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

Improving surgical excellence: first experience of a video-based intervention in outpatients

BACKGROUND

There are limited opportunities for surgeons to engage in active learning programs once they achieve Fellowship, especially for non-technical skills such as communication. This study aims to address this gap by evaluating a peer-based coaching program in non-technical skill using video-recorded patient consultations from a routine outpatient clinic.

METHODS

Standard outpatient consultations between consultant surgeons and patients were video recorded. The surgeon viewed the videos with a peer-coach (senior surgeon) who helped identify areas of strength and areas for improvement. To test the effect of the coaching session, outpatient consultations were recorded roughly 1 month later. Pre and post-coaching videos were assessed using the Maastricht History-Taking and Advice Scoring - Global Rating List (MAAS), a common tool for evaluating non-technical skills in clinicians.

RESULTS

A total of 12 surgeons consented to participate. Coaching significantly improved MAAS scores (mean difference = -0.61; 95% CI (-0.88, -0.33); P < 0.0001). Surgeons were generally positive about the experience. All found the method of learning suitable, and most thought the process improved their skills. Most thought that coaching would improve patient outcomes and the majority thought they would participate in ongoing coaching as part of their employment.

CONCLUSION

This supports the concept of surgical coaching as an effective tool to improve communication skills and the quality of surgical consultation. The next step is to expand beyond a voluntary cohort and link surgical coaching to improved patient outcomes.

Video Commentary & Machine Learning: Tell Me What You See, I Tell You Who You Are

BACKGROUND & OBJECTIVE

Teaching and assessment of complex problem solving are a challenge for medical education. Integrating Machine Learning (ML) into medical education has the potential to revolutionize teaching and assessment of these problem-solving processes. In order to demonstrate possible applications of ML to education, we sought to apply ML in the context of a structured Video Commentary (VC) assessment, using ML to predict residents' training level.

SETTING

A secondary analysis of multi-institutional, IRB approved study. Participants had completed the VC assessment consisting of 13 short (20-40 seconds) operative video clips. They were scored in real-time using an extensive checklist by an experienced proctor in the assessment. A ML model was developed using TensorFlow and Keras. The individual scores of the 13 video clips from the VC assessment were used as the inputs for the ML model as well as for regression analysis.

PARTICIPANTS

A total of 81 surgical residents of all postgraduate years (PGY) 1-5 from 7 institutions constituted the study sample.

RESULTS

Scores from individual VC clips were strongly positively correlated with PGY level (p = 0.001). Some video clips were identified to be strongly correlated with a higher total score on the assessment; others had significant influence when used to predict trainees' PGY levels. Using a supervised machine learning model to predict trainees' PGY resulted in a 40% improvement over traditional statistical analysis.

CONCLUSIONS

Performing better in a few select video clips was key to obtaining a higher total score but not necessarily foretelling of a higher PGY level. The use of the total score as a sole measure may fail to detect deeper relationships. Our ML model is a promising tool in gauging learners' levels on an assessment as extensive as VC. The model managed to approximate residents' PGY levels with a lower MAE than using traditional statistics. Further investigations with larger datasets are needed.

Ventricular Assist Device Self-care Education at Tertiary Care Medical Centers

Ventricular assist device (VAD) implantation requires patients and caregivers to attain self-care knowledge and skills before discharge from implant hospitalization. Inability to perform these skills can have devastating outcomes (i.e., death from pump malfunction, driveline site infections, and stroke). No standard-of-care guiding VAD self-care education exists. We sought to describe how select tertiary care VAD implant centers across the United States currently educate VAD patients and their caregivers. Using a multiple case studies design with a purposive sampling strategy, we conducted semistructured interviews of VAD coordinators responsible for VAD education at 18 centers. From audio recording of interviews, we used rapid qualitative analysis to organize and analyze the data. All centers spent significant time and effort educating patients and caregivers on VAD self-care. Although centers teach similar content, the rigor of assessments and follow-up education differed vastly. Only 3/18 (17%) centers performed competency-based assessments with a skills checklist and minimum passing standard assessing readiness to perform VAD self-care independently. Twelve of 18 (67%) centers provided formal follow-up education to address skills decay, yet wide variation existed in timing and content of education. Due to the diversity among centers regarding VAD self-care education, more prescriptive practice guidelines are needed.

Influence of practical and clinical experience on dexterity performance measured using haptic virtual reality simulator

INTRODUCTION

Development of dexterity, hand-eye coordination and self-assessment are essential during the preclinical training of dental students. To meet this requirement, dental simulators have been developed combining virtual reality with a force feedback haptic interface. The aim of this study was to assess the capability of the VirTeaSy^© haptic simulator to discriminate between users with different levels of practical and clinical experience.

MATERIALS AND METHODS

Fifty-six volunteers divided into five groups (non-dentists, 1st/3rd/final-year dental students, recent graduates) had three attempts to prepare an occlusal amalgam cavity using the simulator. Percentages of volumes prepared inside (%IV) and outside (%OV) the required cavity, skill index and progression rate, referring to the evolution of skill index between trials 1 and 3, were assessed. The dental students and recent graduates completed a questionnaire to gather their opinions about their first hands-on experience with a haptic simulator.

RESULTS

The results showed no significant difference between the groups at the first attempt. Following the third attempt, the skill index was improved significantly. Analysis of progression rates, characterised by large standard deviations, did not reveal significant differences between groups. The third attempt showed significant differences in skill index and %IV between 1st-year undergraduate dental students and both non-dentists and recent dental graduates. The questionnaire indicated a tendency for dental operators to consider the simulator as a complement to their learning and not a substitute for traditional methods.

CONCLUSION

This study did not show the ability of a basic aptitude test on VirTeaSy^© haptic simulator to discriminate between users of different levels of expertise. Optimisations must be considered in order to make simulation-based assessment clinically relevant.

Longitudinal clinical reasoning theme embedded across four years of a medical school curriculum

OBJECTIVES

The acquisition of clinical reasoning (CR) skills is essential for future healthcare providers as they advance through their education. There is growing consensus that CR skills should be longitudinally integrated into undergraduate curriculum for acquisition/application of these skills. However, only a minority of schools reported having CR focused teaching sessions, citing a lack of curricular time and faculty expertise as the largest barriers. We describe the design and implementation of this theme and report the effects of its early introduction in Phase One as measured by the Diagnostic Thinking Inventory (DTI).

METHODS

The Carver College of Medicine developed and implemented a longitudinal four-year clinical reasoning theme (CRT) with a special emphasis on introducing concepts in the preclinical years (Phase One). Educational strategies used to implement the theme relied on following principles: 1) new skills are best acquired in context of application; 2) contextual learning stimulates transfer of knowledge; and 3) knowledge of pathophysiology is necessary but alone is not sufficient to develop CR skills. A patient-centered CR schema served as the framework for developing the theme. Specific focus areas, pedagogies and assessment strategies were established for each of the three phases.

RESULTS

The cohort with CRT demonstrated a significant increase in total DTI score after theme implementation compared to the cohort without.

CONCLUSIONS

A formal 4-year longitudinal CR theme is feasible, allowing for integration of pathophysiology, social determinants of health, and clinical skills. Early introduction of CR concepts as assessed by DTI showed improvement in student reasoning skills post-intervention.

Surgical residents’ approach to training: are elements of deliberate practice observed?

