduate year (PGY) (-0.67; p = 0.02).

CONCLUSIONS

Setting training goals on simulators are associated with improved resident motivation to participate in a simulator curriculum. While more stringent goals may potentiate this effect, they have a limited impact on senior residents. Further research is needed to investigate ways to improve skills laboratory attendance.

An assessment tool for aseptic technique in resident physicians: a journey towards validation in the real world of limited supervision

PURPOSE

The purpose of this study was to describe the validation process for assessing an instrument to assess residents' aseptic technique skills.

METHODS

The validation study entailed comparisons of the performance of aseptic technique procedures between postgraduate year-1 (PGY-1) surgical residents and PGY-2/3 surgical residents. We also compared the performance of PGY-1 surgical residents from 2 different academic years for the same procedures. Finally, we compared the performance of novices (medical students) and experts (operating room nurses) in an effort to determine validity.

RESULTS

Our initial analysis found no significant difference between the performance of PGY-1 (mean score, 75.8) and PGY-2/3 (mean score, 75.6) surgical residents for aseptic technique (t((55))  =  0.84, P  =  0.404). Further investigation of validity was obtained to determine whether the no difference results reflected a lack of reliability or validity or a true equivalence between the 2 cohorts. The comparison of novices and experts produced the following findings. For reliability, the internal consistency of the checklist for each of the 2 raters was 0.87 and 0.71 (Cronbach α), interrater reliability was 0.74, with P < 0.001 (intraclass correlation coefficient) for the global scale. (Internal consistency was done within instrument, ie, between items not between raters.) For validity, operating room nurses outperformed students on the global scale (t(14)  =  7.47, P < 0.0001 and t((14))  =  10.66, P < 0.0001 for the 2 raters, respectively) and on several checklist items. The effect size values for raters were large (Cohen d  =  3.0 and 4.4), providing validity evidence for the ability of this assessment to detect difference in performance on this task.

CONCLUSION

The validation study showed that the instrument exhibited reliability and evidence for validity, making it useful for the assesment of aseptic technique skills in different specialties. Programs may want to consider using a validated instrument to check competence given that appropriate use of sterile technique frequently occurs in the context of unsupervised activities. Further work is needed to enhance resident skills in the area of aspectic technique because of limited improvement despite additional clinical experience.

The utility of simulation in medical education: what is the evidence?

Medical schools and residencies are currently facing a shift in their teaching paradigm. The increasing amount of medical information and research makes it difficult for medical education to stay current in its curriculum. As patients become increasingly concerned that students and residents are "practicing" on them, clinical medicine is becoming focused more on patient safety and quality than on bedside teaching and education. Educators have faced these challenges by restructuring curricula, developing small-group sessions, and increasing self-directed learning and independent research. Nevertheless, a disconnect still exists between the classroom and the clinical environment. Many students feel that they are inadequately trained in history taking, physical examination, diagnosis, and management. Medical simulation has been proposed as a technique to bridge this educational gap. This article reviews the evidence for the utility of simulation in medical education. We conducted a MEDLINE search of original articles and review articles related to simulation in education with key words such as simulation, mannequin simulator, partial task simulator, graduate medical education, undergraduate medical education, and continuing medical education. Articles, related to undergraduate medical education, graduate medical education, and continuing medical education were used in the review. One hundred thirteen articles were included in this review. Simulation-based training was demonstrated to lead to clinical improvement in 2 areas of simulation research. Residents trained on laparoscopic surgery simulators showed improvement in procedural performance in the operating room. The other study showed that residents trained on simulators were more likely to adhere to the advanced cardiac life support protocol than those who received standard training for cardiac arrest patients. In other areas of medical training, simulation has been demonstrated to lead to improvements in medical knowledge, comfort in procedures, and improvements in performance during retesting in simulated scenarios. Simulation has also been shown to be a reliable tool for assessing learners and for teaching topics such as teamwork and communication. Only a few studies have shown direct improvements in clinical outcomes from the use of simulation for training. Multiple studies have demonstrated the effectiveness of simulation in the teaching of basic science and clinical knowledge, procedural skills, teamwork, and communication as well as assessment at the undergraduate and graduate medical education levels. As simulation becomes increasingly prevalent in medical school and resident education, more studies are needed to see if simulation training improves patient outcomes.

Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training

BACKGROUND

The Olympus colonoscopy simulator provides a high-fidelity training platform designed to develop knowledge and skills in colonoscopy. It has the potential to shorten the learning process to competency.

