Deliberate practice and acquisition of expert performance: a general overview

Sociocultural learning in emergency medicine: a holistic examination of competence

Objectives

In the medical community of practice, the resident is situated in systems of professional and cultural activities. How diagnostic competence manifests in their sociocultural context is examined through situativity and systems theories. A holistic model is proposed that could examine diagnostic competence across micro (individual), meso (activity), and macro (cultural) systems.

Methods

Two short scenarios are presented resulting from observations of emergency medicine residents and their supervising physicians. These scenarios are analyzed using a trans-theoretical model of situativity and systems theories to understand how diagnostic competence manifests in practice (activity system).

Results

Assessment of diagnostic competence in a sociocultural context may require assessment of responses to contextual factors that seem immaterial to clinical reasoning. This information may signal that the resident also has the skills to identify appropriate information channels within an activity system and can accurately collect and prioritize clinical information within those channels. Therefore, the formal assessment of competent clinical reasoning performance, as a situated practice, may benefit from delineating how much of the context of an activity system is required to be competently managed and synthesized across the competency milestones.

Conclusions

The examination of diagnostic competence as a sociocultural practice can provide a unique and holistic examination of clinical reasoning performance and assessment.

Online Learning and Residents' Acquisition of Mechanical Ventilation Knowledge: Sequencing Matters

OBJECTIVE

Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains.

DESIGN

A prospective, interventional crossover study conducted from October 2015 to December 2017.

SETTING

Multicenter study conducted in 33 PICUs across eight countries.

SUBJECTS

Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation.

INTERVENTIONS

Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions.

MEASUREMENTS AND MAIN RESULTS

Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008).

CONCLUSIONS

Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

The Impact of Coronavirus Disease 2019 on Plastic Surgery Training: The Resident Perspective

The coronavirus disease 2019 (COVID-19) pandemic has led to marked changes in surgical training, including that of plastic surgery residents. We performed a survey to gain an insight into the self-reported current and future impact of COVID-19 on plastic surgery residents.

METHODS

A 20-point questionnaire was designed by a panel of surgical trainees and trainers, which was filled in by Belgian plastic surgery residents and their international network of peers between 19 and 26 April 2020-week 6 of stringent Belgian lockdown measures. Questions covered the impact of COVID-19 on surgical activity, surgical training, and the future of training.

RESULTS

Thirty-five of 38 plastic surgery residents in Belgium filled in the questionnaire, as did 51 of their international peers from 9 other countries. Decreased surgical activity of >75% was reported by 86% of Belgian trainees and by 73% of international colleagues. All consultations were stopped for 26% of Belgian trainees and 37% of international peers. Forty-six percents of Belgian trainees and 27% of international peers were reassigned to different departments. Eighty-five percent of all trainees felt surgical training had suffered, yet 54% of Belgian residents and 39% of international peers felt training should not be prolonged. Anxiety regarding the pandemic was present in 54% of Belgian residents and 69% of international colleagues.

CONCLUSIONS

This is the first report, expressing the voice of a representative group of plastic surgery residents, showing a significant impact of COVID-19 on training and activity. A joint effort is needed to provide continued forms of education by virtual education and skills-based learning.

Personal Protective Equipment in the coronavirus pandemic: training with Rapid Cycle Deliberate Practice

OBJECTIVE

to discuss the application of Rapid Cycle Deliberate Practice for attire and unattire training in the context of COVID-19 and structure a practical guide to the application at this juncture.

METHODS

this methodological study described theoretical and practical aspects of the application of a simulation strategy as a technological training tool. An application guide was constructed from the search for evidence from the main health authority bodies in Brazil.

RESULTS

maximizing time in Deliberate Practice, feedback with evidence and psychological security are the principles of this strategy. The dynamic involves repetition and feedback. The application guide presents the sequence of actions for attire and unattire.

FINAL CONSIDERATIONS

coping with this pandemic requires appropriate use of personal protective equipment. The authors suggest the Rapid Cycle Deliberate Practice as a technological educational tool for attire/unattire, since it encourages mastery performance.

Psychosocial Work Environment Among Musicians and in the General Workforce in Norway

Musicians suffer from physical and mental health symptoms more frequently than the general population. Although their specific demands and challenges have been researched increasingly in the past, explanations still remain somewhat unclear. We use a large epidemiological data set to compare psychosocial work environment among 1,607 members of the Norwegian Musician’s Union with a national sample of 8,517 employees from the general Norwegian workforce. Musicians reported more control over their work; however, they felt less supported and acknowledged, had more work-family conflicts and less motivation, and perceived their work as more demanding compared to the general workforce. In the musician sample, results indicated that classical and contemporary musicians are experiencing a less favorable psychosocial environment in terms of control, demands, and acknowledgment, orchestral players felt less control and soloist less support. Future studies should explore possible interventions to improve musicians’ psychosocial work environment.

A Collaborative Partnership for Improving Newborn Safety: Using Simulation for Neonatal Resuscitation Training

BACKGROUND

The latest Neonatal Resuscitation Program^® (NRP) guidelines suggest the use of team-based training using simulation. Furthermore, psychometric testing of instruments appropriate to measure team performance in NRP is needed. This study evaluated the effects of simulation on the training and performance of the health care team attending deliveries at a rural community hospital.

METHOD

Twenty-three nurses and nurse anesthetists comprised the sample. A pre- and postintervention repeated measures design was used. Data were collected using the Background/Experience Survey, Self-Assessment and Attitudes Survey, and two Agency for Healthcare Research and Quality TeamSTEPPS tools (the Teamwork Perceptions Questionnaire [T-TPQ] and the TeamSTEPPS Teamwork Attitudes Questionnaire [T-TAQ]), the Simulation Effectiveness Tool-Modified (SET-M), and the Individual and Team Performance Survey.

RESULTS

Data analysis revealed significant findings in team functioning, situation monitoring, and communication. Prebriefing and debriefing were valuable as measured by the SET-M.

CONCLUSION

This project supports the use of simulation to enhance team-based training, performance, and communication. [J Contin Educ Nurs. 2019;50(7):319-324.].

Validation of Training and Acquisition of Surgical Skills in Veterinary Laparoscopic Surgery: A Review

At present, veterinary laparoscopic surgery training is lacking in experiences that provide a controlled and safe environment where surgeons can practice specific techniques while receiving experts' feedback. Surgical skills acquired using simulators must be certified and transferable to the operating room. Most models for practicing laparoscopic skills in veterinary minimally invasive surgery are general task trainers and consist of boxes (simulators) designed for training human surgery. These simulators exhibit several limitations, including anatomic species and procedural differences, as well as general psychomotor training rather than in vivo skill recreation. In this paper, we review the existing methods of training, evaluation, and validation of technical skills in veterinary laparoscopic surgery. Content includes global and specific scales, and the conditions a structured curriculum should meet for improving the performance of novice surgeons during and after training. A focus on trainee-specific assessment and tailored-technical instruction should influence training programs. We provide a comprehensive analysis of current theories and concepts related to the evaluation and validation of simulators for training laparoscopic surgery in small animal surgery. We also highlight the need to develop new training models and complementary evaluation scales for the validation of training and acquisition of basic and advanced skills in veterinary laparoscopic surgery.