Background: Research in the area of deliberate practice has consistently shown that intense, concentrated, goal-oriented practice in a focused domain, such as medicine, can improve both skill development and performance to attain a progressively higher standard of excellence. In theory, utilizing deliberate practice in a medical context could result in improved surgical training and in turn better patient outcomes. Therefore, the purpose of this study was to gain a better understanding of how surgical residents approach their training from the perspective of the surgical residents themselves and to explore if elements of deliberate practice are observed. Methods: Eight surgical trainees participated in one of two focus groups depending on their training level (five junior residents; three senior residents). With the exploratory nature of this research, a focus group methodology was utilized. Results: By employing both deductive and inductive thematic analysis techniques, three themes were extracted from the data: learning resources and strategies, role of a junior/senior, and approaching weaknesses. Conclusions: Although elements of deliberate practice were discussed, higher functioning is necessary to achieve performance excellence, leading to improved patient outcomes.

A Bi-national needs assessment to identify and prioritise procedures in paediatric surgery for simulation-based training

BACKGROUND

Simulation-based education (SBE) has led to significant changes in healthcare education. However, SBE has often been based on available resources and local expertise rather than a systematic approach to curriculum development. The aim of this study was to perform a bi-national needs assessment to identify and prioritise procedures in a paediatric surgery curriculum that can be supported using SBE.

METHOD

A modified 3-round Delphi technique was used to gather consensus from education leaders and trainees in paediatric surgery in Australia and Aotearoa New Zealand (ANZ). Round 1 identified all procedures a newly specialised paediatric surgeon should be able to perform. In Round 2, each procedure was explored for the need for SBE using the Copenhagen Academy for Medical Education and Simulation (CAMES) Needs-Assessment Formula (NAF). This pre-prioritised list from Round 2 was sent back to participants for final exclusion and ranking in Round 3. Results 88 participants were identified and invited. From 174 procedures identified in Round 1, 71 procedures were grouped and categorised for Round 2 using the CAMES NAF. In Round 3, 17 procedures were eliminated resulting in 54 procedures. Appendicectomy, inguinal herniotomy, and central venous access were the highest rank procedures after prioritisation in Round 3. There was a strong correlation (r = 0.99) between the NAF score and the prioritised ranking, as well as between consultants and trainees (r = 0.92 in Round 2 and 0.98 in Round 3).

CONCLUSION

The prioritised list represents a consensus document decided upon by education leaders and stakeholders in paediatric surgery. These procedures should be an integral part of the SBE of paediatric surgeons in the region.

LEVEL OF EVIDENCE

Level V.

Identifying residents' educational needs to optimising postgraduate medical education about shared decision-making

OBJECTIVE

To investigate how to optimise resident engagement during workplace learning of shared decision-making (SDM) by understanding their educational needs.

METHODS

A qualitative multicentre study was conducted using video-stimulated interviews with 17 residents in General Practice. Video recordings of residents' recent clinical encounters were used to facilitate reflection on their educational needs.

RESULTS

Data analysis resulted in five themes regarding residents' educational needs for learning SDM: acquiring knowledge and skills needed to perform SDM; practising SDM; reflection and feedback; longitudinal and integrated training; and awareness and motivation for performing SDM.

CONCLUSION

Residents expressed a need for continuous attention to be paid to SDM during postgraduate medical education. That would help them engage in two parallel learning processes: acquiring the knowledge and skills necessary to perform SDM, and practising SDM in the clinical workplace. Alignment between the educational curriculum, workplace learning and resident learning activities is essential to operationalise SDM attitude, knowledge and skills into clinical performance.

PRACTICE IMPLICATIONS

The identified educational needs provide ingredients for fostering the development of SDM proficiency. The findings suggest that residents and clinical supervisors need parallel training to bridge the gap between education and clinical practice when learning SDM.

Differences in faculty feedback for high, expected, and below-expected clinically performing emergency medicine residents

Objectives

A lifelong pursuit such as medicine is frequently paired with a framework of "deliberate practice" for improvement. It is unclear whether the quality of feedback varies across different learner levels. Our study aims to assess whether a difference exists in the quality of feedback delivered to high-, expected-, and below-expected performer emergency medicine (EM) residents based on their attending-identified performance level.

Methods

We conducted a retrospective review of written EM resident feedback collected between November 2018 and March 2021. Clinical performance level was subjectively determined by attending faculty in their feedback. Feedback was coded on a scale from 0-5 based on the presence (1) or absence (0) of the items modified from the Ende's SMART criteria: Specific (S), Measurable (M), Achievable (A), Relevant (R), and Time-bound (T). The primary outcome was any total modified SMART criteria score difference concerning performance level using logistic regression with Generalized Estimating Equations (GEE). Secondary outcomes were differences for individual criteria.

Results

We analyzed 1284 evaluations (311 high performers, 930 expected performers, and 43 below-expected performers) of 94 unique residents from 66 different evaluators. Mean total modified SMART scores were significantly higher in high and below-expected performers than those designated as expected performers by faculty evaluators. Achievable and Relevant written feedback was provided to high performers in a significantly larger proportion than expected and below-expected performers. Only 278 out of 1284 evaluations met criteria for Specific.

Conclusions

Mean total modified SMART feedback scores were significantly greater in high performers and below-expected performers when compared to expected performers. Achievable and Relevant feedback was provided in greater proportions to high performer residents compared to expected and below-expected performers. These findings are a challenge to academic faculty to engage in quality feedback delivery for residents at all performance levels.

An explainable machine learning method for assessing surgical skill in liposuction surgery

PURPOSE

Surgical skill assessment has received growing interest in surgery training and quality control due to its essential role in competency assessment and trainee feedback. However, the current assessment methods rarely provide corresponding feedback guidance while giving ability evaluation. We aim to validate an explainable surgical skill assessment method that automatically evaluates the trainee performance of liposuction surgery and provides visual postoperative and real-time feedback.

METHODS

In this study, machine learning using a model-agnostic interpretable method based on stroke segmentation was introduced to objectively evaluate surgical skills. We evaluated the method on liposuction surgery datasets that consisted of motion and force data for classification tasks.

RESULTS

Our classifier achieved optimistic accuracy in clinical and imitation liposuction surgery models, ranging from 89 to 94%. With the help of SHapley Additive exPlanations (SHAP), we deeply explore the potential rules of liposuction operation between surgeons with variant experiences and provide real-time feedback based on the ML model to surgeons with undesirable skills.

CONCLUSION

Our results demonstrate the strong abilities of explainable machine learning methods in objective surgical skill assessment. We believe that the machine learning model based on interpretive methods proposed in this article can improve the evaluation and training of liposuction surgery and provide objective assessment and training guidance for other surgeries.

An innovative clinic model for student learning

BACKGROUND

Ambulatory rotations are a key part of medical student education, but there are few educational initiatives aimed to improve student experience.

APPROACH

This initiative implemented a new model for an urgent care clinic, based on Erickson's framework for learning, designed to provide students with more autonomy, and more time for teaching, discussion, feedback and patient encounters. Participants were fourth year medical students in their ambulatory rotation who were randomly assigned to participate in the urgent care clinic. Students were asked to respond to a survey at the end of the rotation.

EVALUATION

A total of 59 fourth-year medical students participated in the ambulatory care rotation, of which 40 students responded to the survey. Students who participated in the urgent care clinic reported more autonomy, feedback, learning and time to see patients. They were happier overall with their experience and felt more prepared for their intern year of residency.

IMPLICATIONS

Our intervention was able to achieve our goals of improving student satisfaction in their ambulatory experience at our institution. This model could be used to design a more effective teaching experience for medical students in other rotations at our institution, as well as at other institutions.

Retention of basic surgical skills in veterinary students

OBJECTIVE

To quantify veterinary students' retention of surgical skills after a 5-month period without practice.

STUDY DESIGN

Prospective longitudinal descriptive study.

SAMPLE POPULATION

Convenience sample of second year veterinary students (n = 57).