OBJECTIVE

To investigate the efficacy of the simulator in training novices in colonoscopy by comparing training outcomes from simulator training with those of standard patient-based training.

DESIGN

Multinational, multicenter, single-blind, randomized, controlled trial.

SETTING

Four academic endoscopy centers in the United Kingdom, Italy, and The Netherlands.

PARTICIPANTS AND INTERVENTION

This study included 36 novice colonoscopists who were randomized to 16 hours of simulator training (subjects) or patient-based training (controls). Participants completed 3 simulator cases before and after training. Three live cases were assessed after training by blinded experts.

MAIN OUTCOME MEASUREMENTS

Automatically recorded performance metrics for the simulator cases and blinded expert assessment of live cases using Direct Observation of Procedural Skills and Global Score sheets.

RESULTS

Simulator training significantly improved performance on simulated cases compared with patient-based training. Subjects had higher completion rates (P=.001) and shorter completion times (P < .001) and demonstrated superior technical skill (reduced simulated pain scores, correct use of abdominal pressure, and loop management). On live colonoscopy, there were no significant differences between the 2 groups.

LIMITATIONS

Assessment tools for live colonoscopies may lack sensitivity to discriminate between the skills of relative novices.

CONCLUSION

Performance of novices trained on the colonoscopy simulator matched the performance of those with standard patient-based colonoscopy training, and novices in the simulator group demonstrated superior technical skills on simulated cases. The simulator should be considered as a tool for developing knowledge and skills prior to clinical practice.

Early experiences of the mini-PAT (Peer Assessment Tool) amongst hospital pharmacists in South East London

Objectives

The aim was to describe early experience of use of the mini-PAT (Peer Assessment Tool) amongst general-level pharmacists working in secondary care, and to capture their views about the method of assessment.

Methods

General-level pharmacists who had completed two rounds of the mini-PAT assessment in their first year post-qualification were asked to complete a semi-structured questionnaire, assessing the usefulness and acceptability of the assessment method.

Key findings

The pharmacists found the assessment method useful and acceptable, with many citing that they found it useful to see how they were doing in relation to their peers. To further improve the assessment method, the general-level pharmacists suggested that any verbatim comments made should have the relevant assessor's name next to it, so the context of the comment can be understood.

Conclusions

Early experience suggests that the mini-PAT is a useful formative assessment tool for use amongst GLPs.

Development of expertise in surgical training

Surgical training is currently undergoing many changes. Moves toward an outcomes-based education based on achievement of core competencies will have a significant impact on how trainees are taught and evaluated. New strategies must therefore be sought to enhance surgical training to achieve outstanding resident education and safe patient care. An extensive body of literature is available concerning the attributes of experts and the development of expertise. It is increasingly apparent that the extent and nature of practice, as well as the practice structure, are critical to the development of complex motor skills. This article reviews the attributes of expert surgeons, as well as the role of deliberate practice, contextual interference, and distributed practice in the development of expertise. The role of simulation in surgical training is also discussed. The findings have direct relevance to surgical training and continuing medical educational courses, and these results may help in the design of future surgical training programs.

Final year medical students' views on simulation-based teaching: a comparison with the Best Evidence Medical Education Systematic Review

BACKGROUND

Simulation is being increasingly used in medical education.

AIM

The aim of this study was to explore in more depth the features of simulation-based teaching that undergraduate medical students value using the Best Evidence Medical Education (BEME) Systematic Review features that lead to effective learning as a framework.

METHOD

Thematic analysis of four semi-structured focus groups with final year medical students who had been taught acute care skills using a medium-fidelity whole-body simulator manikin (SimMan).

RESULTS

Twelve key themes were identified, namely, feedback, integration into curriculum, learning style, learning environment, realism, teamwork, communication skills, confidence/increased self-efficacy, anxiety, performance, perceptions of foundation year 1 (FY1) and SimMan as a resource. Each theme is described with supporting quotes.

CONCLUSION

Six of the ten features listed in the BEME review appeared to be of particular value to the medical students. This study provides a richer understanding of these features. In addition, new insights into the effect of simulation on confidence, anxiety and self-efficacy are discussed which may be affected by the 'performance' nature of simulation role-play. Students also contribute critical thought about the use of SimMan as a resource and provide novel ideas for reducing 'downtime'.