Online Module Builds Skills for Internal Medicine Interns in Responding to Emotions During Complex Serious Illness Conversations

CONTEXT

Responding to emotion cues is an essential skill for communicating with patients and families, but many health care trainees have difficulty applying this skill within the context of a complex conversation.

OBJECTIVES

We created an original online module to facilitate deliberate practice of a three-skill framework for responding to emotion cues during complex or nonlinear serious illness conversations.

METHODS

Our original online module uses a gamebook format, which prompts trainees to engage in focused and repetitive practice of three well-defined skills for responding to emotion cues in a simulated family conference. We implemented the module as a part of a communication skills curriculum for interns rotating in the intensive care unit. After completing the module, all interns answered an open-ended survey question about their perceived skill acquisition. Results were analyzed by a qualitative method and coded into themes.

RESULTS

About 71% of interns (n = 65 of 92) completed the online module and open-ended survey question. About 89% of participants responded that they would use a naming, understanding, respecting, supporting, or exploring statement in response to an emotion cue. Nearly two-thirds of participants articulated their rationale for using naming, understanding, respecting, supporting, or exploring statements (e.g., preparing patients to process complex medical information, eliciting information about patient perspective.) CONCLUSION: Our online emotion cue module is a novel tool for deliberate practice of advanced skills for responding to emotion cues in serious illness conversations. In future studies, we will investigate whether our module's efficacy is enhanced by using it as a part of a flipped classroom curriculum with an in-person simulation session.

Longitudinal resident coaching in the outpatient setting: A novel intervention to improve ambulatory consultation skills

BACKGROUND

Direct observation with feedback to learners should be a mainstay in resident education, yet it is infrequently done and its impact on consultation skills has rarely been assessed.

APPROACH

This project presents the framework and implementation of a longitudinal low-frequency, high-intensity direct observation and coaching intervention, and elaborates on insights learned. Internal medicine interns at one residency training program were randomized to an ambulatory coaching intervention or usual precepting. Over one year, coached interns had three complete primary care visits directly observed by a faculty clinician-coach who provided feedback informed by a behavior checklist. Immediately after each of the coached patient encounters, interns completed a structured self-assessment and coaches led a 30-minute feedback session informed by intern self-reflection and checklist items. Interns with usual precepting had two mini-CEX observations over the course of the year without other formal direct observation in the ambulatory setting.

EVALUATION

As part of the post-intervention assessment, senior faculty members blinded to intervention and control group assignments evaluated videotaped encounters. Coached interns completed an average of 21/23 behaviors from the checklist, while interns from the control group completed 18 (p < 0.05). The median overall grade for coached interns was B+, compared to B-/C+ for controls (p < 0.05).

REFLECTION

Coaching interns longitudinally using a behavior checklist is feasible and associated with improved consultation performance. Direct observation of complete clinical encounters followed by systematic coaching is educationally valuable, but time and resource intensive.

Health care providers' experiences and perceptions participating in a chronic pain telementoring education program: A qualitative study

Background

Chronic pain affects one in five Canadians. Frontline health care providers (HCPs) manage the majority of patients with chronic pain yet receive minimal training to do so. The Extension for Community Healthcare Outcomes (ECHO) model™ is an education intervention aimed at HCPs (not patients) to support and improve care in underserviced communities. ECHO Ontario Chronic Pain and Opioid Stewardship (ECHO PAIN) is an adaptation of the ECHO model where the program goals are to support and improve chronic pain and opioid management in the province of Ontario, Canada.

Aims

This study aimed to investigate the perceptions of HCPs participating in ECHO PAIN.

Methods

Thirteen HCPs attending ECHO PAIN participated in in-depth semistructured phone interviews. Resulting data were analyzed through a qualitative descriptive lens.

Results

Analysis uncovered four themes: (1) HCPs’ motivation for joining ECHO PAIN, (2) interprofessional collaboration through ECHO PAIN, (3) the use of opioids for pain management, and (4) barriers and facilitators to participation and satisfaction in ECHO PAIN. HCPs joined ECHO PAIN because of their struggles managing their complex patients with chronic pain. HCPs also recognized the importance of interprofessional collaboration in pain management and shared examples of integration of different professional approaches in their clinical teams. Opioids for pain management remained a controversial issue, and ECHO served as an opportunity to decrease this knowledge gap. Finally, HCPs described how time constraints, organizational support, and session structure acted as barriers to their participation and satisfaction in the ECHO PAIN program; technology mediated satisfaction.

Conclusions

This study was the first in Canada to explore the motivations of HCPs in attending a chronic pain telementoring program as well as to examine the interprofessional effects of participation. HCPs increased their knowledge about management of chronic pain and increased their interprofessional approach.

Bridging the Gap Between "Do One" and "Teach One": Impact of a Procedural Objective Structured Teaching Encounter on Resident Procedural Teaching Proficiency

PROBLEM

Minimal formal training exists in teaching invasive bedside procedures during Internal Medicine (IM) residency despite the large role trainees have in instructing junior colleagues.

OBJECTIVE AND METHODS

We investigated if using a Procedural Objective Structured Teaching Encounter (PrOSTE) to disseminate a novel method for teaching procedures would improve supervising residents' (n = 7) ability to teach ultrasound-guided peripheral IV's (USGIV) to incoming interns (n = 67) at a single, large academic IM residency. Supervising residents were assigned to receive the PrOSTE training versus standard procedure training, and then, both groups instructed incoming interns. The impact of the PrOSTE was measured by participant surveys, observed changes in teacher behavior, and performance of incoming interns on a USGIV blinded assessment station.

MEASUREMENT AND MAIN RESULTS

PrOSTE-trained residents reported high levels of satisfaction with the session and demonstrated increased desirable behaviors when teaching procedures. There was no statistical difference in incoming intern performance when placing USGIVs between intervention and standard groups (81.0% vs 74.8% items correct; difference 6.2; SD = 12.4; p = 0.22).

CONCLUSION

The PrOSTE is a feasible, well-received tool for training supervising residents in our novel teaching framework, as demonstrated in this pilot study. Despite not showing a difference in learner performance, qualitative data suggests the impact of the PrOSTE would be even greater in a more controlled teaching environment. Using a PrOSTE to deliver this teaching framework has broad applicability to any IM residency, and the tenets can be used with any bedside invasive procedure with an effective task trainer.

