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

Safe Introduction of New Procedures and Emerging Technologies in Surgery: Education, Credentialing, and Privileging

Ongoing horizon scanning is needed to identify new procedures and emerging technologies that should be evaluated for introduction into surgical practice. Following evidence-based evaluation, if a new modality is found ready for adoption in practice, surgeons need education in the safe and effective use of the new modality. The educational experience should include structured teaching and learning, verification of new knowledge and skills, preceptoring or proctoring, and monitoring of outcomes. Credentialing and privileging to perform a new procedure or use an emerging technology should be based on evaluation of knowledge and skills and outcomes of surgical care, and not merely on the numbers of procedures performed. Education of the entire surgical team is also essential. The entire process involving education, verification of knowledge and skills, credentialing, and privileging must be transparent. Patients need to play a central role in making informed decisions regarding their care that involves use of a new procedure or an emerging technology, and they should participate actively in their perioperative care.

Construct and face validity and task workload for laparoscopic camera navigation: virtual reality versus videotrainer systems at the SAGES Learning Center

BACKGROUND

Laparoscopic camera navigation (LCN) training on simulators has demonstrated transferability to actual operations, but no comparative data exist. The objective of this study was to compare the construct and face validity, as well as workload, of two previously validated virtual reality (VR) and videotrainer (VT) systems.

METHODS

Attendees (n = 90) of the SAGES 2005 Learning Center performed two repetitions on both VR (EndoTower) and VT (Tulane Trainer) LCN systems using 30 degrees laparoscopes and completed a questionnaire regarding demographics, simulator characteristics, and task workload. Construct validity was determined by comparing the performance scores of subjects with various levels of experience according to five parameters and face validity according to eight. The validated NASA-TLX questionnaire that rates the mental, physical, and temporal demand of a task as well as the performance, effort, and frustration of the subject was used for workload measurement.

RESULTS

Construct validity was demonstrated for both simulators according to the number of basic laparoscopic cases (p = 0.005), number of advanced cases (p < 0.001), and frequency of angled scope use (p < 0.001), and only for VT according to training level (p < 0.001) and fellowship training (p = 0.008). Face validity ratings on a 1-20 scale averaged 15.4 +/- 3 for VR vs. 16 +/- 2.6 for VT (p = 0.04). Ninety-six percent of participants rated both simulators as valid educational tools. The NASA-TLX overall workload score was 69.5 +/- 24 for VR vs. 68.8 +/- 20.5 for VT (p = 0.31).

CONCLUSIONS

This is the largest study to date that compares two validated LCN simulators. While subtle differences exist, both VR and VT simulators demonstrated excellent construct validity, good face validity, and acceptable workload parameters. These systems thus represent useful training devices and should be widely used to improve surgical performance.

Assessing procedural skills in context: Exploring the feasibility of an Integrated Procedural Performance Instrument (IPPI)

BACKGROUND

The assessment of clinical procedural skills has traditionally focused on technical elements alone. However, in real practice, clinicians are expected to be able to integrate technical with communication and other professional skills. We describe an integrated procedural performance instrument (IPPI), where clinicians are assessed on 12 clinical procedures in a simulated clinical setting which combines simulated patients (SPs) with inanimate models or items of medical equipment. Candidates are observed remotely by assessors whose data are fed back to the clinician within 24 hours of the assessment. This paper describes the feasibility of IPPI.

RESULTS

A full-scale IPPI and 2 pilot studies with trainee and qualified health care professionals has yielded an extensive data set including 585 scenario evaluations from candidates, 60 from clinical assessors and 31 from simulated patients (SPs). Interview and questionnaire data showed that for the majority of candidates IPPI provided a powerful and valuable learning experience. Realism was rated highly. Remote and real-time assessment worked effectively, although for some procedures limited camera resolution affected observation of fine details.