Perspectives on competency-based medical education from the learning sciences

A central component of competency-based medical education is a framework of higher-order and more fundamental competencies whose purpose is to focus instruction and learning. In the language of the learning sciences, many of these competencies are complex cognitive-perceptual or cognitive-motor skills. Competency-based medical education has been criticized for being reductionistic, that is, for focusing on atomistic skills and failing to capture the essence of professional activities as manifested by complex, integrated capabilities. The value of identifying fundamental skill components is supported by theory and evidence from the learning sciences, however. Complex skills are constructed from fundamental, component skills. Proficient performance of the former is achieved as components are refined and integrated during repeated performance of the skill in a realistic context and as feedback on performance is provided. Competency-based medical education does not propose specific methods for teaching competencies. The learning and instructional sciences, however, posit a number of conditions for learning that support the acquisition of simple skills and their flexible integration into complex capabilities. Learners' motivation and self-regulation skills will also have an impact on the extent to which they engage in learning processes that result in the integration of knowledge and skills into complex competencies.

Developing expertise in surgery

The concept of expertise is widely embraced but poorly defined in surgery. Dictionary definitions differentiate between authority and experience, while a third view sees expertise as a mind-set rather than a status. Both absolute and relative models of expertise have been developed, and each allows a richer understanding of the application of these concepts to emerge. Trainees must develop both independent and interdependent expertise, and an appreciation of the essentially constructivist and uncertain nature of medical knowledge. Approach may be more important than innate talent; the concepts of 'flow', sustained 'deliberate practice' and 'adaptive expertise' are examples of expert approaches to learning. Non-analytical reasoning plays a key role in decision making at expert levels of practice. A technically gifted surgeon may be seen as a safety hazard rather than an expert if inter-dependent expertise has not been developed. Key roles of a surgical educator are to facilitate the development of an expert approach to education and to enable entry into and movement towards the centre of an expert community of practice.

Self-organisation, integration and curriculum in the complex world of medical education

CONTEXT

The world of medical education is more complex than ever and there seems to be no end in sight. Complexity science is particularly relevant as medical education embraces a movement towards more authentic curricula focusing on integration, interactive small-group learning, and early and sustained clinical and community experiences.

DISCUSSION

A medical school as a whole, and the expression of its curriculum through the interactions, exchanges and learning that take place within and outside of it, is a complex system. Complexity science, a derivative of the natural sciences, is the study of the dynamics, conditions and consequences of interactions. It addresses the nature of the conditions favourable to change and transformation (learning).

CONCLUSIONS

The core process of complexity, self-organisation, requires a system that is open and far from equilibrium, with ill-defined boundaries and a large number of non-linear interactions involving short-loop feedback. In such a system, knowledge does not exist objectively 'out there'; rather, it exists as a result of the exchange between participants, an action that becomes knowing. Understanding is placed between participants rather than being contained in one or the other. Knowledge is not constructed separately in the mind of the knower, but, rather, it emerges; it is co-created during the exchange in an authentic recursive transactive process. Learning and knowing become adaptive responses to continuously evolving circumstances. An approach to curriculum based on self-organisation is characterised as rich, recursive, relational and rigorous and it illuminates how a curriculum can be understood as a complex adaptive system. The perspective of complexity applied to medical education broadens and enriches research questions relevant to health professions education. It focuses our attention onto how we are together as human beings. How we respond to and frame the issues of learning and understanding that challenge contemporary medicine and, by extension, medical education, in a complex and rapidly changing world can have profound effects on the preparedness of tomorrow's health professionals and their impact on society.

Aging and cognitive performance: challenges and implications for physicians practicing in the 21st century

The demands of physician practice are growing. Some specialties face critical shortages and a significant percentage of physicians are aging. To improve health care it is paramount to understand and address challenges, including cognitive issues, facing aging physicians. In this article, we outline several issues related to cognitive performance and potential implications associated with aging. We discuss important findings from other fields and draw parallels to the practice of medicine. In particular, we discuss the possible effects of aging through the lens of situated cognition theory, and we outline the potential impact of aging on expertise, information processing, neurobiology, intelligence, and self-regulated learning. We believe that work done in related fields can provide a better understanding of physician aging and cognition, and thus can inform more effective approaches to continuous professional development and lifelong learning in medicine. We conclude with implications for the health care system and areas of future research.

Establishing an integrated multiprofessional skills training programme

BACKGROUND

Opportunities to learn and practice skills are becoming less with changes in the health care environment. Responses to this have included curriculum change and the development of skills programmes. Although the skills programmes, often taught in simulated settings in skills Centres have been frequently described, such a model may not be appropriate for all Universities or have the best outcomes. Firstly access to a centre may not be available and secondly, the training may not alter students' behaviour in the workplace in terms of applying and practicing these skills.