Standardizing education in interventional pulmonology in the midst of technological change

Interventional pulmonology (IP) is a maturing subspecialty of pulmonary medicine. The robust innovation in technology demands standardization in IP training with both disease and technology driven training. Simulation based training should be considered a part of IP training as seen in other procedural and surgical subspecialties. Procedure volume is a component of training; however, this does not guarantee or translate into competency for learners. Basic competency skills can be assessed using standardized well validated assessment tools designed for various IP procedures including flexible bronchoscopy, endobronchial ultrasound guided transbronchial needle aspiration (EBUS TBNA), rigid bronchoscopy and chest tube placement; however, further work is needed to validate tools in all procedures as new technologies are introduced beyond fellowship training. Currently there are at least 39 IP fellowship programs in the United States (US) and Canada which has led to improved training by accreditation of programs who meet rigorous requirements of standardized curriculum and procedural volume. The challenge is to be innovative in how we teach globally with intention and how to best integrate new evolving technology training for those not only during fellowship training but also beyond fellowship training.

How to stich? 90 degrees: The perfect angle

OBJECTIVE

This is a discussion about correct suturing techniques and implications that follow inappropriate suturing. We deconstruct the suturing needle angles and methods to be adopted to acquire the perfect needle angle to the tissue being sutured. A study of angles confirms that 90° is perceptible to the naked eye and easy to identify, making it an appropriate foundation to explain, communicate and teach the concepts in the wet-lab and the operating room.

BACKGROUND

There is a lack of robust teaching regarding entry of the needle orthogonal to the tissue planes. In addition, objective methods of assessing angles of the needle relative to the tissue and consequences of inaccuracy are lacking. The authors aim to deconstruct the steps of suturing with the aim of demonstrating ninety degrees is the perfect suturing angle.

STUDY DESIGN

We conducted a study to identify 90° (the perfect suturing angle) as an angle easy to identify with the naked eye. Angles from 86° to 94° and 41° to 49° were printed and presented to volunteers with the instruction to identify the angles of 90° and 45°.

RESULTS

Fifty-one volunteers replied to the 90° angle study and sixty-five volunteers replied to the 45° study. 92% correctly identified at least one 90° angle and 72% identified both the 90° angles. 63% identified at least one 45° angle and only 27% identified both the 45° angles presented to them. This supported our hypothesis that 90° is an angle that is readily identifiable to the human eye.

CONCLUSIONS

Objective assessment of surgical skills and training should focus on the basic needle skills with particular emphasis on suturing angles, progressing to higher skills using low and intermediate fidelity models and correlating practice alongside the trainees' operative progress.

Improving junior doctor medicine prescribing and patient safety: An intervention using personalised, structured, video-enhanced feedback and deliberate practice

AIMS

This research investigated the effectiveness of an intervention for improving the prescribing and patient safety behaviour among Foundation Year doctors. The intervention consisted of simulated clinical encounters with subsequent personalised, structured, video-enhanced feedback and deliberate practice, undertaken at the start of four-month sub-specialty rotations.

METHODS

Three prospective, non-randomised control intervention studies were conducted, within two secondary care NHS Trusts in England. The primary outcome measure, error rate per prescriber, was calculated using daily prescribing data. Prescribers were grouped to enable a comparison between experimental and control conditions using regression analysis. A break-even analysis evaluated cost-effectiveness.

RESULTS

There was no significant difference in error rates of novice prescribers who received the intervention when compared with those of experienced prescribers. Novice prescribers not participating in the intervention had significantly higher error rates (P = .026, 95% confidence interval [CI] Wald 0.093 to 1.436; P = .026, 95% CI 0.031 to 0.397) and patients seen by them experienced significantly higher prescribing error rates (P = .007, 95% CI 0.025 to 0.157). Conversely, patients seen by the novice prescribers who received the intervention experienced a significantly lower rate of significant errors compared to patients seen by the experienced prescribers (P = .04, 95% CI -0.068 to -0.001). The break-even analysis demonstrates cost-effectiveness for the intervention.

CONCLUSION

Simulated clinical encounters using personalised, structured, video-enhanced feedback and deliberate practice improves the prescribing and patient safety behaviour of Foundation Year doctors. The intervention is cost-effective with potential to reduce avoidable harm.

Video Coaching Improving Contemporary Technical and Nontechnical Ability in Laparoscopic Education

OBJECTIVE

A video coaching (VC) system has been developed in surgical education. This study compares the educational effect on technical and nontechnical skills of the VC method for teaching laparoscopic surgery.

DESIGN

We conducted a prospectively randomized study of an education program to teach laparoscopic procedures.

SETTING

The study was performed at the Chang Gung Memorial Hospital, a university hospital in Taiwan.

PARTICIPANTS

We enrolled sixteen first- or second-year surgical residents.The participants were randomized into VC and conventional teaching (CT) groups, and their surgical skills were judged by the Global Operation Assessment of Laparoscopic Skills (GOALS) and the Objective Structured Assessment of Technical Skills (OSATS). Nontechnical skills were evaluated by the Non-Technical Skills for Surgeons (NOTSS) assessment and self-efficacy questionnaires (SEQs). After the program, posttraining scores were compared to assess improvements.

RESULTS

The 16 enrolled participants finished the entire course and completed all the videos during the study period. Comparing the VC and CT groups, we found that the pretraining GOALS, OSATS, NOTSS and SEQ scores were similar between both groups. However, after training, the OSATS score gain was higher in the VC groupthan in the CT group (9.25 ± 2.05 vs. 6.50 ± 1.51, p=0.009). Regarding nontechnical skills, the NOTSS score improved more in the VC group than in the CT group (5.50 ± 0.93 vs. 4.25 ± 0.89, p=0.015). The SEQ score was also higher in the VC group (32.13 ± 2.10) than in the CT group (29.50 ± 1.77), with a significant difference (p=0.018).

CONCLUSION

VC can help surgeons build their expertise using a more accessible method. Additionally, VC can shorten the learning curve and improve self-efficacy, thereby contributing to surgeons' education.

Enhancing Operative Feedback: A Descriptive Trajectory for Surgical Development in Otolaryngology

OBJECTIVE

Developmental frameworks are narrative descriptions of learner performance that may be useful to provide operative feedback tools in surgical education. The authors previously proposed the Technician, Anatomist, Anticipator, Strategist, Executive (TAASE) framework utilizing data collected from general surgeons and conjectured its applicability in other surgical specialties. Here, we construct a developmental framework in otolaryngology using similar techniques, then compare the results to TAASE.

DESIGN

Ten otolaryngology educators participated in semi-structured, audio-recorded interviews, to explore how otolaryngology faculty characterize surgical learning at different levels of training. Researchers analyzed the transcripts using a thematic analysis approach to build a developmental framework. Results were then qualitatively compared to the TAASE trajectory.

SETTING

Single tertiary academic medical center.

PARTICIPANTS

Faculty within the Department of Otolaryngology-Head and Neck Surgery.

RESULTS

Otolaryngology faculty characterized surgical development as an integrated trajectory of technical and cognitive skills progressing from specific operative tasks to a global understanding of patients and procedures largely consistent with stages outlined in the Technician, Anatomist, Anticipator, Strategist, and Executive model. A new theme identified was learner emotions, which may impact learning and hinder or enhance progression along the trajectory.