DISCUSSION

IPPI offers an innovative approach to assessing clinical procedural skills. Although resource-intensive, it has the potential to provide insight into individual's performance over a spectrum of clinical scenarios and at no risk to the safety of patients. Additional benefits of IPPI include assessment in real time from experts (allowing remote rating by external examiners) as well as provision of feedback from simulated patients.

Development, implementation and outcomes of a training program for responders to acts of terrorism

INTRODUCTION

Responding to acts of terrorism requires the effective use of public-safety and medical-response resources. The knowledge, skills and attitudes necessary to respond to future threats is unfamiliar to most emergency responders.

OBJECTIVES

The purpose of this report to describe the development, implementation and evaluation of a multidisciplinary, interactive and simulation-enhanced course to prepare responders to acts of terrorism.

METHODS

We used a 5-step systematic process to develop a blended-learning, simulation-enhanced training program. Learners completed a self-confidence questionnaire and written examination prior to the course and a self-confidence questionnaire, written examination and course evaluation when they finished the course.

RESULTS

From July 7, 2003 to March 8, 2005, 497 consenting learners completed the course. After course completion, learners demonstrated significant increases in their knowledge of terrorism response (t = -64.3, df = 496, p < 0.05) and their confidence in responding to terrorist events (t = -45.5, df = 496, p < 0.05). Learner feedback about the course was highly positive.

CONCLUSIONS

We successfully implemented a two-day course for professionals likely to respond to terrorist acts that included scenario-based performance training and assessment. Course participants increased their knowledge and were more confident in their ability to respond to acts of terrorism after participating in this course.

A longitudinal study of internal medicine residents' retention of advanced cardiac life support skills

BACKGROUND

Internal medicine residents must be competent in Advanced Cardiac Life Support (ACLS) for board certification. Traditional ACLS courses have limited ability to enable residents to achieve and maintain skills. Educational programs featuring reliable measurements and improved retention of skills would be useful for residency education.

METHOD

We developed a training program using a medical simulator, small-group teaching and deliberate practice. Residents received traditional ACLS education and subsequently participated in four two-hour educational sessions using the simulator. Resident performance in six simulated ACLS scenarios was assessed using a standardized checklist.

RESULTS

After the program, resident ACLS skill improved significantly. The cohort was followed prospectively for 14 months and the skills did not decay.

CONCLUSIONS

Use of a simulation-based educational program enabled us to achieve and maintain high levels of resident performance in simulated ACLS events. Given the limitations of traditional methods to train, assess and maintain competence, simulation technology can be a useful adjunct in high-quality ACLS education.

Comparison of three simulation-based training methods for management of medical emergencies

Trainee medical officers (TMOs) participated in a study comparing three methods of simulation-based training to treat medical emergencies occurring in a hospital setting. The methods were: All groups had the same total teaching time. Participants (n=61) had an initial (pre-training) assessment by written tests, self assessment and simulations of medical emergencies ('VT' and 'HYPOglycaemia'). Participants were tested again post-training using similar simulations to the initial scenario and a new scenario ('ANAphylaxis'). Trained 'experts', blinded to the teaching group of participants, watched video-CDs of the simulations to assess participants' performance. All groups demonstrated increased knowledge and confidence (pre-training scores compared to post-training) but no differences could be detected between the three groups. In simulated emergencies, post-training scores were also improved. There was no difference between groups in the 'HYPO' scenario but in the 'VT' scenario there was moderate evidence that Group 3 was superior. In the 'ANA' scenario, Group 3 had far better test scores, especially in behavioural items. There did not appear to be any significant advantage of using whole body manikins over CSBT and simple part-task trainers. Full-mission simulation training helped develop the ability to recognise when skills learnt to manage one type of medical emergency can be useful in managing another emergency not previously encountered.

Challenges for educationalists

Medical education has to change to meet the shifts in public and professional attitudes. Experts gathering at the annual meeting of the Association for Medical Education in Europe next week have plenty to discuss

Prior experiences associated with residents' scores on a communication and interpersonal skill OSCE

OBJECTIVE

This exploratory study investigated whether prior task experience and comfort correlate with scores on an assessment of patient-centered communication.

