Deliberate practice and acquisition of expert performance: a general overview

Simulation and Modeling Applications in Global Health Security

Global health security (GHS) is dependent upon having an adequate and prepared health security workforce. There are currently numerous challenges in establishing and maintaining a health security workforce. The frequency and magnitude of disasters have increased significantly over the past 30 years. Current and future GHS threats, both manmade and natural, require a prepared and flexible healthcare provider workforce ready to respond to current or emerging GHS threats. Developing and maintaining GHS -specific skills in the healthcare workforce is a tremendous logistical challenge. Innovative education technologies, including simulation and digital learning, can be leveraged to achieve preparedness for GHS threats.

This chapter focuses on the application of modeling and simulation to support Global Health Security planning, preparedness and operations.

"A Taste of Real Medicine": Third Year Medical Students' Report Experiences of Early Workplace Encounters

INTRODUCTION

Medical students extend their preparatory learning on entering the clinical work environment, by joining their clinical team as peripheral participants and start to care for "real" patients. This learning is situated, experiential, varied, mainly unstructured, highly dependent on clinical opportunities (affordances), and students' motivation to learn (learner agency). Students ideally contribute to workplace activities, which allow their practical skills, confidence and professional identity to evolve. This study sought to investigate senior students' perspectives in their early stages of workplace learning, by using social learning theory as a framework. The focus is on team integration, practical skills performance, professional development and their evolving professional identity.

METHODS

Between 2015 and 2018, we conducted five focus groups, with a total of 36 volunteers, out of a possible 200 (18% Stage 3 (Year 3)) medical students. Each focus group session was audio recorded and transcribed verbatim. Participants were de-identified, and framework analysis used the theoretical frameworks of communities of practice, and workplace affordances to gain insight into their work-place learning experience during the first two months of their clinical rotation.

RESULTS

Thirty-six students out of 200 (18%) attended focus groups over a four-year period. The results are presented using the theoretical frameworks of community of practice and workplace affordances and presented as themes of: meaning, "learning as experience", practice, "learning as doing" community, "learning as belonging", and identity, "learning as becoming".

DISCUSSION

Participants reported many positive examples of workplace learning while dealing directly with patients. Students were also exposed to ethical dilemmas and unexpected risks in the workplace. These included lack of site orientation, unsupportive teams, lack of supervision, and students' inability to initiate agency, all of which contributed to their workplace uncertainty. Performing manageable tasks for their team provided a role in their community of practice, strengthening their identity as evolving doctors. Exposure to both positive and negative role models allowed students to reflect on ethical issues, further extending their own professional identities.

SUMMARY

Participants were quick to observe and report workplace dynamics as they were exposed to the positive and negative aspects of the hidden curriculum. This allowed them to reflect on patient safety, and ethical concerns promoting the development of their professional identity.

Analysis of Surgical Resident Operative Volumes on China's Resident Training

Doctors entering surgical residency with different educational degrees and from different specialties is a unique feature of the Chinese medical system. The effect of this on the experience of surgical residents is not known. We retrospectively investigated whether residents' operative volumes were based on highest educational degree or postgraduate specialty. Using our operating data management system, a retrospective analysis of surgical resident operative experience at Shanghai General Hospital from 2012 to 2017 was conducted. The overall monthly average operative volume for surgical residents was 17.7 (12.6-26.5), but this decreased with each advanced degree of education from 26.0 (19.2-34.5) for those with a bachelor's degree only, to 19.5 (16.0-28.1) for a master's degree, to 15.9 (12.2-22.9) for those with a doctorate. Regarding specialty, residents in plastic surgery had the highest operative volume, and those in cardiothoracic surgery and neurosurgery had the lowest. At Shanghai General Hospital, the operative volumes of surgical residents differed according to their highest educational degree and postgraduate specialty. This analysis should be useful for the future planning of surgical residency programs in China.

Development and validation of a procedure-specific assessment tool for hands-on surgical training in congenital heart surgery

BACKGROUND

Hands-on surgical simulation has been sought to address training limitations within congenital heart surgery (CHS). However, there is a need for objective assessment methods to measure surgeons' performance to justify its global adoption. This study aimed to validate a procedure-specific assessment tool for the simulation of the arterial switch operation on 3D-printed models and to evaluate the consistency of scoring among evaluators with different levels of experience in CHS.

METHODS

Five "expert" and 5 "junior" surgeons performed the arterial switch procedure on 3D-printed models with transposition of the great arteries during 2 hands-on surgical training courses. Their performance was retrospectively assessed by 9 evaluators with varying experience in CHS (staff surgeons, resident surgeons, and non-MD raters). Assessments were done using 2 assessment tools: the Hands-On Surgical Training-Congenital Heart Surgery (HOST-CHS) assessment tool and the global rating scale (GRS).