CONCLUSIONS

Otolaryngology and general surgeons agree upon a common arc to operative maturity reflected by the TAASE trajectory. The TAASE framework may be useful as a tool for intraoperative assessment in otolaryngology to help promote quality feedback. Further research is needed to understand how emotions may influence operative skill development.

Cadaveric Simulation Training in Cardiothoracic Surgery: A Systematic Review

Simulation training has become increasingly relevant in the educational curriculum of surgical trainees. The types of simulation models used, goals of simulation training, and an objective assessment of its utility and effectiveness are highly variable. The role and effectiveness of cadaveric simulation in cardiothoracic surgical training has not been well established. The objective of this study was to evaluate the current medical literature available on the utility and the effectiveness of cadaveric simulation in cardiothoracic surgical residency training. A literature search was performed using PubMed, Cochrane Library, Embase, Scopus, and CINAHL from inception to February 2019. Of the 362 citations obtained, 23 articles were identified and retrieved for full review, yielding ten eligible articles that were included for analysis. One additional study was identified and included in the analysis. Extraction of data from the selected articles was performed using predetermined data fields, including study design, study participants, simulation task, performance metrics, and costs. Most of these studies were only descriptive of a cadaveric or perfused cadaveric simulation model that could be used to augment clinical operative training in cardiothoracic surgery. There is a paucity of evidence in the literature that specifically evaluates the utility and the efficacy of cadavers in cardiothoracic surgery training. Of the few studies that have been published in the literature, cadaveric simulation does seem to have a role in cardiothoracic surgery training beyond simply learning basic skills. Additional research in this area is needed.

Design and Evaluation of a Low-Cost Bronchoscopy-Guided Percutaneous Dilatational Tracheostomy Simulator

Supplemental digital content is available in the text.

Introduction

Bronchoscopy-guided percutaneous dilatational tracheostomy (BG-PDT) is an invasive procedure regularly performed in the intensive care unit. Risk of serious complications have been estimated in up to 5%, focused during the learning phase. We have not found any published formal training protocols, and commercial simulators are costly and not widely available in some countries. The objective of this study was to present the design and simulator performance of a low-cost BG-PDT simulator.

Methods

A simulator was designed with materials available in a hardware store, synthetic skin pads, ex vivo bovine tracheas, and a pipe inspection camera. The simulator was tested in 8 experts and 9 novices. Sessions were video recorded, and participants were equipped with the Imperial College Surgical Device, a hand motion–tracking device. Performance was evaluated with a multimodal approach, including first attempt success rate, global success rate, total procedural time, Imperial College Surgical Device–derived proficiency parameters, and global rating scale applied blindly by 2 expert observers. A satisfaction survey was applied after the procedure.

Results

A simulator was successfully constructed, allowing multiple iterations per assembly, with a fixed cost of US $30 and $4 per use. Experts had greater global and first attempt success rate, performed the procedure faster, and with greater proficiency. It presented high user satisfaction and fidelity.

Conclusions

A low-cost BG-PDT simulator was successfully constructed, with the ability to discriminate between experts and novices, and with high fidelity. Considering its ease of construction and cost, it can be replicated in almost any intensive care unit.

Impact of an Immersive Virtual Reality Curriculum on Medical Students' Clinical Assessment of Infants With Respiratory Distress

OBJECTIVE

To determine whether exposure to an immersive virtual reality curriculum on pediatric respiratory distress improves medical students' recognition of impending respiratory failure.

DESIGN

Randomized, controlled, prospective study conducted from July 2017 to June 2018. Evaluators blinded to student groupings.

SETTING

Academic, free-standing children's hospital.

PARTICIPANTS

All third-year medical students (n = 168) were eligible. The standard curriculum was delivered to all students during their pediatric rotation with optional inclusion of research data per Institutional Review Board review. A randomized selection of students was exposed to the virtual reality curriculum.

INTERVENTION

All students received standard training on respiratory distress through didactics and high-fidelity mannequin simulation. Intervention students underwent an additional 30-minute immersive virtual reality curriculum, experienced through an OculusRift headset, with three simulations of an infant with 1) no distress, 2) respiratory distress, and 3) impending respiratory failure.

MEASUREMENTS AND MAIN RESULTS

The impact of the virtual reality curriculum on recognition/interpretation of key examination findings, assignment of an appropriate respiratory status assessment, and recognition of the need for escalation of care for patients in impending respiratory failure was assessed via a free response clinical assessment of video vignettes at the end of the pediatric rotation. Responses were scored on standardized rubrics by physician experts. All eligible students participated (78 intervention and 90 control). Significant differences between intervention and control were demonstrated for consideration/interpretation of mental status (p < 0.01), assignment of the appropriate respiratory status assessment (p < 0.01), and recognition of a need for escalation of care (p = 0.0004).

CONCLUSIONS

Exposure to an immersive virtual reality curriculum led to improvement in objective competence at the assessment of respiratory distress and recognition of the need for escalation of care for patients with signs of impending respiratory failure. This study represents a novel application of immersive virtual reality and suggests that it may be effective for clinical assessment training.

Plastic frontal pole cortex structure related to individual persistence for goal achievement

Persistent goal-directed behaviours result in achievements in many fields. However, the underlying neural mechanisms of persistence and the methods that enhance the neuroplasticity underlying persistence, remain unclear. We here demonstrate that the structural properties of the frontal pole cortex (FPC) before tasks contain information that can classify Achievers and Non-achievers (goal-directed persistence) participating in three tasks that differ in time scale (hours to months) and task domains (cognitive, language, and motor learning). We also found that most Achievers exhibit experience-dependent neuroplastic changes in the FPC after completing language and motor learning tasks. Moreover, we confirmed that a coaching strategy that used subgoals modified goal-directed persistence and increased the likelihood of becoming an Achiever. Notably, we discovered that neuroplastic changes in the FPC were facilitated by the subgoal strategy, suggesting that goal-striving, using effective coaching, optimizes the FPC for goal persistence.

Hosoda et al. study the neurobiological underpinnings of goal pursuit and persistence. They use MRI data and identify areas in the frontal pole cortex that could predict performance on various tasks. They also show that coaching results in neuroplastic remodeling that increases the likelihood of goal persistence.

Sequence matters: patterns in task-based clinical reasoning

Background

The cognitive pathways that lead to an accurate diagnosis and efficient management plan can touch on various clinical reasoning tasks (1). These tasks can be employed at any point during the clinical reasoning process and though the four distinct categories of framing, diagnosis, management, and reflection provide some insight into how these tasks map onto clinical reasoning, much is still unknown about the task-based clinical reasoning process. For example, when and how are these tasks typically used? And more importantly, do these clinical reasoning task processes evolve when patient encounters become complex and/or challenging (i.e. with contextual factors)?