METHODS

A six-station standardized patient exam assessed patient-centered communication of 79 PGY2-3 residents in Internal Medicine and Family Medicine. A survey provided information on prior experiences. t-tests, correlations, and multi-factorial ANOVA explored relationship between scores and experiences.

RESULTS

Experience with a task predicted comfort but did not predict communication scores. Comfort was moderately correlated with communication scores for some tasks; residents who were less comfortable were indeed less skilled, but greater comfort did not predict higher scores. Female gender and medical school experiences with standardized patients along with training in patient-centered interviewing were associated with higher scores. Residents without standardized patient experiences in medical school were almost five times more likely to be rejected by patients.

CONCLUSIONS

Task experience alone does not guarantee better communication, and may instill a false sense of confidence. Experiences with standardized patients during medical school, especially in combination with interviewing courses, may provide an element of "deliberate practice" and have a long-term impact on communication skills.

PRACTICE IMPLICATIONS

The combination of didactic courses and practice with standardized patients may promote a patient-centered approach.

Design of integrated practice for learning professional competences

To acquire professional competences that entail performance of complex skills, an authentic learning environment is required focused on the integration of all aspects of competences. However, most educational programmes offer separate building blocks, such as separate modules for knowledge and skills. Students accumulate what they have learned in these modules as they progress through the curriculum. In this paper the authors advocate the Four-Component Instructional Design model (4C/ID), which offers a whole-task approach to course design for programmes in which students learn complex skills. The four core components of this approach are: learning tasks, supportive information, just-in-time information and part-task practice. A concrete example from medical education will be presented to clarify both the general ideas behind this approach and the differences between the whole-task approach and conventional educational designs.

Psychomotor testing predicts rate of skill acquisition for proficiency-based laparoscopic skills training

BACKGROUND

Laparoscopic simulator training translates into improved operative performance. Proficiency-based curricula maximize efficiency by tailoring training to meet the needs of each individual; however, because rates of skill acquisition vary widely, such curricula may be difficult to implement. We hypothesized that psychomotor testing would predict baseline performance and training duration in a proficiency-based laparoscopic simulator curriculum.

METHODS

Residents (R1, n = 20) were enrolled in an IRB-approved prospective study at the beginning of the academic year. All completed the following: a background information survey, a battery of 12 innate ability measures (5 motor, and 7 visual-spatial), and baseline testing on 3 validated simulators (5 videotrainer [VT] tasks, 12 virtual reality [minimally invasive surgical trainer-virtual reality, MIST-VR] tasks, and 2 laparoscopic camera navigation [LCN] tasks). Participants trained to proficiency, and training duration and number of repetitions were recorded. Baseline test scores were correlated to skill acquisition rate. Cutoff scores for each predictive test were calculated based on a receiver operator curve, and their sensitivity and specificity were determined in identifying slow learners.

RESULTS

Only the Cards Rotation test correlated with baseline simulator ability on VT and LCN. Curriculum implementation required 347 man-hours (6-person team) and 795,000 dollars of capital equipment. With an attendance rate of 75%, 19 of 20 residents (95%) completed the curriculum by the end of the academic year. To complete training, a median of 12 hours (range, 5.5-21), and 325 repetitions (range, 171-782) were required. Simulator score improvement was 50%. Training duration and repetitions correlated with prior video game and billiard exposure, grooved pegboard, finger tap, map planning, Rey Figure Immediate Recall score, and baseline performance on VT and LCN. The map planning cutoff score proved most specific in identifying slow learners.

CONCLUSIONS

Proficiency-based laparoscopic simulator training provides improvement in performance and can be effectively implemented as a routine part of resident education, but may require significant resources. Although psychomotor testing may be of limited value in the prediction of baseline laparoscopic performance, its importance may lie in the prediction of the rapidity of skill acquisition. These tests may be useful in optimizing curricular design by allowing the tailoring of training to individual needs.