AIM

This paper offers tips for developing a centrally coordinated, integrated, multidisciplinary skills training programme.

METHODS

These 12 tips are based upon current literature, discussion with other skills training providers and reflection on local experiences of establishing and maintaining a skills training programme.

RESULTS

The programme, outlined here, used a multidisciplinary, multiprofessional group to design and run a skills programme, which was clearly linked back to clinical attachments, emphasising ongoing practice with feedback.

CONCLUSIONS

The twelve tips highlight the importance of broad ownership of the programme; separate funding and good evaluation are essential if the programme is to be continued in the absence of a specific Centre or a School to run it.

A critical review of simulation-based medical education research: 2003-2009

OBJECTIVES

This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.

METHODS

This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969-2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003-2009.

RESULTS

The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.

CONCLUSIONS

Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.

A model for reflection for good clinical practice

Rationale and aim The rapidly changing knowledge base of clinical practice highlights the need to keep abreast of knowledge changes that are most relevant for the practitioner. We aimed to develop a model for reflection on clinical practice that identified the key elements of medical knowledge needed for good medical practice. Method The dual theory of cognition, an integration of intuitive and analytic processes, provided the framework for the study. The design looked at the congruence between the clinical thinking process and the dual theory. A one-year study was conducted in general practice clinics in Oxfordshire, UK. Thirty-five general practitioners participated in 20-minute interviews to discuss how they worked through recently seen clinical cases. Over a one-year period 72 cases were recorded from 35 interviews. These were categorized according to emerging themes, which were manually coded and substantiated with verbatim quotations. Results There was a close fit between the dual theory and participants' clinical thinking processes. This included instant problem framing, consistent with automatic intuitive thinking, focusing on the risk and urgency of the case. Salient features accounting for these choices were recognizable. There was a second reflective phase, leading to the review of initial judgements. Conclusions The proposed model highlights the critical steps in decision making. This allows regular recalibration of knowledge that is most critical at each of these steps. In line with good practice, the model also links the crucial knowledge used in decision making, to value judgments made in relation to the patient.

Remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or below-standard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.

Towards effective evaluation and reform in medical education: a cognitive and learning sciences perspective

Health professions education is dealing with major transformations in light of the changing nature of the health care delivery system, including the use of technology for "just in time" delivery of care, evidence-based practice, personalized medical care and learning, as health professionals strive to integrate biomedical advances and clinical practice. This has forced the medical education community to reassess the current teaching and learning practices and more importantly, the evaluation of the medical education process. There have been recent advances in cognitive and learning sciences theories, some of which can inform medical educators about best teaching and learning practices and their impact on the evaluation process. An understanding of these theories provides a sound rationale for choosing specific instructional strategies and choosing evaluation measures that assess the curricular objectives. The review begins with an overview of evaluation and assessment in education, followed by an overview of major theories from the cognitive and learning sciences. Next, the role of cognitive and learning sciences theories in informing the process of medical education evaluation is discussed, including its impact on student learning, performance and professional competence, as well as recommendations for reform of medical curricula based on such theories. The paper continues with the elaboration of current trends in health sciences education, particularly medical education, and available evidence for the impact on student learning and performance as well as areas where more research is needed.

Issues of concern to emergency physicians in pre-retirement years: a survey

BACKGROUND

Many members of the American College of Emergency Physicians are now over the age of 50. Little is known regarding age-specific issues that may impact the careers of emergency physicians in the latter stages of their professional lives.

OBJECTIVES

To determine issues of concern regarding aging and retirement among a cohort of emergency physicians in pre-retirement years.

METHODS

A survey of a randomized sample of 1000 American College of Emergency Physicians members over the age of 55 years was conducted with two separate mailings in the fall of 2006 and winter of 2007. The survey instrument consisted of 30 questions relating primarily to issues of health, finances, and the ability to practice emergency medicine. Four open-ended questions were included at the end of the survey, relating to means of promoting career longevity.