Methods

We examine these questions through the lens of situated cognition, context specificity, and cognitive load theory. Sixty think-aloud transcripts from 30 physicians who participated in two separate cases – one with a contextual factor and one without – were coded for 26 clinical reasoning tasks (1). These tasks were organized temporally, i.e. when they emerged in their think-aloud process. Frequencies of each of the 26 tasks were aggregated, categorized, and visualized in order to analyze task category sequences.

Results

We found that (a) as expected, clinical tasks follow a general sequence, (b) contextual factors can distort this emerging sequence, and (c) the presence of contextual factors prompts more experienced physicians to clinically reason similar to that of less experienced physicians.

Conclusions

These findings add to the existing literature on context specificity in clinical reasoning and can be used to strengthen teaching and assessment of clinical reasoning.

Enhancing task-demands disrupts learning but enhances transfer gains in short-term task-switching training

Content variability was previously suggested to promote stronger learning effects in cognitive training whereas less variability incurred transfer costs (Sabah et al. Psychological Research, 10.1007/s00426-018-1006-7, 2018). Here, we expanded these findings by additionally examining the role of learners’ control in short-term task-switching training by comparing voluntary task-switching to a yoked control forced task-switching condition. To this end, four training conditions were compared: (1) forced fixed content, (2) voluntary fixed content, (3) forced varied content, and (3) voluntary varied content. To further enhance task demands, bivalent stimuli were used during training. Participants completed baseline assessment commencing with task-switching and verbal fluency blocks, followed by seven training blocks and last by task-switching (near transfer) and verbal fluency (far transfer) blocks, respectively. For the baseline and transfer task-switching blocks, we used the exact same baseline and first transfer block from Sabah et al. (Psychological Research, 10.1007/s00426-018-1006-7, 2018), employing univalent stimuli and alternating-runs task sequence. Our results pointed again to the contribution of content variability to task-switching performance. No indications for far transfer were observed. Allowing for learners’ control was not found to produce additional transfer gains beyond content variability. A between-study comparison suggests that enhanced task demands, by means of bivalency, promoted higher transfer gains in the current study when compared to Sabah et al. (Psychological Research, 10.1007/s00426-018-1006-7, 2018). Taken together, the current results provide further evidence to the beneficial impact of variability on training outcomes. The lack of modulatory effect for learners’ control is discussed in relation to possible methodological limitations.

Development of a median sternotomy simulation model for cardiac surgery training

Objective

We sought to develop a simulation model to train resident physicians in the performance of a median sternotomy.

Methods

A modified Delphi consensus process was used with cardiac surgery staff to develop a 20-point checklist for the safe performance of a median sternotomy. Thirteen junior cardiac surgery trainees from across Canada participated in this study to assess the simulation model. Trainees performed the sternotomy before and after reviewing an instructional video. Two senior cardiac surgery resident physicians assessed the participants with the checklist during each session. An entry and exit questionnaire was given to the participants to evaluate the simulation model.

Results

Participants scored higher after the training (14.3 ± 2.0) compared with before training (8.0 ± 3.1) (P < .001). The mean duration of time for participants to complete the sternotomy was shorter before training (188 ± 52 seconds vs 228 ± 58 seconds; P = .003). The checklist interrater reliability was κ = 0.47 (moderate) for before training and κ = 0.37 (fair) for after training. All study participants rated the simulation sessions as very useful or extremely useful.

Conclusions

Using the simulation model, training video, and checklist, trainees were able to improve their skill in performing a median sternotomy. This improvement was associated with longer times to complete all procedure steps. Rater training may further improve interrater reliability. Our median sternotomy checklist and simulation model can be adopted for the technical skills training of future cardiac surgery trainees.

Achieving expert performance through simulation-based education and application of mastery learning principles

Medical education has undergone significant change as we have moved from a purely apprenticeship model to one of competence. Simulation-based education can and does play a significant role in the development of an expert surgeon. Proven concepts of simulation-based education include distributed deliberate practice, content that challenges the learner, formative and summative feedback. The application of mastery learning principles is critical to achieve the best retention and outcomes related to an educational program. In this manuscript, we explore the methodology and justification for Mastery Learning as the gold standard of surgical education.

CAEP 2019 Academic Symposium: Got competence? Best practices in trainee progress decisions

Background

Competence committees play a key role in a competency-based system of assessment. These committees are tasked with reviewing and synthesizing clinical performance data to make judgments regarding residents’ competence. Canadian emergency medicine (EM) postgraduate training programs recently implemented competence committees; however, a paucity of literature guides their work.

Objective

The objective of this study was to develop consensus-based recommendations to optimize the function and decisions of competence committees in Canadian EM training programs.

Methods

Semi-structured interviews of EM competence committee chairs were conducted and analyzed. The interview guide was informed by a literature review of competence committee structure, processes, and best practices. Inductive thematic analysis of interview transcripts was conducted to identify emerging themes. Preliminary recommendations, based on themes, were drafted and presented at the 2019 CAEP Academic Symposium on Education. Through a live presentation and survey poll, symposium attendees representing the national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback and identified consensus among symposium attendees on a final set of nine high-yield recommendations.

Conclusion

The Canadian EM community used a structured process to develop nine best practice recommendations for competence committees addressing: committee membership, meeting processes, decision outcomes, use of high-quality performance data, and ongoing quality improvement. These recommendations can inform the structure and processes of competence committees in Canadian EM training programs.

Effect of face-to-face verbal feedback compared with no or alternative feedback on the objective workplace task performance of health professionals: a systematic review and meta-analysis

OBJECTIVE

Verbal face-to-face feedback on clinical task performance is a fundamental component of health professions education. Experts argue that feedback is critical for performance improvement, but the evidence is limited. The aim of this systematic review was to investigate the effect of face-to-face verbal feedback from a health professional, compared with alternative or no feedback, on the objective workplace task performance of another health professional.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched the full holdings of Ovid MEDLINE, CENTRAL, Embase, CINAHL and PsycINFO up to 1 February 2019 and searched references of included studies. Two authors independently undertook study selection, data extraction and quality appraisal. Studies were included if they were randomised controlled trials investigating the effect of feedback, in which health professionals were randomised to individual verbal face-to-face feedback compared with no feedback or alternative feedback and available as full-text publications in English. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. For feedback compared with no feedback, outcome data from included studies were pooled using a random effects model.

RESULTS

In total, 26 trials met the inclusion criteria, involving 2307 participants. For the effect of verbal face-to-face feedback on performance compared with no feedback, when studies at high risk of bias were excluded, eight studies involving 392 health professionals were included in a meta-analysis: the standardised mean difference (SMD) was 0.7 (95% CI 0.37 to 1.03; p<0.001) in favour of feedback. The calculated SMD prediction interval was -0.06 to 1.46. For feedback compared with alternative feedback, studies could not be pooled due to substantial design and intervention heterogeneity. All included studies were summarised, and key factors likely to influence performance were identified including components within feedback interventions, instruction and practice opportunities.