Teaching technical skills to surgical residents: a survey of empirical research

We review a series of empirical studies on the use of simulators and bench models in training technical skills and subsequent retention of those skills. We discuss recent research on the transfer of training from bench models and simulators to the clinical setting and provide a theoretical structure to organize the findings. The transfer of training from inanimate bench models and simulators to live patients has recently been demonstrated in a number of areas. The effectiveness of this training is enhanced if focus is placed on the operative, or process-oriented, aspects of the procedure, with suspension of disbelief regarding the physical structure of the training platform. The retention of trained skills is an area of research only beginning to evolve, with recent results suggesting that effective retention can be demonstrated if training is tightly focused and involves an entire procedure. An emerging area of research involves the use of simulators as assessment instruments for high-stakes testing, and recent results involving simulated trauma management support this novel application. Based on these findings, we encourage the use of a wide variety of high- and low-fidelity platforms, with emphasis on training procedural knowledge involving an entire procedure.

Effect of practice on standardised learning outcomes in simulation-based medical education

OBJECTIVES

This report synthesises a subset of 31 journal articles on high-fidelity simulation-based medical education containing 32 research studies drawn from a larger qualitative review published previously. These studies were selected because they present adequate data to allow for quantitative synthesis. We hypothesised an association between hours of practice in simulation-based medical education and standardised learning outcomes measured as weighted effect sizes.

METHODS

Journal articles were screened using 5 exclusion and inclusion criteria. Response data were extracted and 3 judges independently coded each study. Learning outcomes were standardised using a common metric, the average weighted effect size (AWES), due to the heterogeneity of response measures in individual studies. anova was used to evaluate AWES differences due to hours of practice on a high-fidelity medical simulator cast in 5 categories. The eta squared (eta2) statistic was used to assess the association between AWES and simulator practice hours.

RESULTS

There is a strong association (eta2=0.46) between hours of practice on high-fidelity medical simulators and standardised learning outcomes. The association approximates a dose-response relationship.

CONCLUSIONS

Hours of high-fidelity simulator practice have a positive, functional relationship with standardised learning outcomes in medical education. More rigorous research methods and more stringent journal editorial policies are needed to advance this field of medical education research.

Emergency and critical care pediatrics: use of medical simulation for training in acute pediatric emergencies

PURPOSE OF THE REVIEW

Recent data suggest that pediatric trainees receive insufficient training to manage acute pediatric emergencies. This review addresses the use of medical simulation as a way for medical learners to acquire and maintain skills needed to manage pediatric resuscitations.

RECENT FINDINGS

Recent work highlights the value of deliberate practice in the context of simulated medical environments to promote development of medical expertise. Several studies demonstrate the benefit of simulation-based training for improved skill acquisition in advanced life support, emergency airway management, and nontechnical skills. Work in other fields of medicine supports the integration of simulation into pediatric training programs.

SUMMARY

Medical simulation holds great promise to enhance existing pediatric training curricula by increasing skills and expertise in resuscitation. Future research is needed to identify best methods of pediatric simulation-based training.

Graduating internal medicine residents' self-assessment and performance of advanced cardiac life support skills

Internal medicine residents in the US must be competent to perform procedures including Advanced Cardiac Life Support (ACLS) to become board-eligible. Our aim was to determine if residents near graduation could assess their skills in ACLS procedures accurately. Participants were 40 residents in a university-based training program. Self-assessments of confidence in managing six ACLS scenarios were measured on a 0 (very low) to 100 (very high) scale. These were compared to reliable observational ratings of residents' performance on a high-fidelity simulator using published treatment protocols. Residents expressed strong self-confidence about managing the scenarios. Residents' simulator performance varied widely (range from 45% to 94%). Self-confidence assessments correlated poorly with performance (median r = 0.075). Self-assessment of performance by graduating internal medicine residents was not accurate in this study. The use of self-assessment to document resident competence in procedures such as ACLS is not a proxy for objective evaluation.

Self-assessment during a 2-day laparoscopic colectomy course: can surgeons judge how well they are learning new skills?