METHODS

Students practiced ovariohysterectomy (OVH) on a model during 4 clinical skills laboratories during spring 2021. Students were assessed performing OVH on their model using a validated 22-item rubric. Students not meeting expectations repeated their assessment 2 weeks later. All students had a 5-month period, including summer break, without skills practice. Students were again assessed performing OVH on their model in the fall. Students' rubric scores and pass rates were compared before and after summer break.

RESULTS

Students scored lower on their retention test in fall (median = 43) than at the spring assessment (median = 56, P < .001). No difference was detected between lower and higher performing students. Five students (9%) did not meet expectations on their first assessment; more students (17/57, 30%) failed to meet expectations on their retention test (P = .004).

CONCLUSION

Students experienced a decay in the surgical skills required to perform OVH after a 5-month period without practice, regardless of the quality of their initial performance.

CLINICAL SIGNIFICANCE

Veterinary educators should emphasize the importance of continual practice to maintain skills and should consider assisting students in regaining skills during review sessions on models to improve surgical skill retention after a prolonged break.

Evaluating the effectiveness of a virtual reality simulation for preclinical local anaesthesia dental education

INTRODUCTION

Traditional manikin training has limitations that virtual reality can address. This study investigated the effectiveness of two part-task training simulation methods, a virtual reality (VR Sim) vs a plastic manikin (PM Sim), on learning outcomes for local anaesthesia skills for second-year pre-clinical dental students.

METHODS

In an experimental study, 58 second-year students were randomly assigned to one of two groups, VR Sim or PM Sim. Both groups completed the same pre-post survey. The VR Sim group practiced with a VR simulation, completed a built-in treatment test and a transfer test with a live person, and was evaluated by an expert teaching assistant (TA) with a rubric. The PM Sim group practiced with a plastic manikin and completed a treatment test on the same manikin evaluated by a TA, followed by the same transfer test with a live person and evaluated by a TA with a rubric.

RESULTS

Covering knowledge and skills in the delivery of local anaesthesia, mean final transfer test scores were statistically significantly higher for the PM Sim compared to VR Sim, F(1, 57) = 9.719, p = .003 with effect size, η2 p  = 0.148. Scores on respective treatment tests were similar to final transfer test scores for each group suggesting differences were localised to the practice methods. Pre-survey results indicated participants had low prior experience with VR technology.

CONCLUSION

Whilst outcomes showed higher results for plastic manikin tutor training over the VR training method, they are complementary. As students practice more with the technology and the VR simulation they may improve further. Likewise, as the technology for haptics with VR improves beyond hand controllers so may the experience and learning of this skill for students.

The Effect of Anonymity on Quality of Resident Feedback

OBJECTIVE

Quality feedback is critical to facilitate better performance and quicker learning. However, faculty may be hesitant to provide quality constructive feedback, especially in written form, due to fear of retaliation. We evaluated the impact of faculty anonymity on the quality of faculty-to-resident feedback.

DESIGN

A retrospective review was undertaken of faculty evaluation of resident performance from 2017 to 2018, when evaluations were identifiable, compared to 2018-2019, when evaluations were anonymous. Evaluations included 27 individual items with Likert type scoring and 2 open-ended questions. Open-ended responses and overall performance were de-identified and scored by 2 reviewers independently using the task, performance gap, action scoring model. Comparisons between groups were performed with the Wilcoxon-Mann-Whitney test.

SETTING

Tertiary Care Institution, University of Michigan, Ann Arbor, MI PARTICIPANTS: 415 resident performance evaluations were available for analysis with 251 in the identifiable group and 164 in the anonymous group.

RESULTS

The average composite score for the identifiable group was 105.2 and 103.4 in the anonymous group (p = 0.22). The effect size of the impact on composite score was small (Cohen's d 0.084, 95% CI -0.11-0.28). There was excellent inter-rater reliability. There were no differences between feedback groups for any of the 3 components of task, performance gap, and action model. While average scores for all 3 components were low, action scores were lowest.

CONCLUSIONS

Anonymity did not significantly impact faculty evaluations of resident performance. The quality of open-ended feedback on written evaluations was generally poor, especially in identifying actions for continued performance improvement. Additional mechanisms to improve feedback quality should be sought.

Randomized controlled trials in neurosurgery

Randomized controlled trials (RCTs) have become the standard method of evaluating new interventions (whether medical or surgical), and the best evidence used to inform the development of new practice guidelines. When we review the history of medical versus surgical trials, surgical RCTs usually face more challenges and difficulties when conducted. These challenges can be in blinding, recruiting, funding, and even in certain ethical issues. Moreover, to add to the complexity, the field of neurosurgery has its own unique challenges when it comes to conducting an RCT. This paper aims to provide a comprehensive review of the history of neurosurgical RCTs, focusing on some of the most critical challenges and obstacles that face investigators. The main domains this review will address are: (1) Trial design: equipoise, blinding, sham surgery, expertise-based trials, reporting of outcomes, and pilot trials, (2) trial implementation: funding, recruitment, and retention, and (3) trial analysis: intention-to-treat versus as-treated and learning curve effect.

Assessment of neurosurgical resident milestone evaluation reporting and feedback processes

OBJECTIVE

Structured performance evaluations are important for the professional development and personal growth of resident learners. This process is formalized by the Accreditation Council for Graduate Medical Education milestones assessment system. The primary aim of this study was to understand the current feedback delivery mechanism by exploring the culture of feedback, the mechanics of delivery, and the evaluation of the feedback itself.

METHODS

Face-to-face interviews were conducted with 10 neurosurgery residents exploring their perceptions of summative feedback. Coded data were analyzed qualitatively for overriding themes using the matrix framework method. A priori themes of definition of feedback, feedback delivery, and impact of feedback were combined with de novo themes discovered during analysis.

RESULTS

Trainees prioritized formative over summative feedback. Summative and milestone feedback were criticized as being vague, misaligned with practice, and often perceived as erroneous. Barriers to implementation of summative feedback included perceived veracity of feedback, high interrater variability, and the inconstant adoption of a developmental progression model. Gender bias was noted in degree of feedback provided and language used.

CONCLUSIONS

Trainee perception of feedback provided multiple areas of improvement. This paper can serve as a baseline to study improvements in the milestone feedback process and optimize learning.

Development of a residents-as-teachers curriculum for neurosurgical training programs

Neurosurgery residents spend a significant amount of their time teaching patients, families, students, residents, and other health professionals. To help ensure competence in their residents’ teaching abilities, many specialties have established formal residents-as-teachers (RAT) curricula; however, such formalized curricula are often lacking in neurosurgery programs. The authors’ goal was to develop and implement a formal RAT curriculum, designed with neurosurgery residents’ other responsibilities in mind, to improve residents’ formal and informal teaching abilities. Here, the authors report on the design of a formalized teaching curriculum tailored for the needs of neurosurgical residents, with a focus on deliberate practice and minimal time needed for preparation. The curriculum, designed using Kern’s 6 steps of curriculum design as a framework, comprises 5 lecture series spread over 3 years, repeated twice through a resident’s training, with each lecture series outlined with its respective topics and objectives. Opportunities for observed teaching as well as informal and formal evaluation will be provided to residents. The program will be evaluated on a yearly basis using direct and anonymized resident feedback on the RAT curriculum. Measures of program success will also include pre- and postprogram medical student and peer evaluation of residents. These data will be used for continual improvement of the curriculum as it is implemented. Successes and shortcomings of this program will be disseminated by publication, presentations, and placement on the authors’ department website and social media. This paper may serve as a foundation for other neurosurgical programs to develop RAT curricula for greater enhancement of resident teaching abilities.