CONCLUSIONS

Verbal face-to-face feedback in the health professions may result in a moderate to large improvement in workplace task performance, compared with no feedback. However, the quality of evidence was low, primarily due to risk of bias and publication bias. Further research is needed. In particular, we found a lack of high-quality trials that clearly reported key components likely to influence performance.

TRIAL REGISTRATION NUMBER

CRD42017081796.

Group Video Feedback is an Effective and Efficient Tool for Enhancing Skills of Surgical Interns

BACKGROUND

Our group has shown that personalized video feedback (PVF) is better than a task demonstration video at increasing wound closure skills among incoming surgical interns. However, offering PVF can be time-consuming. We sought to compare the educational effects and time required for group video feedback (GVF) and PVF.

METHODS

We have mailed our matched incoming "surgical" interns a "welcome package" in mid-March for the past 3 y. The package includes similar resources each year. Incoming interns were asked to video record themselves performing six tasks three separate times between April 1 and June 15. After each submission in 2016 and 2017, incoming interns received 2 min of personalized feedback on their three separate wound closure videos (PVF). In 2018, incoming interns received 5 min of group-based feedback three separate times covering all six tasks (GVF). We compared performance (July Surgical Olympics) of these six skills against the interns from the previous 2 y who received PVF on only one skill (suturing).

RESULTS

Twenty-three incoming interns received the pre-residency package and participated in the 2018 Surgical Olympics. This 2018 GVF class had a higher overall mean score for six stations (31.5 [standard deviation = ±7.7]) than the 2016 and 2017 PVF classes (25.6 [standard deviation = ±8]; P < 0.0001). Knot tying ability and suturing skill were similar between the classes. The GVF group performed better on the remaining four skills . The total time of surgical staff and educators spent per class in 2018 (GVF class) was 30 min and includes six tasks compared with 276 min of effort in each of the 2016 and 2017 classes (PVF included one task).

CONCLUSIONS

GVF and PVF as a component of preemptive training had the same effect on improving suturing skills among the interns. GVF required less educator editing and voice over time. GVF is effective and efficient in enhancing incoming interns' performance in multiple skills.

Interindividual differences in the capability to change automatized movement patterns

When modifying established, automatized skills, performers often experience proactive interference resulting in initial performance decrements. Notably, individuals seem to differ quite largely with respect to their interference susceptibility. The aim of the present study was to scrutinize the roots of these interindividual differences by examining the role of executive functions, age, baseline performance and gaze behavior applying a motor skill change task. As the ability to deal with proactive interference seems to be particularly linked to inhibitory mechanisms, we also assessed whether the application of a motor restriction which prevents unwanted movements may facilitate inhibition and hence result in less proactive interference. To this end, skilled touch-typists were confronted with a rule change that prohibited the left index finger for subsequent typing which immediately disrupted participants' automatized typing fluency. Regression analyses revealed that the amount of interference was significantly related to age and that the application of a motor restriction tended to predict less proactive interference. Additional correlation analyses revealed that a higher amount of proactive interference was also associated with higher baseline performance and lower prepotent response inhibition abilities. However, none of the remaining executive functions could explain the amount of interference. It follows that individual factors such as age, baseline performance and prepotent response inhibition as well as the physical option to execute a certain movement may play important roles in overcoming proactive interference when changing automatized skills.

Eight Years of Scottish Surgical Boot Camps: How We Do It Now

BACKGROUND

Scottish Surgical Boot Camps are the induction course for new start Core Surgical Trainees (Residents) in Scotland. The aim is to capitalise on trainees' receptiveness at a time of transition, and to give them a safe and "flying start." At their inception, these were the first such courses in the UK to integrate technical and non-technical skills training. As well as knowledge and skills, trainees have learned norms and expectations of a community of professional practice.

METHODS

Over 9 consecutive years of delivery and quality improvement, faculty have learned much about the safe use of simulation, as an adjuvant training modality for a range of competences required in the operating room, the clinic/office, the wards and other clinical domains.

CONCLUSION

In this paper we describe the development and content of the course, discuss the importance of the whole "activity system," and present some evaluation data. We give tips for success, such as using simulations of escalating complexity, and the power of seemingly incidental Learning Outcomes.

Simulation Training for Critical Care Airway Management: Assessing Translation to Clinical Practice Using a Small Video-Recording Device

BACKGROUND

Critical care airway management (CCAM) is a key skill for critical care physicians. Simulation-based training (SBT) may be an effective modality in training intensivists in CCAM.

RESEARCH QUESTION

Is SBT of critical care fellows an effective means of providing training in CCAM, in particular in urgent endotracheal intubation?

STUDY DESIGN AND METHODS

Thirteen first-year pulmonary critical care medicine (PCCM) fellows at an academic training program underwent SBT with a computerized patient simulator (CPS) in their first month of fellowship training. At the end of the training period, the fellows underwent video-based scoring using a 46-item checklist (of which 40 points could be scored) while performing a complete CCAM sequence on the CPS. They were then tested, using video-based scoring on their first real-life CCAM. Maintenance of skill at CCAM was assessed during the fellows' second and third year of training, using the same scoring method.

RESULTS

For the first-year fellows, the score on the CPS was 38.3 ± 0.75 SD out of a maximum score of 40. The score on their first real-life patient CCAM was 39.0 ± 0.81 SD (P = .003 for equivalence; 95% CI for difference between real-life patient CCAM and CPS scores, 0.011-1.373). Sixteen second- and third-year fellows were tested at a real-life CCAM event later in their fellowship to examine for maintenance of skill. The mean maintenance of skill score of this group was 38.7 ± 1.14 SD.

INTERPRETATION

Skill acquired through SBT of critical care fellows for CCAM transfers effectively to the real-life patient care arena. Second- and third-year fellows who had initially received SBT maintained skill at CCAM.

Why Physiology Is Critical to the Practice of Medicine: A 40-year Personal Perspective

Accuracy in diagnosis trumps all other elements in clinical decision making. If diagnosis is inaccurate, management is likely to prove futile if not dangerous. Knowledge of physiology provides a periscope for identifying abnormalities beneath the skin responsible for clinical manifestations on the surface. Expert diagnosticians suspect disorders based on pattern recognition and automatic retrieval of knowledge stored in memory. A superior diagnostician looks at the same findings other clinicians see but thinks of causes that others have not imagined. Solving clinical mysteries depends on a clinician's power of imagination, not the capacity to recite an algorithm or apply a protocol.

How do teaching quality and pedagogical practice enhance vocational student engagement? A mixed-method classroom observation approach

Purpose

The purpose of this paper is to investigate vocational teaching behaviours in facilitating pedagogical practice concerning students' classroom engagement.

Design/methodology/approach

A mixed-method approach with quantitative classroom observations and qualitative field notes was conducted at two higher vocational institutions in Guangdong province, south of China. Sixty lesson observations were rated combining with supplementary field notes from 20 teacher participants analysed through a comparative coding process.