BACKGROUND

The objectives of this study were to (1) establish the utility of an assessment tool for participants in a laparoscopic colectomy course and (2) to determine the accuracy of technical skill self-assessment in this group.

METHODS

Twenty-two surgeons enrolled in a 2-day course participated. During the animal laboratory, each participant's operative performance was videotaped. Participants completed a global rating scale (GRS) instrument to self-assess their performances. By using the same GRS, 2 trained raters independently assessed each performance by videotape review.

RESULTS

For the trained raters, the GRS showed excellent interrater reliability (r = .76, P < .001). There was no correlation between trained rater scores and self-assessment scores. Furthermore, the trained rater scores (mean, 2.62 and 2.99) were significantly lower than the self-assessment scores (4.05, P < .001).

CONCLUSIONS

Surgeons consistently overestimated their performance during a laparoscopic colectomy course as measured by reliable GRS. This finding highlights the issue of credentialing and the importance of preceptorship for surgeons completing such courses.

Physician characteristics associated with proficiency in feedback skills

BACKGROUND

Providing and eliciting high-quality feedback is valuable in medical education. Medical learners' attainment of clinical competence and professional growth can be facilitated by reliable feedback. This study's primary objective was to identify characteristics that are associated with physician teachers' proficiency with feedback.

METHODS

A cohort of 363 physicians, who were either past participants of the Johns Hopkins Faculty Development Program or members of a comparison group, were surveyed by mail in July 2002. Survey questions focused on personal characteristics, professional characteristics, teaching activities, self-assessed teaching proficiencies and behaviors, and scholarly activity. The feedback scale, a composite feedback variable, was developed using factor analysis. Logistic regression models were then used to determine which faculty characteristics were independently associated with scoring highly on a dichotomized version of the feedback scale.

RESULTS

Two hundred and ninety-nine physicians responded (82%) of whom 262 (88%) had taught medical learners in the prior 12 months. Factor analysis revealed that the 7 questions from the survey addressing feedback clustered together to form the "feedback scale" (Cronbach's alpha: 0.76). Six items, representing discrete faculty responses to survey questions, were independently associated with high feedback scores: (i) frequently attempting to detect and discuss the emotional responses of learners (odds ratio [OR]=4.6, 95% confidence interval [CI] 2.2 to 9.6), (ii) proficiency in handling conflict (OR=3.7, 95% CI 1.5 to 9.3), (iii) frequently asking learners what they desire from the teaching interaction (OR=3.5, 95% CI 1.7 to 7.2), (iv) having written down or reviewed professional goals in the prior year (OR=3.2, 95% CI 1.6 to 6.4), (v) frequently working with learners to establish mutually agreed upon goals, objectives, and ground rules (OR=2.2, 95% CI 1.1 to 4.7), and (vi) frequently letting learners figure things out themselves, even if they struggle (OR=2.1, 95% CI 1.1 to 3.9).

CONCLUSIONS

Beyond providing training in specific feedback skills, programs that want to improve feedback performance among their faculty may wish to promote the teaching behaviors and proficiencies that are associated with high feedback scores identified in this study.

Influence of clerkship experiences on clinical competence

BACKGROUND

Clerkship experiences are considered crucial for the development of clinical competence. Yet whether there is a direct relationship between the nature and volume of patient encounters and learning outcomes is far from clear. Some evidence in the literature points towards the importance of clinical supervision on student learning, but the relationship between clinical supervision, patient encounters and student competence remains unclear.

OBJECTIVES

This study aimed firstly to determine the variation in students' clinical experiences within and across sites; secondly, to identify the causes of this variation, and thirdly, to investigate the consequences of this variation on students' competence.

METHODS

Clerkship students at 12 hospital sites recorded their patient encounters in logbooks. Site characteristics that might influence the variation in patient encounters were collected. Student competence was determined by 3 independent indicators: a practical end-of-clerkship examination; a theoretical end-of-clerkship examination, and an evaluation of professional performance. A model was developed to test the available clerkship data using structural equation modelling (SEM) software.