RESULTS

There were 802 usable responses received (response rate 80%). The average respondent was 57 years old and worked 30 clinical and 12 non-clinical h per week. The average estimated time to complete retirement was 7.8 years. Respondents generally viewed themselves as competent clinicians with improved ability to relate to patients and staff and little decline in procedural skills. However, a substantial proportion reported age-related concerns. Seventy-four percent reported less ability to recover from night shifts, 44% reported a higher level of emotional exhaustion at end of shift, 40% reported less ability to manage heavy patient volume, 36% reported less ability to handle stress of emergency medicine, 28% reported health limitations on ability to practice, 28% reported memory somewhat or considerably worse, and 25% reported less ability to incorporate new modalities of diagnosis and treatment. With regard to retirement-related issues, 42% reported concerns about adequate financial preparations and 44% reported concerns regarding loss of identity upon retirement. The practice modifications most commonly reported to impact career longevity were the reduction or elimination of night shifts, a reduction in the number of hours per shift, and an increase in physician and support staffing.

CONCLUSIONS

Respondents to this survey generally viewed themselves as competent, empathic practitioners. Yet a substantial percentage acknowledged at least some degree of cognitive or physical decline. The results suggest a role for the national organizations in emergency medicine in endorsing practice modifications that promote career longevity and clinical competence among its senior members.

The Rise of Simulation in Technical Skills Teaching and the Implications for Training Novices in Anaesthesia

Changes in work practices have led to a decline in the opportunities for anaesthetic trainees to learn technical procedures in supervised practice. Efforts to mitigate medical error and other changes have coincided with the development of alternative training methods so that it is increasingly difficult to justify the traditional model of teaching technical procedures.

The range of simulators available for training in technical procedures in anaesthesia continues to expand. While simulation has been widely adopted in anaesthesia for crisis management training, there is little documented evidence of its use for technical skills training.

The theoretical basis for the use of simulation to aid the acquisition of psychomotor skills and the development of expertise is now well established. In addition, practical frameworks that allow this theory to be applied in a systematic fashion have been developed and successfully used in other specialties.

Using the available simulation equipment and educational tools, trainees can be prepared to begin supervised practice having demonstrated adequate procedural knowledge and expertise in simulation. With the use of simulated patients there is also the opportunity to integrate non-technical skills as well where appropriate.

This review summarises the justification for the use of simulation in technical skills training in anaesthesia and the educational theory that supports its use, and outlines one of the available frameworks that can be used to aid its application.

Do workshops in evidence-based practice equip participants to identify and answer questions requiring consideration of clinical research? A diagnostic skill assessment

Evidence-based practice (EBP) requires practitioners to identify and formulate questions in response to patient encounters, and to seek, select, and appraise applicable clinical research. A standardized workshop format serves as the model for training of medical educators in these skills. We developed an evaluation exercise to assess the ability to identify and solve a problem requiring the use of targeted skills and administered it to 47 North American junior faculty and residents in various specialties at the close of two short workshops in EBP. Prior to the workshop, subjects reported prior training in EBP and completed a previously validated knowledge test. Our post-workshop exercise differed from the baseline measures and required participants to spontaneously identify a suitable question in response to a simulated clinical encounter, followed by a description of a stepwise approach to answering it. They then responded to successively more explicitly prompted queries relevant to their question. We analyzed responses to identify areas of skill deficiency and potential reasons for these deficiencies. Twelve respondents (26%) initially failed to identify a suitable question in response to the clinical scenario. Ability to choose a suitable question correlated with the ability to connect an original question to an appropriate study design. Prior EBP training correlated with the pretest score but not with performance on our exercise. Overall performance correlated with ability to correctly classify their questions as pertaining to therapy, diagnosis, prognosis, or harm. We conclude that faculty and residents completing standard workshops in EBP may still lack the ability to initiate and investigate original clinical inquiries using EBP skills.

Commentary: Missing the elephant in my office: recommendations for part-time careers in academic medicine

Several recent articles in this journal, including the article by Linzer and colleagues in this issue, discuss and promote the concept of part-time careers in academic medicine as a solution to the need to achieve a work-life balance and to address the changing demographics of academic medicine. The article by Linzer and colleagues presents the consensus of a task force that attempted to address practical considerations for part-time work in academic internal medicine. Missing from these discussions, however, are a consensus on the definition of part-time work, consideration of how such strategies would be available to single parents, how time or resources will be allocated to part-time faculty to participate in professional associations, develop professional networks, and maintain currency in their field, and how part-time work can allow for the development of expertise in research and scholarly activity. Most important, the discussions about the part-time solution do not address the root cause of dissatisfaction and attrition: the ever-increasing and unsustainable workload of full-time faculty. The realization that an academic full-time career requires a commitment of 80 hours per week begs the question of whether part-time faculty would agree to work 40 hours a week for part-time pay. The historical underpinnings of the current situation, the implications of part-time solutions for the academy, and the consequences of choosing part-time work as the primary solution are discussed. Alternative strategies for addressing some of the problems facing full-time faculty are proposed.