Neurosurgery resident training using blended learning concepts: course development and participant evaluation

OBJECTIVE

Restrictions on working time and healthcare expenditures, as well as increasing subspecialization with caseload requirements per surgeon and increased quality-of-care expectations, provide limited opportunities for surgical residents to be trained in the operating room. Yet, surgical training requires goal-oriented and focused practice. As a result, training simulators are increasingly utilized. The authors designed a two-step blended course consisting of a personalized adaptive electronic learning (e-learning) module followed by simulator training. This paper reports on course development and the evaluation by the first participants.

METHODS

Adaptive e-learning was curated by learning engineers based on theoretical information provided by clinicians (subject matter experts). A lumbar spine model for image-guided spinal injections was used for the simulator training. Residents were assigned to the e-learning module first; after its completion, they participated in the simulator training. Performance data were recorded for each participant’s e-learning module, which was necessary to personalize the learning experience to each individual’s knowledge and needs. Simulator training was organized in small groups with a 1-to-4 instructor-to-participant ratio. Structured assessments were undertaken, adapted from the Student Evaluation of Educational Quality.

RESULTS

The adaptive e-learning module was curated, reviewed, and approved within 10 weeks. Eight participants have taken the course to date. The overall rating of the course is very good (4.8/5). Adaptive e-learning is well received compared with other e-learning types (8/10), but scores lower regarding usefulness, efficiency, and fun compared with the simulator training, despite improved conscious competency (32.6% ± 15.1%) and decreased subconscious incompetency (22.8% ± 10.2%). The subjective skill level improved by 20%. Asked about the estimated impact of the course, participants indicated that they had either learned something new that they plan to use in their practice (71.4%) or felt reassured in their practice (28.6%).

CONCLUSIONS

The development of a blended training course combining adaptive e-learning and simulator training in a rapid manner is feasible and leads to improved skills. Simulator training is rated more valuable by surgical trainees than theoretical e-learning; the impact of this type of training on patient care needs to be further investigated.

Police Uses of Force in the USA: a Wealth of Theories and a Lack of Evidence

Research Question

How adequate is research in the USA for discovering best policies and practices, and best implementation strategies, for reducing loss of life and injury from police use of force.

Data

This analysis examines police agency policies on the use of force regulation, evaluations of training initiatives, research on supervision, problem officers, and other dimensions of the issues and possible solutions.

Methods

The analysis examines both documented correlates and the strength of causal inference about those correlates of reductions in the use of force.

Findings

The analysis concludes that while many promising ideas have been offered, there are few tested strategies that have demonstrated substantial effects in reducing the use of force. There are virtually no successful strategies that have been replicated.

Conclusions

The current proliferation of untested programs may divert effort from a coherent and well-funded program of research to test and select effective policies that are urgently needed.

The role of mentoring, supervision, coaching, teaching and instruction on professional identity formation: a systematic scoping review

BACKGROUND

Mentoring's pivotal role in nurturing professional identity formation (PIF) owes much to its combined use with supervision, coaching, tutoring, instruction, and teaching. However the effects of this combination called the 'mentoring umbrella' remains poorly understood. This systematic scoping review thus aims to map current understanding.

METHODS

A Systematic Evidence-Based Approach guided systematic scoping review seeks to map current understanding of the 'mentoring umbrella' and its effects on PIF on medical students and physicians in training. It is hoped that insights provided will guide structuring, support and oversight of the 'mentoring umbrella' in nurturing PIF. Articles published between 2000 and 2021 in PubMed, Scopus, ERIC and the Cochrane databases were scrutinised. The included articles were concurrently summarised and tabulated and concurrently analysed using content and thematic analysis and tabulated. The themes and categories identified were compared with the summaries of the included articles to create accountable and reproducible domains that guide the discussion.

RESULTS

A total of 12201 abstracts were reviewed, 657 full text articles evaluated, and 207 articles included. The three domains identified were definitions; impact on PIF; and enablers and barriers. The mentoring umbrella shapes PIF in 3 stages and builds a cognitive base of essential knowledge, skills and professional attitudes. The cognitive base informs thinking, conduct and opinions in early supervised clinical exposure in Communities of practice (COP). The COPs' individualised approach to the inculcation of desired professional characteristics, goals, values, principles and beliefs reshapes the individual's identity whilst the socialisation process sees to their integration into current identities.

CONCLUSION

The mentoring umbrella's provides personalised longitudinal support in the COP and socialisation process. Understanding it is key to addressing difficulties faced and ensuring holistic and timely support.

Teaching Quality Improvement: The Use of Education Theories Across the Medical Education Spectrum

It is well recognized that the principles and practices of patient safety and quality improvement (QI) need to be included in medical education. The implementation of patient safety and QI learning experiences at the undergraduate medical education (UME) and graduate medical education (GME) levels has been variable. Consistent teaching of QI across the UME-GME-continuing medical education (CME) spectrum may result in a systemic change of improved patient care and patient safety in clinical practice. We propose using education theories to frame the development of QI curricula for a longitudinal integration in medical education and clinical practice. The basic principles of four education theories, namely, reflective practice, deliberate practice, social constructivism, and organizational learning, are briefly described, and examples of their applications to QI teaching are discussed. The incorporation of education theory into the design and implementation of a longitudinal QI curriculum threaded across the UME-GME-CME spectrum may empower learners with a comprehensive and lasting understanding of QI principles and training in patient safety practice, which are essential prerequisites for the formation of a physician workforce capable of creating sustainable change in patient care.

Combing pre-workshop, web-based learning and hands-on workshop as a flipped classroom clinical skill training model during the COVID-19 pandemic

Objective

Due to the COVID-19 pandemic, there is a dramatic drop in in-person residency training due to the implementation of isolation and triage measurements. Here, we propose a new flipped classroom clinical skill training model utilizing a combination of pre-workshop, web-based learning and hands-on workshop that shortens in-person contact time to maintain residency training during the pandemic. Effectiveness of this training model was evaluated with a pre-test and post-test skills competency assessment, two-way feedback, and a five-point Likert scale structured survey questionnaire.

Materials and methods

The workshop was conducted in a flipped classroom fashion by the obstetrics and gynecology (OBGYN) department of a single tertiary teaching medical center covering topics from five OBGYN subspecialities. Every topic consisted of a pre-workshop, web-based, mini lecture (PWML) followed by a hands-on workshop (HW). All first to fourth year OBGYN residents were invited to attend the workshop. All the trainees were required to complete the PWML prior to the day of HW. The workshop consisted of rotational station for each topic and was conducted within one afternoon. A 0-100-point scale pre-test and post-test skills competency evaluation were performed for each station and was assessed by the attending doctor or fellow doctor of each subspeciality. Two-way feedback was done after the post-test evaluation. A five-point Likert scale structured survey instrument consisting of participant’s perceptions of the workshop design, relevance to clinical practice, and quality of instructors and materials was created during the curriculum development process and sent to each participant one month after the workshop.

Results

A total of 19 residents including five first-year, six second-year, three third-year, and five fourth-year residents completed the entire pre-workshop lecture, workshop, pre-test, and post-test. For all residents, the average post-test score of 5 stations was 95 and was significantly higher than the pre-test score of 60 (p < 0.001). For both junior residents and senior residents, the average post-test scores of 5 stations were also significantly higher than pre-test scores (p < 0.001). Survey generated one month after the workshop showed a high overall satisfaction with the workshop instructors on their professional knowledge, communication skills, and interactions between the instructors and trainees. The average satisfaction scores for manipulation of vaginal breech delivery (VBD), semen analysis (SA), cervical conization (CC), obstetrics anal sphincter injury (OASIS), and laparoscopic suture techniques (LST) were 4.84, 4.96, 4.92, 4.88, and 4.92, respectively The average score for practical application of the training materials, class design and teaching method, overall satisfaction of the session, and time scheduling was 4.84, 4.96, 4.96, and 4.48, respectively. The entire HW was completed within 180 min and was carried out within half a day.