Findings

Means of dimensions of teaching behaviours and student engagement were calculated based on taking the averages of the means of items theoretically associated with each dimension. Through thematic analysis of observational notes, vocational instructions and students' engagement in vocational learning environment were more diversified in terms of vocational teaching practice, which manifested that vocational teaching behaviours focused more on adjusting students' practical learning.

Research limitations

The limitation is shown that the quantitative sample is small, yet affords greater depth of data for further discussion.

Originality/value

This study develops its setting and orientation by applying the classroom observation instrument into the Chinese high vocational context and offers more in-depth insights and exploration of the characteristics of teaching practice in vocational classrooms.

Primary Health Care Pediatricians' Self-Perception of Theoretical Knowledge and Practical Skills in Life-Threatening Emergencies: A Cross-Sectional Study

INTRODUCTION

Within out-of-hospital emergencies, Primary Health Care (PHC) pediatricians will likely be the first to provide health care at the scene of a life-threatening emergency (LTE) in children. Pediatricians should be trained to initially intervene, safely and effectively the LTEs, including the activation of Emergency Medical Systems (EMS), an adequate stabilization of patients and transport to the hospital.

STUDY OBJECTIVES

The aims of this study are to know the training received for out-of-hospital LTEs by PHC pediatricians of the Principality of Asturias (Spain) and the perception they have about their own theoretical knowledge and practical skills in a series of emergency procedures used in LTEs; also, to analyze the differences according to the geographical context of their work.

METHODS

This was a cross-sectional, descriptive, and observational study of a sample of 27 PHC pediatricians from PHC Service of Asturias, Spain, from among the total of 88 pediatricians who make up the staff of pediatricians, conducted from April through May 2019. The survey was designed ad hoc using the Curriculum in Primary Care Pediatrics (CPCP) proposed by the European Confederation of Primary Care Pediatricians (ECPCP; Europe), which indicates the theoretical and practical procedures that must be acquired by the PHC pediatricians. It is composed of 30 procedures or techniques employed in LTEs using a 11-point Likert scale rating to detect their self-perception about theoretical knowledge and practical skills from zero ("Minimum") to 10 ("Maximum").

RESULTS

There are significant differences in the mean of theoretical knowledge and practical skills in many procedures or techniques studied, depending on the different areas of work.

CONCLUSION

Asturian pediatricians are generally well-prepared to solve LTEs with a few exceptions. The degree of self-perception and acquisition of general theoretical knowledge and general practical skills in LTEs is heterogeneous, with differences according to the scope of work.

Applying Educational Theory and Best Practices to Solve Common Challenges of Simulation-based Procedural Training in Emergency Medicine

OBJECTIVES

Procedural competency is an essential prerequisite for the independent practice of emergency medicine. Multiple studies demonstrate that simulation-based procedural training (SBPT) is an effective method for acquiring and maintaining procedural competency and preferred over traditional paradigms ("see one, do one, teach one"). Although newer paradigms informing SBPT have emerged, educators often face circumstances that challenge and undermine their implementation. The goal of this paper is to identify and report on best practices and theory-supported solutions to some of these challenges as derived using a process of expert consensus building and reviews of the existing literature on SBPT.

METHODS

The Society for Academic Emergency Medicine (SAEM) Simulation Academy SBPT Workgroup convened approximately 8 months prior to the 2019 SAEM Annual Meeting to perform a review of the literature and participate in a consensus-building process to identify solutions (in the form of best practices and educational theory) to these challenges faced by educators engaging in SBPT.

RESULTS AND ANALYSIS

Thirteen distinct educational challenges to SBPT emerged from the expert group's primary literature reviews and consensus-building processes. Three domains emerged upon further analysis of the 13 challenges: learner, educator, and curriculum. Six challenges within the "learner" domain were selected for comprehensive discussion in this paper, as they were deemed representative of the most common and most significant threats to ideal SBPT. Each of the six challenges aligns with one of the following themes: 1) maximizing active learning, 2) maintaining learner engagement, 3) embracing learner diversity, 4) optimizing cognitive load, 5) promoting mindfulness and reflection, and 6) emphasizing deliberate practice for mastery learning. Over 20 "special treatments" for mitigating the impact of the 13 challenges were derived from the secondary literature search and consensus-building process prior to and during the preconference workshop; 11 of these that best address the six learner-centered challenges are explored, including implications for educators involved in SBPT.

CONCLUSIONS/IMPLICATIONS FOR EDUCATORS

We propose multiple consensus-generated solutions (in the form of best practices and applied educational theory) that we believe are suitable and well aligned to overcome commonly encountered learner-centered challenges and threats to optimal SBPT.

Theoretical considerations on programmatic assessment

Introduction: Programmatic assessment (PA) is an approach to assessment aimed at optimizing learning which continues to gain educational momentum. However, the theoretical underpinnings of PA have not been clearly described. An explanation of the theoretical underpinnings of PA will allow educators to gain a better understanding of this approach and, perhaps, facilitate its use and effective implementation. The purpose of this article is twofold: first, to describe salient theoretical perspectives on PA; second to examine how theory may help educators to develop effective PA programs, helping to overcome challenges around PA.Results: We outline a number of learning theories that underpin key educational principles of PA: constructivist and social constructivist theory supporting meaning making, and longitudinality; cognitivist and cognitive development orientation scaffolding the practice of a continuous feedback process; theory of instructional design underpinning assessment as learning; self-determination theory (SDT), self-regulation learning theory (SRL), and principles of deliberate practice providing theoretical tenets for student agency and accountability.Conclusion: The construction of a plausible and coherent link between key educational principles of PA and learning theories should enable educators to pose new and important inquiries, reflect on their assessment practices and help overcome future challenges in the development and implementation of PA in their programs.

A video anchored rating scale leads to high inter-rater reliability of inexperienced and expert raters in the absence of rater training

BACKGROUND

Our objective was to assess the impact of incorporating videos in a behaviorally anchored performance rating scale on the inter-rater reliability (IRR) of expert, intermediate and novice raters.

METHODS

The Intra-corporeal Suturing Assessment Tool (ISAT) was modified to include short video clips demonstrating poor, average, and expert performances. Blinded raters used this tool to assess videos of trainees performing suturing on a porcine model. Three attending surgeons, 4 residents, and 4 novice raters participated; no rater training was provided. The IRR was then compared among rater groups.

RESULTS

The IRR using the modified ISAT was high at 0.80 (p < 0.001). Ratings were significantly correlated with trainee objective suturing scores for all rater groups (experts: R = 0.84, residents: R = 0.81, and novices: R = 0.69; p < 0.001).

CONCLUSIONS

Incorporating video anchors (to define performance) in the ISAT led to high IRR and enabled novices to achieve similar consistency in their ratings as experts.