Progress testing in postgraduate medical education

BACKGROUND

The role of knowledge in postgraduate medical education has often been discussed. However, recent insights from cognitive psychology and the study of deliberate practice recognize that expert problem solving requires a well-organized knowledge database. This implies that postgraduate assessment should include knowledge testing. Longitudinal assessment, like progress testing, seems a promising approach for postgraduate progress knowledge assessment.

AIMS

To evaluate the validity and reliability of a national progress test in postgraduate Obstetrics and Gynaecology training.

METHODS

Data of 10 years of postgraduate progress testing were analyzed on reliability with Cronbach's alpha and on construct validity using one-way ANOVA with a post hoc Scheffe test.

RESULTS

Average reliability with true-false questions was 0.50, which is moderate at best. After the introduction of multiple-choice questions average reliability improved to 0.65. Construct validity or discriminative power could only be demonstrated with some certainty between training year 1 and training year 2 and higher training years.

CONCLUSION

Validity and reliability of the current progress test in postgraduate Obstetrics and Gynaecology training is unsatisfactory. Suggestions for improvement of both test construct and test content are provided.

Efficacy of a novel educational curriculum using a simulation laboratory on resident performance of hysteroscopic sterilization

OBJECTIVE

To assess whether a novel educational curriculum using a simulation teaching laboratory improves resident knowledge, comfort with, and surgical performance of hysteroscopic sterilization.

DESIGN

An educational prospective, pretest/posttest study.

SETTING

The Montefiore Institute of Minimally Invasive Surgery Laboratory. PATIENT(S)/SUBJECT(S): Thirty-four OB/GYN residents in an academic medical center.

INTERVENTION(S)

Hysteroscopic sterilization simulation laboratory and a brief didactic lecture.

MAIN OUTCOME MEASURE(S)

Differences in scores on validated skill assessment tools: Task specific checklist, Global Rating Scale (GRS), pass fail assessment, and a multiple-choice examination to evaluate knowledge and attitude.

RESULT(S)

In the entire cohort improvements were observed on all evaluation tools after the simulation laboratory, with 31% points (SD+/-11.5, 95% confidence interval [CI] 27.3-35.3) higher score on the written evaluation; 63% points (SD+/-15.7, 95% CI 57.8-68.8) higher score on the task specific checklist; and 54% points (SD+/-13.6, 95% CI 48.8-58.3) higher score on the GRS. Higher PGY status was correlated with better pretest performance, but was not statistically significant in posttest scores. Residents reported an improvement in comfort performing the procedure after the laboratory.

CONCLUSION(S)

Simulation laboratory teaching significantly improved resident knowledge, comfort level, and technical skill performance of hysteroscopic sterilization.

Toward a science of exceptional achievement: attaining superior performance through deliberate practice

Exceptional performance is frequently attributed to genetic differences in talent. Since Sir Francis Galton's book, Hereditary Genius, many scientists have cited heritable factors that set limits of performance and only allow some individuals to attain exceptional levels. However, thus far these accounts have not explicated the causal processes involved in the activation and expression of unique genes in DNA that lead to the emergence of distinctive physiological attributes and cognitive capacities (innate talent). This article argues on the basis of our current knowledge that it is possible to account for the development of elite performance among healthy children without recourse to innate talent (genetic endowment)--excepting the innate determinants of body size. Our account is based on the expert-performance approach and proposes that the distinctive characteristics of exceptional performers are the result of adaptations to extended and intense practice activities that selectively activate dormant genes that are contained within all healthy individuals' DNA. Furthermore, the theoretical framework of expert performance explains the apparent emergence of early talent by identifying factors that influence starting ages for training and the accumulated engagement in sustained extended deliberate practice, such as motivation, parental support, and access to the best training environments and teachers. In sum, our empirical investigations and extensive reviews show that the development of expert performance will be primarily constrained by individuals' engagement in deliberate practice and the quality of the available training resources.

Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit

BACKGROUND

Central venous catheter (CVC) insertions are performed frequently by internal medicine residents. Complications, including arterial puncture and pneumothorax, decrease when operators use fewer needle passes to insert the CVC. In this study, we evaluated the effect of simulation-based mastery learning on CVC insertion skill.