Conclusion

With the implementation of isolation and triage measures in the COVID-19 pandemic, there is a dramatic drop in in-person exposure to all aspects of the residency training, in particular, non-emergent surgeries. Utilization of PWML saved 1/3 of in-person time and the entire workshop was completed within 180 min that could be carried out within half a day. The decrease of person-to-person contact time during the COVID-19 pandemic is necessary while still providing curriculum-based residency training in spite of decreased hands-on experience.

Training residents in minimally invasive surgery; confirming competence or hoping for the best?

Background

Veterinary minimally invasive surgery (MIS) is rapidly developing, and most surgeons are performing MIS in their clinical practice. The technical skills of presented surgical techniques are increasingly complex. Required training of American College of Veterinary Surgeons (ACVS) surgical residents in soft tissue MIS (laparoscopy/thoracoscopy) are limited to traditional apprentice training. Unfortunately, such training has been found insufficient to create competent MIS surgeons.

Aim of the review

This review discusses development of MIS training for Doctor of Medicine (M.D.) residents in context of veterinary applicability and investigates comparative evidence for how to best train veterinary residents in soft tissue MIS.

Conclusions

A structured curriculum, with validated tasks and clear training goals have been found imperative for training success. Such a curriculum includes both didactic sessions and manual skills training, with video tutorials and reading material to inform and motivate the residents.

Implications of key findings

ACVS residents and diplomates may benefit if a MIS curriculum was developed and made available to all training programs.

To sim or not to sim-choosing wisely for procedural skills training in paediatrics

Objectives

Simulation is a commonly used modality to teach paediatric procedural skills, however, it is resource intensive. Which paediatric skills are best taught using simulation is not known. This study aims to examine what skills to simulate, allowing for the best use of resources in ever expanding curricula.

Method

We administered a questionnaire to community and hospitalist general paediatricians in Canada asking them to rate the importance of maintaining competency in each paediatric procedural skill and the frequency with which they perform the skill in their practice.

Results

Skills that were rated as highly important and also high frequency were: bag-mask ventilation (BMV), lumbar puncture, neonatal cardiopulmonary resuscitation (CPR), specimen procurement for infectious diseases, immunization, and ear curettage. Skills that were rated as highly important but low frequency were: paediatric CPR, intraosseous needle insertion, neonatal intubation, defibrillation, gathering specimens for evidence of child maltreatment, paediatric intubation, cervical spine immobilization, and oral/nasogastric tube placement.

Conclusion

Paediatric procedural skills are rated variably in terms of importance and frequency of use in general paediatric practice. Eight skills of high importance are infrequently performed and should be targeted for teaching via simulation.

From Centralized to Decentralized Model of Simulation-Based Education: Curricular Integration of Take-Home Simulators in Nursing Education

In a centralized model of simulation-based education (Ce-SBE), students practice skills in simulation laboratories, while in a decentralized model (De-SBE), they practice skills outside of these laboratories. The cost of “take-home” simulators is a barrier that can be overcome with additive manufacturing (AM). Our objective was to develop and evaluate the quality of education when year one nursing students practiced clinical skills from home following normal curricular activities but in the De-SBE format. A group of expert educators, designers, and researchers followed a two-cycle, iterative design-to-cost approach to develop three simulators: wound care and urethral catheterization (male and female). The total cost of manufacturing all three simulators was USD 5,000. These were sent to all year one nursing students who followed an online curriculum. Twenty-nine students completed the survey, which indicated that the simulators supported the students’ learning needs, and several changes were requested to improve the educational value. The results indicate that substituting traditional simulators with AM-simulators provided an acceptable alternative for nursing students to learn wound care and urethral catheterization off-campus in De-SBE. The feedback also provided suggestions to improve each of the simulators to make the experience more authentic.

Practice makes perfect? Association between students' performance measures in an advanced dental simulation course

PURPOSE

This study examines the relationship between student performance measures during practice and exams using advanced dental simulation.

METHODS

Data from 11 classes of first-year dental students were extracted from Advanced Simulation software (DentSim™) related to Class I and Class II preparations including: total number of practice sessions, average practice score, exam scores, average time preparing teeth during practice/exam, and average time self-evaluating preparations during practice/exam. Comparisons of average practice and exam scores were examined using paired t-test. Relationships between practice/exam measures and exam scores were determined with multiple linear regression.

RESULTS

Practice mean and exam scores were significantly associated; exam scores were significantly higher in both procedures. Class I: a significant positive relationship exists between both practice and exam measures: The average practice score was significantly associated with exam score (p < 0.001); time spent preparing the exam tooth was negatively associated with the exam score (p < 0.001); conversely, time spent self-evaluating the exam tooth was significantly associated with an increase in exam score (p = 0.0135). Class II: exam score was significantly associated with two practice measures but neither of the exam measures: exam score for Class II mesioocclusal preparation was significantly associated with average practice score (p < 0.001) and the number of practice attempts (p = 0.025).

CONCLUSION

This study emphasizes the predictive value of novice learners' deliberate, repetitive practice using advanced dental simulation, which enhances self-assessment in early stages of psychomotor skill development. Future studies are needed to demonstrate the translation of these skills into a patient care setting.

Expert visual assessment strategies for equine lameness examinations in a straight line and circle: A mixed methods study using eye tracking

BACKGROUND

A large number of lameness indicators have been suggested for the visual equine lameness assessment. However, it remains unknown which of these are commonly used by experts.

METHODS

Twenty-four expert lameness assessors from 10 leading UK institutions viewed 28 video clips of sound and mildly lame horses (median score 2/10). Horses were shown at trot in a straight line (rear and front view) and circle (side view, left and right rein). Eye tracking data were collected at 60 Hz while participants evaluated each clip. A questionnaire captured contextual information.

RESULTS

During assessment on the straight line, participants consistently looked mostly at the head and pelvis. On the circle, many participants consistently looked at the head, yet the subsequent choice, weighting and order of examined body regions was unsystematic between and within participants, and there was a bias towards prolonged assessment of the horse's front region. Questionnaires revealed different descriptions of lameness indicators for the same body region and different approaches to decision making under uncertainty.

CONCLUSION

In contrast to reasonably high similarity on the straight line, expert veterinarians have not developed a consistent assessment approach when evaluating horses on the circle. The reliability of various lameness indicators on the circle requires a stronger evidence base for a more systematic, repeatable approach.

Anterior plating technique for distal radius: comparing performance after learning through naive versus deliberate practice

BACKGROUND

Surgical teaching is most often carried out in the operating theatre through mentorship, and the performance of surgical procedures is rarely measured. The objective of this article is to compare the progression in learning curves of junior surgeons trained in the anterior plating technique for the distal radius on a nonbiological model according to three different methods.

METHODS

The materials comprised 12 junior surgeons of level 1 or 2 (as per Tang and Giddins) divided into three groups: control (G1), naive practice (G2), and deliberate practice (G3). The three groups watched a demonstration video of a level 5 expert. The four G1 surgeons (two level 1 and two level 2) saw the video only once, and each inserted five plates. The four G2 surgeons (two level 1 and two level 2) inserted five plates and watched the video before each time. The four G3 surgeons (two level 1 and two level 2) saw the video before the first plate insertion. Before posing the subsequent four plates, the four G3 surgeons watched their own video, and the expert indicated their errors and how to avoid them next time. A 12-criteria OSATS defined on the basis of the 60 videos, each graded from one (min.) to five (max.), was used to measure the objective surgical performance per plating (min. 12; max. 60) and per series of five plate fixations (min. 60, max. 300).