RESULTS

Analysis of the logbooks revealed a large variation in the number of patients encountered by students. The average length of patient stay, number of patients admitted, and quality of supervision accounted partly for this variation. An increased number of patient encounters did not directly lead to improved competence. Quality of supervision turned out to be crucially important because it directly impacted student learning and also positively influenced the number of patient encounters.

CONCLUSION

Monitoring the effectiveness of clerkship by merely asking students to keep a tally of the problems and diseases they encounter, without paying attention to the quality of supervision, does not contribute towards improving student learning.

Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice

BACKGROUND

Internal medicine residents must be competent in advanced cardiac life support (ACLS) for board certification.

OBJECTIVE

To use a medical simulator to assess postgraduate year 2 (PGY-2) residents' baseline proficiency in ACLS scenarios and evaluate the impact of an educational intervention grounded in deliberate practice on skill development to mastery standards.

DESIGN

Pretest-posttest design without control group. After baseline evaluation, residents received 4, 2-hour ACLS education sessions using a medical simulator. Residents were then retested. Residents who did not achieve a research-derived minimum passing score (MPS) on each ACLS problem had more deliberate practice and were retested until the MPS was reached.

PARTICIPANTS

Forty-one PGY-2 internal medicine residents in a university-affiliated program.

MEASUREMENTS

Observational checklists based on American Heart Association (AHA) guidelines with interrater and internal consistency reliability estimates; deliberate practice time needed for residents to achieve minimum competency standards; demographics; United States Medical Licensing Examination Step 1 and Step 2 scores; and resident ratings of program quality and utility.

RESULTS

Performance improved significantly after simulator training. All residents met or exceeded the mastery competency standard. The amount of practice time needed to reach the MPS was a powerful (negative) predictor of posttest performance. The education program was rated highly.

CONCLUSIONS

A curriculum featuring deliberate practice dramatically increased the skills of residents in ACLS scenarios. Residents needed different amounts of training time to achieve minimum competency standards. Residents enjoy training, evaluation, and feedback in a simulated clinical environment. This mastery learning program and other competency-based efforts illustrate outcome-based medical education that is now prominent in accreditation reform of residency education.

Reflection: a critical proficiency essential to the effective development of a high competence in communication

Reflection, or the ability to step back from an experience and consider it critically, in an analytical, non-subjective manner, is an essential aspect of problem solving and decision making, and also of effective communication with clients and colleagues. Reflective practice has been described as the essence of professionalism and is therefore a core professional skill; rarely, however, has it been explicitly taught in veterinary curricula, and it has only a recent history in undergraduate human medical curricula. We describe here two preliminary case studies, one in a veterinary medical education context and the other within a human medical education framework, as examples of approaches to assessing a student's ability for ''reflection.'' The case studies also illustrate some of the key principles. Both of the case studies described had as their end goal the enhancement of communication skills through critical reflection. At Monash University, Australia, the majority of students were assessed as being at a level of ''reflection in development.'' The students in the Ontario Veterinary College case study showed moderately good use of self-awareness and critical reflection as a basis for modifying and integrating communication skills into practice. While both preliminary case studies point to the fact that students recognize the importance of communication and value the opportunity to practice it, few students in either case study identified the importance of reflection for lifelong learning and professional competence. Opportunities to complete critical reflection exercises in other parts of curricula and outside of communication would likely reinforce its importance as a generic skill. Ongoing scholarly approaches to teaching, learning, and evaluating reflection and self-awareness are needed.

Comparison of two standard-setting methods for advanced cardiac life support training

BACKGROUND

This study used the Angoff and Hofstee standard-setting methods to derive minimum passing scores for six advanced cardiac life support (ACLS) procedures.

METHOD

An expert panel provided item-based (Angoff) and group-based (Hofstee) judgments about six ACLS performance checklists on two occasions separated by ten weeks. Interrater reliabilities and test-retest reliability (stability) of the judgments were calculated. Derived ACLS passing standards are compared to historical ACLS performance data from two groups of ACLS-trained internal medicine residents.