Video Modeling and Video Feedback to Reduce Time to Perform Intravenous Cannulation in Medical Students: A Randomized-Controlled Mixed-Methods Study

PURPOSE

Combined video modeling (VM) and video feedback (VF) may be more beneficial than traditional feedback when teaching procedural skills. This study examined whether repeated VM and VF compared with VM alone reduced the time required for medical students to perform peripheral intravenous (IV) cannulation.

METHODS

Twenty-five novice medical students were randomly assigned to groups in a one-way blinded embedded mixed-methods study to perform IV cannulation. Participants received standardized instruction and performed IV cannulation on each other while being audio-video recorded. They were assigned to review a video of an expert performing IV cannulation (VM alone), or both the expert video and a video of their own most recent IV cannulation (VM+VF), before returning to perform another IV cannulation. This was repeated for a total of four IV cannulation encounters and three video reviews. A post-test interview was also conducted and analyzed qualitatively using thematic content analysis.

RESULTS

The median [interquartile range] time required to perform IV cannulation in the final encounter was significantly different between the VM+VF group vs VM alone group (126 [93-226] sec vs 345 [131-537] sec, respectively; median difference, 111 sec; 95% confidence interval, 8 to 391; P = 0.02). There was no significant difference in IV cannulation success between VM alone and VM+VF in the final encounter (75% vs 85% respectively; P = 0.65). For the VM+VF group, the time to perform IV cannulation was reduced after the final encounter compared with the baseline encounter (P = 0.002), which was not true of the VM alone group (P = 0.35).

CONCLUSION

Video modeling and feedback shortened time to IV skill completion, reduced complications, and improved satisfaction in novice medical students.

Role of Peer Learning in Students' Skill Acquisition and Interest in Plastic Surgery

Supplemental Digital Content is available in the text.

Although the number of plastic surgery residency positions increased over the past decade, interest among Canadian medical students experienced the opposite trajectory. The aim of this study was to assess the effect of a low intensity, basic surgical skills workshop on medical students’ confidence and interest in surgery in general, and plastic surgery in particular.

Expertise among critical care nurses: A grounded theory study

OBJECTIVES

Explore critical care nurses' personal perceptions of expertise, expert performance and transition from novice to expert performer in clinical practice.

DESIGN

Following constructivist approach to grounded theory this investigation used qualitative open-ended interviews focused on the social construction of expertise in critical care nursing and the experiences of clinical practice that define that process.

SETTING

A multi-site urban area in the southeastern United States.

PARTICIPANTS

10 certified critical care nurses, three males and seven females, with 10-30+ years of critical care experience.

FINDINGS

Experience and knowledge are the foundation of expertise and expert performance. The higher the acuity the more frequent the experience the greater the nurses' aptitude and opportunity for learning and professional growth. It was also noted that self-actualisation was a major determinant in the development of expertise in critical care.

CONCLUSION

Key findings suggested that clinical experience and personal motivation combined with self-actualisation, the drive to maximise personal potential, determine critical care nurse's trajectory towards professional excellence. Expert performance evolves over time. Knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Social expectations and experiences have a direct impact on professional aptitude and development if expertise.

Cognitive Fitness Framework: Towards Assessing, Training and Augmenting Individual-Difference Factors Underpinning High-Performance Cognition

The aim of this article is to introduce the concept of Cognitive Fitness (CF), identify its key ingredients underpinning both real-time task performance and career longevity in high-risk occupations, and to canvas a holistic framework for their assessment, training, and augmentation. CF as a capacity to deploy neurocognitive resources, knowledge and skills to meet the demands of operational task performance, is likely to be multi-faceted and differentially malleable. A taxonomy of CF constructs derived from Cognitive Readiness (CR) and Mental fitness (MF) literature maps into phases of operational cycles from foundational to advanced, mission-ready and recovery. Foundational cognitive attributes, such as attention, executive control and co-action, were hypothesized to be trainable at the initial Cognitive Gym phase. More advanced training targets at the CR phase included stress and arousal regulation, adaptability, teamwork, situation awareness (including detection, sense-making and prediction) and decision making (de-biasing and confidence calibration). The mission-ready training phase is focused on tolerances (to sleep loss, monotony, pain, frustration, uncertainty) and resistance (to distraction, deception or manipulation). Operational Augmentation phase relies on support tools such as decision aids and fatigue countermeasures, while the Recovery phase employs reflexive (e.g., mindfulness), and restorative practices (e.g., nutrition and sleep hygiene). The periodization of cognitive training in this cycle is hypothesized to optimize both real-time cognitive performance and the resilience that enables life-long thriving. One of the most promising avenues of validating this hypothesis is by developing an expert consensus on the key CF ingredients and their relative importance in high-performance settings.

Clinician Perspectives Regarding In-Hospital Cardiac Arrest Resuscitation: A Multicenter Survey

OBJECTIVES

Evaluate clinicians' sentiments about participating in cardiac arrest resuscitations and identify factors associated with confidence in resuscitation of cardiac arrest.

DESIGN

Electronic survey.

SETTING

Twenty-one hospitals in Utah and Idaho.

SUBJECTS

All attending physicians, residents, and nurses in a multilevel healthcare system likely to participate in an in-hospital cardiac arrest resuscitation at least once every 2 years.

INTERVENTIONS

None.

MEASUREMENTS AND METHODS

A survey instrument evaluating clinician perceptions of in-hospital cardiac arrest resuscitation participation was developed after literature review and iteratively revised based on expert input and cognitive pretesting. Survey responses were collected anonymously. Sixty percent of 1,642 contacted clinicians (n = 977) submitted complete responses, of whom 874 met study inclusion criteria (190 attending physicians, 576 nurses, and 110 residents). Most respondents (74%) participated in less than or equal to six in-hospital cardiac arrest events per year, and 41% of respondents were most likely to participate in in-hospital cardiac arrest resuscitation at a community, rural, or critical access hospital. Confidence in in-hospital cardiac arrest participation was high overall (92%), but lower among residents (86%) than nurses (91%) or attending physicians (96%; p = 0.008). Fewer residents (52%) than nurses (73%) or attending physicians (95%; p < 0.001) reported feeling confident leading in-hospital cardiac arrest teams. Residents (63%) and attending physicians (36%) were more likely to worry about making errors during an in-hospital cardiac arrest event than nurses (18%; p < 0.001). Only 15% of residents and 50% of respondents overall reported they were both confident participating in in-hospital cardiac arrest resuscitation and did not worry about making errors. In-hospital cardiac arrest participation frequency was the dominant predictor of respondents' confidence leading or participating in an in-hospital cardiac arrest resuscitation.

CONCLUSIONS

Many clinicians, especially residents, who participate in or lead in-hospital cardiac arrest resuscitation events lack confidence or worry about management errors. Hospitals-particularly smaller hospitals-should consider methods to provide in-hospital cardiac arrest teams additional "effective experience," potentially using simulation or telemedicine consultation.