RESULTS

The total average objective performance of G1 was 44.73, of G2 was 50.57 and of G3 was 54.35. Change in objective performance was better for G3 (13.25) than G2 (5) or G1 (3.75). For all groups, the progression in objective performance was better amongst level 1 surgeons (9) than level 2 surgeons (5.6).

CONCLUSION

Surgical teaching is based on mentorship and experience. However, since "see one, practice many, do one" has started to replace "see one, do one, teach one", learning techniques have increasingly relied on procedure simulators. Against this background, few studies have looked at measuring the performance of surgical procedures and improved learning curves. Our results appear to suggest that deliberate practice, when used in addition to mentorship, is the best option for shortening the growth phase of the learning curve and improving performance. Deliberate practice is a learning technique for surgical procedures that is complementary to mentorship and experience, which allows the growth phase of the learning curve to be shortened and the objective performance of junior surgeons to be improved.

A scoping review: virtual patients for communication skills in medical undergraduates

BACKGROUND

Communication is an essential competence for medical students. Virtual patients (VP), computerized educational tools where users take the role of doctor, are increasingly used. Despite the wide range of VP utilization, evidence-based practical guidance on supporting development of communication skills for medical students remains unclear. We focused this scoping review on VP affordance for student learning especially important in the current environment of constrained patient access.

METHODS

This scoping review followed Arksey & O'Malley's methodology. We tested and used a search strategy involving six databases, resulting in 5,262 citations. Two reviewers independently screened titles, full texts (n= 158) and finally performed data extraction on fifty-five included articles. To support consideration of educational affordance the authors employed a pragmatic framework (derived from activity theory) to map included studies on VP structure, curricular alignment, mediation of VP activity, and socio-cultural context.

RESULTS

Findings suggest that not only the VP itself, but also its contextualization and associated curricular activities influence outcomes. The VP was trialled in the highest proportion of papers as a one-off intervention (19 studies), for an average duration of 44.9 minutes (range 10-120min), mainly in senior medical students (n=23), notably the largest group of studies did not have VP activities with explicit curricular integration (47%). There was relatively little repeated practice, low levels of feedback, self-reflection, and assessment. Students viewed VPs overall, citing authenticity and ease of use as important features. Resource implications are often omitted, and costings would facilitate a more complete understanding of implications of VP use.

CONCLUSION

Students should be provided with maximal opportunity to draw out the VPs' full potential through repeated practice, without time-constraint and with curricular alignment. Feedback delivery enabling reflection and mastery is also key. The authors recommend educators to explicitly balance computerized authenticity with instructional design integrated within the curriculum.

Teaching Communication as a Procedure by Utilizing a Mixed-Methods Curriculum: A Pilot Study

Objective

In this study, we aimed to develop and pilot a mixed-methods curriculum among pediatric subspecialty fellows that combined didactics, role-play, and bedside coaching with a procedure card. We hypothesized that this curriculum would improve fellows’ ability to navigate difficult conversations and would be feasible to implement across training programs.

Methods

This study was conducted from 2019 to 2020. Phase 1 focused on establishing baseline performance. Phase 2 involved the education of participants and faculty. During phase 3, participants communicated difficult news to patients and families using the procedure card as a prompt with the aid of faculty coaching. Six months later, participants' performance was re-evaluated and compared with baseline performance.

Results

A total of 10 out of 17 (60%) participants completed the pilot study. Likert self-efficacy results revealed an improvement in the skill of delivering difficult news (3.0 pre-intervention, 4.1 post-intervention, p=0.0001), conducting a family conference (2.5 pre-intervention, 3.6 post-intervention, p=0.0001), and responding to emotions (3.4 pre-intervention, 4.2 post-intervention, p=0.0003). Investigator assessments showed improvement in fellows’ ability to communicate information clearly (2.5 pre-intervention, 3.9 post-intervention, p=0.0001) and demonstrate empathy (2.7 pre-intervention, 3.3 post-intervention, p=0.005).

Conclusions

In this pilot study, coaching at the bedside with a procedure-card prompt was effective at improving specific self-perceived and observed communication skills. Future research is needed to evaluate modifications to this curriculum to enhance its feasibility.

The burn injury transfer feedback form: A 16 year Australian statewide review of burn inter-hospital transfer

INTRODUCTION

Modern burn care is centralised, and studies show that early, prompt referral to dedicated burn services improve clinical outcomes. We describe the use of a novel clinical instrument, the burn injury Transfer Feedback Form, to support and educate referring clinicians about the early assessment and management of burn injuries. Since 2005, Transfer Feedback Forms have been completed for all burn-injured patients with inter-hospital transfer to a specialised burn unit in the state of New South Wales (NSW), Australia. The aim of this study was to review physiological, procedural, and system or process issues in the care of both adult and paediatric burn-injured patients needing retrieval and transfer in NSW as identified by the Transfer Feedback Form. Secondary objectives were to determine any significant differences in these parameters between metropolitan and regional or remote referring institutions, and if any improvements occurred in these parameters over time.

METHODS

This was a retrospective analysis of all patients who were transferred to a burn unit in NSW between July 2005 and July 2021 using their prospectively completed Transfer Feedback Forms. Patients were divided into metropolitan and non-metropolitan referral sources based on geographic location. Clinical issues or deficiencies identified during each patient transfer were then classified into various groups. To determine if transfer-related clinical concerns had changed with time, two distinct periods before and after 2015, when the NSW Trauma App was introduced, were analysed. We compared trends in frequency of transfer-related concerns before and after App introduction by using interrupted time series analysis.

RESULTS

A total of 3233 patients had Feedback Forms submitted during the 16-year period. We included 929 children (28.7%) and 2304 adults (71.3%). Transfer-related clinical issues were identified in 904 adults (39.0%) and 484 children (52.0%). In both adult and paediatric patients, the most common transfer-related clinical deficiency was in relation to burn size estimation with 525 patients (43.7%) and 207 patients (30.6%), respectively. Between the time periods analysed, the number of issues arising during inter-hospital transfer fell significantly for both adults (from 46.1% to 26.1%; p < 0.05) and children (from 55.3% to 40.7%; p < 0.05). Segmented regression analysis demonstrated a significant break in the rate of transfer-related clinical issues in 2014 (p < 0.05) and 2015 (p < 0.01) for adults. Accurate body surface area estimations also increased significantly by 53% and 50% for adults and children (p < 0.05 for both), respectively, after 2015.

CONCLUSION

Our analysis indicates that the early care of burn-injured patients undergoing inter-hospital transfer is associated with clinical, technical, and logistical challenges. However, introduction of the burn injury Transfer Feedback Form has been associated with improvements in early burn care by referring centres both temporally and geographically. Smartphone-based applications such as the NSW Trauma App have also probably contributed to these findings. Adopting these simple, inexpensive strategies into burn care systems will augment inter-hospital transfer of burn-injured patients, and improve clinical outcomes.

Practical Tips for Setting Up and Running OSCEs

Objective structured clinical examinations (OSCEs) are used to assess students' skills on a variety of tasks using live animals, models, cadaver tissue, and simulated clients. OSCEs can be used to provide formative feedback, or they can be summative, impacting progression decisions. OSCEs can also drive student motivation to engage with clinical skill development and mastery in preparation for clinical placements and rotations. This teaching tip discusses top tips for running an OSCE for veterinary and veterinary nursing/technician students as written by an international group of authors experienced with running OSCEs at a diverse set of institutions. These tips include tasks to perform prior to the OSCE, on the day of the examination, and after the examination and provide a comprehensive review of the requirements that OSCEs place on faculty, staff, students, facilities, and animals. These tips are meant to assist those who are already running OSCEs and wish to reassess their existing OSCE processes or intend to increase the number of OSCEs used across the curriculum, and for those who are planning to start using OSCEs at their institution. Incorporating OSCEs into a curriculum involves a significant commitment of resources, and this teaching tip aims to assist those responsible for delivering these assessments with improving their implementation and delivery.