RESULTS

Both the Angoff and Hofstee standard-setting methods produced reliable and stable data. Hofstee minimum passing scores (MPSs) were uniformly more stringent than Angoff MPSs. Interpretation of historical ACLS performance data from medical residents shows the MPSs derived in this study would yield higher-than-expected failure rates.

CONCLUSION

Systematic standard setting for ACLS procedures is a necessary step toward the creation of mastery learning educational programs.

Evaluating clinical simulations for learning procedural skills: a theory-based approach

Simulation-based learning is becoming widely established within medical education. It offers obvious benefits to novices learning invasive procedural skills, especially in a climate of decreasing clinical exposure. However, simulations are often accepted uncritically, with undue emphasis being placed on technological sophistication at the expense of theory-based design. The author proposes four key areas that underpin simulation-based learning, and summarizes the theoretical grounding for each. These are (1) gaining technical proficiency (psychomotor skills and learning theory, the importance of repeated practice and regular reinforcement), (2) the place of expert assistance (a Vygotskian interpretation of tutor support, where assistance is tailored to each learner's needs), (3) learning within a professional context (situated learning and contemporary apprenticeship theory), and (4) the affective component of learning (the effect of emotion on learning). The author then offers four criteria for critically evaluating new or existing simulations, based on the theoretical framework outlined above. These are: (1) Simulations should allow for sustained, deliberate practice within a safe environment, ensuring that recently-acquired skills are consolidated within a defined curriculum which assures regular reinforcement; (2) simulations should provide access to expert tutors when appropriate, ensuring that such support fades when no longer needed; (3) simulations should map onto real-life clinical experience, ensuring that learning supports the experience gained within communities of actual practice; and (4) simulation-based learning environments should provide a supportive, motivational, and learner-centered milieu which is conducive to learning.

Research in clinical reasoning: past history and current trends

BACKGROUND

Research in clinical reasoning has been conducted for over 30 years. Throughout this time there have been a number of identifiable trends in methodology and theory.

PURPOSE

This paper identifies three broad research traditions, ordered chronologically, are: (a) attempts to understand reasoning as a general skill--the "clinical reasoning" process; (b) research based on probes of memory--reasoning related to the amount of knowledge and memory; and (c) research related to different kinds of mental representations--semantic qualifiers, scripts, schemas and exemplars.

RESULTS AND CONCLUSIONS

Several broad themes emerge from this review. First, there is little evidence that reasoning can be characterised in terms of general process variables. Secondly, it is evident that expertise is associated, not with a single basic representation but with multiple coordinated representations in memory, from causal mechanisms to prior examples. Different representations may be utilised in different circumstances, but little is known about the characteristics of a particular situation that led to a change in strategy.

IMPLICATIONS

It becomes evident that expertise lies in the availability of multiple representations of knowledge. Perhaps the most critical aspect of learning is not the acquisition of a particular strategy or skill, nor is it the availability of a particular kind of knowledge. Rather, the critical element may be deliberate practice with multiple examples which, on the hand, facilitates the availability of concepts and conceptual knowledge (i.e. transfer) and, on the other hand, adds to a storehouse of already solved problems.

Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial

BACKGROUND

Internal medicine residents must be competent in Advanced Cardiac Life Support (ACLS) for board certification.

PURPOSE

The purpose was to use a medical simulator to assess baseline proficiency in ACLS and determine the impact of an intervention on skill development.

METHOD

This was a randomized trial with wait-list controls. After baseline evaluation in all residents, the intervention group received 4 education sessions using a medical simulator. All residents were then retested. After crossover, the wait-list group received the intervention, and residents were tested again. Performance was assessed by comparison to American Heart Association guidelines for treatment of ACLS conditions with interrater and internal consistency reliability estimates.

RESULTS

Performance improved significantly after simulator training. No improvement was detected as a function of clinical experience alone. The educational program was rated highly.