Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine

Essentials of Pediatric Emergency Medicine Fellowship: Part 3: Clinical Education and Experience

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.

A clinical procedures curriculum for undergraduate medical students: the eight-year history of a third-year immersive experience

BACKGROUND

Procedural skills training is a critical component of medical education, but is often lacking in standard clinical curricula. We describe a unique immersive procedural skills curriculum for medical students, designed and taught primarily by emergency medicine faculty at The Ohio State University College of Medicine.

OBJECTIVES

The primary educational objective of this program was to formally introduce medical students to clinical procedures thought to be important for success in residency. The immersion strategy (teaching numerous procedures over a 7-day period) was intended to complement the student's education on third-year core clinical clerkships.

PROGRAM DESIGN

The course introduced 27 skills over 7 days. Teaching and learning methods included lecture, prereading, videos, task trainers, peer teaching, and procedures practice on cadavers. In year 4 of the program, a peer-team teaching model was adopted. We analyzed program evaluation data over time.

IMPACT

Students valued the selection of procedures covered by the course and felt that it helped prepare them for residency (97%). The highest rated activities were the cadaver lab and the advanced cardiac life support (97 and 93% positive endorsement, respectively). Lectures were less well received (73% positive endorsement), but improved over time. The transition to peer-team teaching resulted in improved student ratings of course activities (p<0.001).

CONCLUSION

A dedicated procedural skills curriculum successfully supplemented the training medical students received in the clinical setting. Students appreciated hands-on activities and practice. The peer-teaching model improved course evaluations by students, which implies that this was an effective teaching method for adult learners. This course was recently expanded and restructured to place the learning closer to the clinical settings in which skills are applied.

Filling the gaps between theory and daily clinical procedural skills training in family medicine

Performance of procedures is an integral part of any family physician/general practitioner's practice. Unfortunately, discrepancy occurs between the existing theoretical methods of procedural teaching and the training imparted during real daily practice, which creates gaps that need to be overcome. This article identifies and reviews teaching gaps in family medicine training and presents suggestions to overcome them with a view to forming holistic psychomotor skills based on the learner's characteristics within the patient-centred philosophy of family medicine.

Similarities and differences of graduate entry-level competencies of chiropractic councils on education: a systematic review

Background

Councils of Chiropractic Education (CCE) indirectly influence patient care and safety through their role of ensuring the standards of training delivered by chiropractic educational institutions. This is achieved by CCEs defining competence and creating lists of descriptive statements to establish the necessary standards for students to attain before graduating. A preliminary review suggested that these definitions and descriptive lists lacked consensus. This creates the potential for variations in standards between the CCE jurisdictions and may compromise patient care and safety and also inter-jurisdictional mutual recognition. The purposes of this study were 1) to investigate similarities and differences between the CCEs in their definitions of competence, domains of educational competencies, components of the domains of competencies, as represented by assessment and diagnosis, ethics, intellectual development, and 2) to make recommendations, if significant deficiencies were found.

Method

We undertook a systematic review of the similarities and differences between various CCEs definitions of competence and the descriptive lists of educational competencies they have adopted. CCEs were selected on the basis of WHO recommendations. Blinded investigators selected the data from CCE websites and direct contact with CCEs. This information was tabulated for a comparative analysis.

Results

All CCEs’ definitions of competence included the elements of “knowledge”, “skills” and “attitudes” whereas only one CCE included the expected “abilities” element. The educational application of the definition of competency among CCEs varied. A high level of similarity when comparing the domains of competence adopted by CCEs was found despite variations in the structure.

Differences between CCEs became increasingly apparent when the three selected representative domains were compared. CCEs were found to stipulate varying levels of prescriptiveness for graduate entry level standards.

Conclusions

A series of recommendations are proposed to create uniform and high quality international standards of care. Future research should compare the levels of CCEs enforcement of standards to see if similarities and differences exist.

Effect of just-in-time simulation training on provider performance and patient outcomes for clinical procedures: a systematic review

Background

Providing simulation training directly before an actual clinical procedure—or ‘just-in-time’ (JiT)—is resource intensive, but could improve both provider performance and patient outcomes.

Objectives

To assess the effects of JiT simulation training versus no JiT training on provider performance and patient complications following clinical procedures on patients.