Validation of a Rubric Used for Skills-Based Assessment of Veterinary Students Performing Simulated Ovariohysterectomy on a Model

Surgical skills are an important competency for new graduates. Simulators offer a means to train and assess veterinary students prior to their first surgical performance. A simulated ovariohysterectomy (OVH) rubric's validity was evaluated using a framework of content evidence, internal structure evidence, and evidence of relationship with other variables, specifically subsequent live surgical performance. Clinically experienced veterinarians (n = 13) evaluated the utility of each rubric item to collect evidence; each item's content validity index was calculated to determine its inclusion in the final rubric. After skills training, veterinary students (n = 57) were assessed using the OVH model rubric in March and August. Internal structure evidence was collected by video-recording 14 students' mock surgeries, each assessed by all five raters to calculate inter-rater reliability. Relationship with other variables evidence was collected by assessing 22 students performing their first live canine OVH in November. Experienced veterinarians included 22 items in the final rubric. The rubric generated scores with good to excellent internal consistency; inter-rater reliability was fair. Students' performance on the March model assessment was moderately correlated with their live surgical performance (ρ = 0.43) and moderately negatively correlated with their live surgical time (ρ = -0.42). Students' performance on the August model assessment, after a summer without surgical skills practice, was weakly correlated with their live surgical performance (ρ = 0.17). These data support validation of the simulated OVH rubric. The continued development of validated assessment instruments is critical as veterinary medicine seeks to become competency based.

On Building Cytomorphology Skills: Influence of Slide Reviewing habits on Diagnostic Competency in Cytology

Objectives

The specific aims of the study are to assess whether the amount of time a cytology learner spends reviewing slides correlates with increased diagnostic competency and to determine whether time spent reviewing slides immediately after the multi‐head sessions correlates with a higher level of proficiency. The paper also seeks to explore the impacts of the time of day at which slides were reviewed on diagnostic learning outcome.

Methods

Data obtained through the cytology laboratory screening logs were reviewed, and the number of hours per day and the times of the day at which the students were present at the glass slide library were tabulated and compared against each of the seven‐unit slide exam scores in the semester to explore possible relationships.

Results

There was a positive linear relationship (r = 0.29) between the number of hours students spent in the laboratory reviewing cases and competency. When the students' unit diagnostic test scores were classified into low and high categories for each test, there was a significant correlation (P = 0.008) between a lack of time spent screening slides in the lab and the number of times a student was ranked at the bottom of the class. Our data do not support a recency effect nor a difference in test scores between those who reviewed cases in the morning vs in the afternoon.

Conclusions

While educating and training a strong cytology workforce may be challenging, our study provides new insights and sheds light on the importance of spending time reviewing slides, and provides guidance for struggling students on how best to improve. Inside this month’s Cytopathology: The aims of this study are to assess whether the amount of time a cytology learner spent reviewing slides correlates with increased diagnostic competency, and to determine whether time spent reviewing slides immediately after the multi‐head sessions correlates with a higher level of proficiency. The paper also seeks to explore the impacts of the time of day at which slides were reviewed on diagnostic learning outcome.

Planning a Collection of Virtual Patients to Train Clinical Reasoning: A Blueprint Representative of the European Population

Background: Virtual patients (VPs) are a suitable method for students to train their clinical reasoning abilities. We describe a process of developing a blueprint for a diverse and realistic VP collection (prior to VP creation) that facilitates deliberate practice of clinical reasoning and meets educational requirements of medical schools. Methods: An international and interdisciplinary partnership of five European countries developed a blueprint for a collection of 200 VPs in four steps: (1) Defining the criteria (e.g., key symptoms, age, sex) and categorizing them into disease-, patient-, encounter- and learner-related, (2) Identifying data sources for assessing the representativeness of the collection, (3) Populating the blueprint, and (4) Refining and reaching consensus. Results: The blueprint is publicly available and covers 29 key symptoms and 176 final diagnoses including the most prevalent medical conditions in Europe. Moreover, our analyses showed that the blueprint appears to be representative of the European population. Conclusions: The development of the blueprint required a stepwise approach, which can be replicated for the creation of other VP or case collections. We consider the blueprint an appropriate starting point for the actual creation of the VPs, but constant updating and refining is needed.

The Use of Simulators for Teaching Practical Clinical Skills to Veterinary Students - A Review

In the context of veterinary education, simulators are devices or sets of conditions aiming to imitate real patients and enable students to practice skills without the need for live animal use. Simulator use in veterinary education has increased significantly in recent years, allowing consistent practical teaching without reliance on clinical cases. This review examines the available literature regarding the use of simulation and simulators for teaching practical day one competences to veterinary students. Scientific databases were searched and 73 relevant articles were reviewed. The reviewed articles revealed that there are a number of simulators currently available to veterinary educators, that simulators can enhance student skills and provide an alternative learning environment without the need for live animal and/or cadaver use, and that they usually receive positive feedback from the students who use them. There appears to be a bias towards small animal simulators - however, some skills that are developed through the use of small animal or table-top models will be transferrable to other species. The majority of large animal simulators focus on bovine rectal palpation and/or pregnancy diagnosis. Further research is required to increase the repertoire of available simulators for use in veterinary education, in order to improve the practical skills of veterinary students and reduce the use of live animals and cadaver material for teaching purposes.

Online training module for micro suturing incorporating motor imagery and mental practice: a design and development research study

INTRODUCTION

There have been reduced opportunities for surgical skill acquisition due to the COVID-19 pandemic and the regulated training hours. Despite these challenges, self-regulated learning allows trainees to learn continuously, and one form of this is through mental practice and motor imagery. The study aimed to design and develop an online basic micro suturing training module for skill acquisition for self-regulated learning using a low-fidelity rubber glove model.

METHODS

This study utilized a design and developmental research framework and Mayer's multimedia theory guidelines. The primary author created an online instructional module on micro suturing based on the ADDIE instructional design model. This module was then evaluated in a pilot study comparing the new training model to traditional methods of learning using an experimental design.

RESULTS

This study describes the use of Design and Development Research to create a new model for surgical skill training and a tool for producing instructional materials and learning products for online learning. The product was evaluated using an experimental design and showed a significant effect on the quality of motor skill outcome and the richness of motor imagery using the resource developed in the research.

CONCLUSION

This study describes the methodological approach of a design and developmental framework to create an online training module for micro suturing which has significant utility in hand surgery.

What's the evidence? A review of current instruction and assessment in veterinary surgical education

Veterinary surgical education is improved by studying the relevant literature. The aim of this literature review was to report the theory and methods used to provide surgical education to veterinary students; to discuss the training most likely to create a competent general practitioner; and to review assessment methods for simulated and live surgeries. The literature reviewed demonstrates that new graduates are expected to perform small animal sterilization, dental extraction, onychectomy, abscess treatment, aural hematoma repair, and mass removal with little or no supervision. Students require repetitive practice to reach competence; some practice can take place in a clinical skills laboratory on models or cadavers. When training novices, distributing practice over a longer time improves retention, but months without practice causes skills to decay. Suturing skills may be taught on models at a ratio of 1 instructor per 10 students. Veterinary students require 6-10 repetitions of each small animal sterilization surgery to reach competence; however, learning curves for other surgeries have not been established. Assessment of surgical skills has been undertaken using objective structured clinical examinations (OSCEs) and observed model and live surgeries. Additional validated rubrics are needed in the field. Surgical educators are urged to continue to search for innovative ways to foster deliberate practice, assess skill, and provide feedback for students.