DESIGN

This was a cohort study of internal jugular (IJ) and subclavian (SC) CVC insertions by 41 internal medicine residents rotating through the medical intensive care unit (MICU) over a five-month period. Thirteen traditionally-trained residents were surveyed about the number of needle passes, complications, and procedural self-confidence on CVCs inserted in the MICU. Concurrently, 28 residents completed simulation-based training in IJ and SC CVC insertions. Simulator-trained residents were expected to perform CVC insertions to mastery standards on a central line simulator. Simulator-trained residents then rotated through the MICU and were surveyed regarding CVC placement. The impact of simulation training was assessed by comparing group survey results.

RESULTS

No resident met the minimum passing score (MPS) (79.1%) for CVC insertion at baseline: mean (M) (IJ) = 48.4%, standard deviation (SD) = 23.1, M(SC) = 45.2%, SD = 26.3. All residents met or exceeded the MPS at testing after simulation training: M(IJ) = 94.8%, SD = 10.0, M(SC) = 91.1%, SD = 17.8 (p < 0.001). In the MICU, simulator-trained residents required fewer needle passes to insert a CVC than traditionally-trained residents: M = 1.79, SD = 1.0 versus M = 2.78, SD = 1.77 (p = 0.04). Simulator-trained residents displayed more self-confidence about their procedural skills: (M = 81, SD = 11 versus M = 68, SD = 20, p = 0.02).

CONCLUSIONS

Simulation-based mastery learning increased residents' skills in simulated CVC insertion, decreased the number of needle passes when performing actual procedures, and increased resident self-confidence.

Computer-enhanced visual learning method: a paradigm to teach and document surgical skills

INNOVATION

Changes in health care are stimulating residency training programs to develop new methods for teaching surgical skills. We developed Computer-Enhanced Visual Learning (CEVL) as an innovative Internet-based learning and assessment tool. The CEVL method uses the educational procedures of deliberate practice and performance to teach and learn surgery in a stylized manner.

AIM OF INNOVATION

CEVL is a learning and assessment tool that can provide students and educators with quantitative feedback on learning a specific surgical procedure. Methods involved examine quantitative data of improvement in surgical skills. Herein, we qualitatively describe the method and show how program directors (PDs) may implement this technique in their residencies.

RESULTS

CEVL allows an operation to be broken down into teachable components. The process relies on feedback and remediation to improve performance, with a focus on learning that is applicable to the next case being performed. CEVL has been shown to be effective for teaching pediatric orchiopexy and is being adapted to additional adult and pediatric procedures and to office examination skills. The CEVL method is available to other residency training programs.

Impact of intensity of practice after stroke: Issues for consideration

PURPOSE

The present debate paper addresses four relevant issues related to the impact of intensity of practice after stroke. First, the best way to define intensity of practice is discussed. Second, the paper describes the evidence that exists for a dose-response relationship in stroke rehabilitation. Third, the relevance of an appropriate patient selection for a meaningful intensive practice is explored. Finally, the paper raises the question of what it is that patients actually learn when they improve their functional skills. Search strategy. For this purpose articles from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE and PiCarta and references presented in relevant publications were examined.

DISCUSSION AND CONCLUSION

Although, there is strong evidence that early augmented exercise therapy time (expressed as time dedicated to practice) may enhance functional recovery, there is a discrepancy between the evidence for the benefits of intensive practice, on the one hand, and, the implementation of intensive rehabilitation treatment programmes in the current healthcare system on the other. Further emphasis should be given on a better understanding of the time-dependency of prognostic factors that determine the effectiveness of intensive practice in patients with stroke. In addition, a better understanding is needed of the neurophysiological and biomechanical mechanisms that underlie compensation-related learning of functional tasks after stroke.

Perspective: Simulation and transformational change: the paradox of expertise

Simulation is widely seen as a space where procedural skills can be practiced in safety, free from the pressures and complexities of clinical care. Central to this approach is the notion of simplification, a stripping down of skills into their component parts. Yet the definition of simplicity is contestable, often determined by experts without reference to those they teach.The author uses the ha-ha, a hidden ditch around a large country house used by 18th-century English landscape gardeners to create an illusion that the house is surrounded by untamed nature, as a metaphor for the differing perspectives of expert and novice. The author proposes that this difference of perspective lies at the heart of many current problems with simulation and simulators.This article challenges the philosophy of simplification, arguing that procedural skills should not be divorced from their clinical context and that oversimplification of a complex process can interfere with deep understanding. The author draws on Meyer and Land's notions of threshold concepts and troublesome knowledge and on his own experience with patient-focused simulation to propose an alternative view of simulation, framing it as a safe space which can reflect the uncertainties of clinical practice and recreate the conditions of real-world learning. By reintroducing complexity and human unpredictability, simulation can provide a safe environment for assisting the transformational change that is essential to becoming a competent clinician.