Study selection

We searched MEDLINE, Cochrane Library, CINAHL, PsycINFO, ERIC, ClinicalTrials.gov, simulation journals indexes and references of included studies during October 2014 for randomised trials, non-randomised trials and before-after studies comparing JiT simulation training versus no JiT training among providers performing clinical procedures. Findings were synthesised qualitatively.

Findings

Of 1805 records screened, 8 studies comprising 3540 procedures and 1969 providers were eligible. 5 involved surgical procedures; the other 3 included paediatric endotracheal intubations, central venous catheter dressing changes, or infant lumbar puncture. Methodological quality was high. Of the 8 studies evaluating provider performance, 5 favoured JiT simulation training with 18–48% relative improvement on validated clinical performance scales, 16–20% relative reduction in surgical time and 12% absolute reduction in corrective prompts during central venous catheter dressing changes; 3 studies were equivocal with no improvement in intubation success, lumbar puncture success or urological surgery clinical performance scores. 3 studies evaluated patient complications; 1 favoured JiT simulation training with 45% relative reduction in central line-associated blood stream infections; 2 studies found no differences following intubation or laparoscopic nephrectomy.

Conclusions

JiT simulation training improves provider performance, but currently available literature does not demonstrate a reduction in patient complications.

Simulation in Pediatric Emergency Medicine Fellowships

BACKGROUND AND OBJECTIVES

Graduate medical education faces challenges as programs transition to the next accreditation system. Evidence supports the effectiveness of simulation for training and assessment. This study aims to describe the current use of simulation and barriers to its implementation in pediatric emergency medicine (PEM) fellowship programs.

METHODS

A survey was developed by consensus methods and distributed to PEM program directors via an anonymous online survey.

RESULTS

Sixty-nine (95%) fellowship programs responded. Simulation-based training is provided by 97% of PEM fellowship programs; the remainder plan to within 2 years. Thirty-seven percent incorporate >20 simulation hours per year. Barriers include the following: lack of faculty time (49%) and faculty simulation experience (39%); limited support for learner attendance (35%); and lack of established curricula (32%). Of those with written simulation curricula, most focus on resuscitation (71%), procedures (63%), and teamwork/communication (38%). Thirty-seven percent use simulation to evaluate procedural competency and resuscitation management. PEM fellows use simulation to teach (77%) and have conducted simulation-based research (33%). Thirty percent participate in a fellows' "boot camp"; however, finances (27%) and availability (15%) limit attendance. Programs receive simulation funding from hospitals (47%), academic institutions (22%), and PEM revenue (17%), with 22% reporting no direct simulation funding.

CONCLUSIONS

PEM fellowships have rapidly integrated simulation into their curricula over the past 5 years. Current limitations primarily involve faculty and funding, with equipment and dedicated space less significant than previously reported. Shared curricula and assessment tools, increased faculty and financial support, and regionalization could ameliorate barriers to incorporating simulation into PEM fellowships.

Is a haptic simulation interface more effective than computer mouse-based interface for neonatal intubation skills training?

Objective

To compare the efficacy of a three-dimensional (3D) haptic interface to a two-dimensional (2D) mouse interface for a screen-based simulation (SBS) neonatal intubation (NI) training intervention. Primary hypothesis: a haptic interface is more effective than a mouse interface for SBS training intervention for NI. Secondary hypothesis: SBS training, regardless of interface, will result in improved NI performance on a neonatal airway simulator.

Methods

45 participants were randomised to either a haptics or a mouse interface to complete an identical SBS training intervention for NI over a five-month period. Participants completed pre- and post-training surveys to assess demographics, experience, knowledge and attitudes. The primary outcome of participants’ NI skills performance was assessed on a neonatal manikin simulator. Skills were measured pre- and post- training by number of attempts and time to successfully intubate, and airway visualization.

Results

The demographics, training and experience were similar between groups. There was no difference in the improvement in skills, knowledge, attitudes or satisfaction ratings pre- and post-training between the groups. There was a significant decrease in number of attempts to intubate a neonatal airway simulator (2.89 vs 1.96, p<0.05) and improvement in the percent of subjects intubating in <30 seconds (22% vs 27%, p=0.02) from pre- to post-training in the study population overall.

Conclusion

Using a haptic interface did not have an advantage over a mouse interface in improving NI skills, knowledge, attitudes, or satisfaction. Overall, a SBS training intervention for NI improved skills measured on a neonatal airway simulator.