Simulation-based procedure training (SBPT) in rarely performed procedures: a blueprint for theory-informed design considerations

Simulation-based procedure training is now integrated within health professions education with literature demonstrating increased performance and translational patient-level outcomes. The focus of published work has been centered around description of such procedural training and the creation of realistic part-task models. There has been little attention with regards to design consideration, specifically around how simulation and educational theory should directly inform programme creation. Using a case-based approach in cardiology as an example, we present a blueprint for theory-informed simulation-based procedure training linking learning needs analysis and defining suitable objectives to matched fidelity. We press the importance of understanding how to implement and utilise task competence benchmarking in practice, and the role of feedback and debriefing in cycles of repeated practice. We conclude with evaluation and argue why this should be considered part of the initial design process rather than an after-thought following education delivery.

Achieving person-centred care through a team-based care ecosystem approach

The implementation of Person-Centred Care (PCC) by primary care teams is complex. Framed through the Quadruple Aim, successful healthcare system redesigns result in improved health outcomes of individuals and populations, reduce costs, and ensure an engaged and productive workforce. However, how can primary care teams achieve the Quadruple Aim? This article provides a learning and performance framework to support PCC through a Team-Based Care (TBC) ecosystem approach. We developed our approach using action research to improve TBC orientations, workshops, and consultations for teams and their leaders in Urgent Primary Care Centres and Primary Care Networks in Canada. This paper provides a synthesis of our experience in the context of the relevant evidence. We aim to share our efforts and acknowledge that our experience is still ongoing and complemented by ongoing improvement activities by others in the TBC ecosystem.

The Interactive Relationship Between Instructor Perceptions and Learner Personality on Surgical Skills Performance

OBJECTIVE

The objective of this study was to examine the association between learner personality and capacity to be trained (i.e., performance improvement) on a surgical task, and how instructor perceptions of the learners' capacity to be trained interact with learner personality and performance during training and feedback. There is meaningful heterogeneity in the degree of learner surgical skills acquisition despite receiving the same amount of training. While learner personality may independently contribute to skill acquisition, the instructor-learner feedback process is also important to consider. To better understand this interpersonal relationship, it is necessary to also consider instructor factors (i.e., perceptions), and how this may contribute to learner variability in skills training.

DESIGN

This exploratory study employed a prospective two-phase design. Medical and non-medical undergraduate students (N = 62) completed measures of personality and participated in two 20-minute training sessions with expert feedback 2 weeks apart, performing an end-to-side anastomosis on a low-fidelity model. Learner performance and instructors' perceptions of a learner's capacity to be trained were assessed.

PARTICIPANTS

Sixty-two medical and non-medical undergraduate students.

RESULTS

There was a significant interaction between learner Extraversion and instructor's perceptions of learner capacity to be trained. Higher learner Extraversion was only associated with an increase in performance improvement for those who were considered trainable (OR = 4.83, p = 0.017). Post hoc analysis revealed a significant difference in the amount of feedback provided to participants who were considered trainable (M = 9.45) versus not trainable (M = 16.48).

CONCLUSIONS

This study highlights the importance of both individual learner factors and instructor perceptions on surgical skill acquisition.

Combining virtual reality and 3D-printed models to simulate patient-specific dental operative procedures-A study exploring student perceptions

INTRODUCTION

Students face a number of challenges in translating the skills acquired in pre-clinical simulation environments to the delivery of real patient care. These are particularly emphasised for complex operative procedures such as tooth preparations for indirect restorations. This paper reports student perceptions of a novel approach designed to improving student confidence when undertaking operative procedures on patients for the first time, by providing patient-specific simulation using virtual reality (VR) and 3D-printed models of the student's real clinical case.

MATERIALS AND METHODS

Students practised on patient-specific models, in the presence of a clinical tutor, firstly using VR simulation then with 3D-printed models in a clinical skills laboratory. The students then carried out the operative procedure on their patients, on the third occasion of practice. After providing the treatment for their patients, students attended a semi-structured interview to discuss their experiences. The qualitative data were analysed using two forms of inductive analysis.

RESULTS

Students most frequently cited: the value of the educator, increased confidence and efficiency during the clinical procedure, improved patient confidence and the complementary benefits of the two simulation modalities. Thematic analysis of participants' responses uncovered five key themes: The value of virtual reality dental simulators The value of clinical skills laboratory simulation with 3D-printed models The value of educator engagement The impact on the clinical procedure and the patient The VR and clinical skills laboratory balance CONCLUSION: This paper reports the early findings of an intervention that improves dental student confidence through the use of patient-specific VR exercises and 3D-printed models. These provided an incremental learning experience for an operative clinical procedure, prior to treatment of the live patient. Early results suggest this is a positive experience for the students, providing a valuable contribution to their confidence and preparedness.

Simulation in plastic and reconstructive surgery: a scoping review

Since the origins of surgery, simulation has played an important role in surgical education, particularly in plastic and reconstructive surgery. This has greater relevance in contemporary settings of reduced clinical exposure resulting in limited work-based learning opportunities. With changing surgical curricula, it is prescient to examine the role of simulation in plastic and reconstructive surgery.

A scoping review protocol was used to identify relevant studies, with an iterative process identifying, reviewing and charting the data to derive reported outcomes and themes.

Of the 554 studies identified, 52 studies were included in this review. The themes identified included simulator modalities, curriculum elements targeted and relevant surgical competencies. There was a predominance of synthetically based simulators, targeting technical skills largely associated with microsurgery, paediatric surgery and craniomaxillofacial surgery.

Existing simulators largely address high-complexity procedures. There are multiple under-represented areas, including low-complexity procedures and simulation activities addressing communication, collaboration, management and leadership. There are many opportunities for simulation in surgical education, which requires a contextual appreciation of educational theory. Simulation may be used both as a learning method and as an assessment tool.

This review describes the literature relating to simulation in plastic and reconstructive surgery and proposes opportunities for incorporating simulation in a broader sense, in the surgical curriculum.

Healthcare Simulation: A Key to the Future of Medical Education - A Review

Aim

Simulation originates from its application in the military and aviation. It is implemented at various levels of healthcare education and certification today. However, its use remains unevenly distributed across the globe due to misconception regarding its cost and complexity and to lack of evidence for its consistency and validity. Implementation may also be hindered by an array of factors unique to the locale and its norms. Resource-poor settings may benefit from diverting external funds for short-term simulation projects towards collaboration with local experts and local material sourcing to reduce the overall cost and achieve long-term benefits. The recent shift of focus towards patient safety and calls for reduction in training duration have burdened educators with providing adequate quantity and quality of clinical exposure to students and residents in a short time. Furthermore, the COVID-19 pandemic has severely hindered clinical education to curb the spread of illness. Simulation may be beneficial in these circumstances and improve learner confidence. We undertook a literature search on MEDLINE using MeSH terms to obtain relevant information on simulation-based medical education and how to best apply it. Integration of simulation into curricula is an essential step of its implementation. With allocations for deliberate practice and mastery learning under supervision of qualified facilitators, this technology is becoming essential in medical education.

Purpose

To review the adaptation, spectrum of use, importance, and resource challenges of simulation in medical education and how best to implement it according to learning theories and best practice guides.

Conclusion

Simulation offers students and residents with adequate opportunities to practice their clinical skills in a risk-free environment. Unprecedented global catastrophes provide opportunities to explore simulation as a viable training tool. Future research should focus on sustainability of simulation-based medical education in LMICs.