A program to enhance competence in clinical transaction skills

The ability to take a comprehensive and accurate clinical history, perform a thorough and nuanced physical examination, engage in sequential clinical reasoning using all relevant clinical and laboratory data, and communicate clearly and compassionately with patients and other providers--the skills of the clinical transaction--are critical to a successful therapeutic outcome. Yet few medical schools' curricula include an explicit focus on developing these skills beyond the introductory level. Vanderbilt Medical School has developed a structured curriculum, integrated into the traditional clerkships of the third and fourth years, that ensures that each student receives specific instruction in clinical transaction skills. The clinical transaction curriculum is based on a set of 25 presenting problems, with learning objectives identified for each problem. Primary responsibility for instruction relating to each presenting problem is assigned to specific core clerkships, with the major portion of teaching provided by a nucleus of specially selected and compensated master clinical teachers. The Clinical Transaction Project at Vanderbilt was begun in 2004. Future development will focus on enhancing approaches to student assessment.

Development and evaluation of a simulation-based pediatric emergency medicine curriculum

PURPOSE

The infrequency of severe childhood illness limits opportunities for emergency medicine (EM) providers to learn from real-world experience. Simulation offers an evidence-based educational approach to develop and practice clinical skills.

METHOD

This was a two-phase, randomized trial with a wait-list control condition. The development phase (2005-2006) involved systematic curriculum and rating checklist creation, producing a six-case, simulation-based curriculum linked to three evaluation cases.In the validation phase (2006-2007), the authors randomized 69 residents from two EM residencies to either an intervention group that received the curriculum one month before the first assessment of all participants or a wait-list control group that received the identical curriculum three months later. A final assessment of all residents followed one month after that. Two raters evaluated all residents. Primary outcome measures are percentages of items completed correctly. The authors assessed rater agreement using intraclass correlation (ICC) and compared group performance using mixed-model analysis of variance.

RESULTS

ICCs surpassed 0.78. The instructional intervention produced a statistically significant effect for two of three evaluation cases for the validation phase of the study, a case x occasion interaction. Training year was significantly associated with better performance. In a multivariate analysis, training year and session correlated with score, but study group did not.

CONCLUSIONS

A one-day, simulation-based pediatric EM curriculum produced limited results. The evaluation approach is reasonable and reproducible for the population studied. Instructional dose strength and factors may have limited curriculum effectiveness. Focused, frequent, and effortful instructional interventions are necessary to achieve substantial performance improvements.

How far will simulators be involved into training?

The expansion of laparoscopy and endoscopic surgery has promoted a change in surgical skills acquisition. This review aims to identify problems that modulate surgical skills acquisition and the role of simulation in the current training programs. Social, medical, and working time constraints, together with patient safety issues, lead to a decreased availability of operating room (OR) training opportunities. Systematic reviews show that there is a positive "model to model" transfer of skills more evident for virtual reality (VR) simulation, although transfer from video tower exists for naïve trainees, both of which supplement standard laparoscopic training. VR to OR positive transfer is proven for laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, although not for all parameters analyzed. A mixed model integrating both types of trainers into surgical curricula may strengthen their respective possibilities. To what extent simulation will be included in the surgical training programs depends on development of objective and finer assessment tools and proficiency-based criteria.

The American College of Chest Physicians evidence-based educational guidelines for continuing medical education interventions: a critical review of evidence-based educational guidelines

The American College of Chest Physicians comprehensive review of continuing medical education is an ambitious attempt to summarize a vast and heterogeneous literature. Nevertheless, there appear to be some consistencies; multiple media and instructional methods appear to be consistently better than single approaches, and multiple occasions work better than one-shot events. While this appears, at first glance, to be perfectly reasonable, one must be careful to treat media and method separately. Other research has shown that many media manipulations can reduce, not enhance, learning. In a similar vein, while the role of simulation in continuing medical education is largely unexplored, applications must be considered with clear understanding of what can and cannot be achieved with simulation.