RESULTS

The HOST-CHS tool showed a higher interrater and intrarater reliability compared with the GRS. Total scores for expert surgeons were highly consistent across all evaluators. Non-MD raters' total scores for junior surgeons were slightly higher than those of residents and staff evaluators. All grades of evaluator were able to discriminate between junior and expert surgeons.

CONCLUSIONS

This study demonstrates the development and validation of an objective, procedure-specific assessment tool for the arterial switch operation with consistency among evaluators with different experience. There is now a platform for quantifying and accurately evaluating performance, which will be highly beneficial in training and developing the next generation of congenital heart surgeons.

Feedback based simulator training reduces superfluous forces exerted by novice residents practicing knot tying for vessel ligation

BACKGROUND

Technological advances have led to the development of state-of-the-art simulators for training surgeons; few train basic surgical skills, such as vessel ligation.

METHODS

A novel low-cost bench-top simulator with auditory and visual feedback that measures forces exerted during knot tying was tested on 14 surgical residents. Pre- and post-training values for total force exerted during knot tying, maximum pulling and pushing forces and completion time were compared.

RESULTS

Mean time to reach proficiency during training was 11:26 min, with a mean of 15 consecutive knots. Mean total applied force for each knot were 35% lower post-training than pre-training (7.5 vs. 11.54 N (N), respectively, p = 0.039). Mean upward peak force was significantly lower after, compared to before, training (1.29 vs. 2.12 N, respectively, p = 0.004).

CONCLUSIONS

Simulator training with visual and auditory force feedback improves knot-tying skills of novice surgeons.

A Developmental Approach to Internal Medicine Residency Education: Lessons Learned from the Design and Implementation of a Novel Longitudinal Coaching Program

BACKGROUND

Resident physicians' achievement of professional competencies requires reflective practice skills and faculty coaching. Graduate medical education programs, however, struggle to operationalize these activities.

OBJECTIVE

To (1) describe the process and strategies for implementing an Internal Medicine (IM) resident coaching program that evolved in response to challenges, (2) characterize residents' professional learning plans (PLPs) and their alignment with EPAs, and, (3) examine key lessons learned.

DESIGN

The program began in 2013 and involved all postgraduate years (PGY) residents (n = 60, 100%), and 20 faculty coaches who were all IM trained and practicing in an IM-related specialty. One coach was linked with 3-4 residents for three years. Through 1:1 meetings, resident-coach pairs identified professional challenges ('disorienting dilemmas' or 'worst days'), reviewed successes ('best days'), and co-created professional learning plans. Typed summaries were requested following meetings. Coaches met monthly for professional development and to discuss program challenges/successes, which informed programmatic improvements; additionally, a survey was distributed after three program years. Data were analyzed using quantitative and qualitative methodologies.

RESULTS

Disorienting dilemmas and professional learning plans mapped to all 16 EPAs and four additional themes: work-life balance, career planning, teaching skills, and research/scholarship. The most-frequently mapped topics included: PGY1 - leading and working within interprofessional care teams (EPA 10), research and scholarship, and work-life balance; PGY2 - improving quality of care (EPA 13), demonstrating personal habits of lifelong learning (EPA15), and research and scholarship; PGY3 - lifelong learning (EPA15); career planning was common across all years.

CONCLUSIONS

Lessons learned included challenges in coordination of observations, identifying disorienting dilemmas, and creating a shared mental model between residents, faculty, and program leadership. The coaching program resulted in professional learning plans aligned with IM EPAs, in addition to other professional development topics. Operationalization of aspects of these results can inform the development of similar programs in residency education.

Implementation and feasibility considerations of an avatar-based intervention for military family caregivers

OBJECTIVE

Military family caregivers (MFCGs) are a growing population with well-being and quality of life (QOL) challenges. New technologies can help meet their needs while minimizing disruption to caregiving responsibilities. Preliminary research needs to address intervention implementation challenges before larger-scale efficacy studies are conducted. This study aimed to evaluate the feasibility of implementing an avatar-based intervention and preliminarily investigate outcomes.

METHODS

One-hundred twenty-four MFCGs were recruited to participate in this feasibility study. Sixty-four MFCGs completed the intervention. Data were analyzed using repeated-measures analysis of variance to assess 3- and 6-month differences.

RESULTS

Meeting the a priori goal of 50 MFCGs completing the program supported feasibility. Preliminary results indicated significant reductions in depression, anxiety, and somatic symptoms, and significant improvements in physical health and overall QOL.

CONCLUSIONS

Findings support for the feasibility of implementing an avatar-based intervention for MFCGs and present promising findings related to improving caregiver well-being and overall QOL.

Competency-based medical education in ophthalmology residency training: a review

Competency-based medical education (CBME) is an outcomes-based training model that has become the new standard of medical education internationally. Regulatory and accrediting bodies have responded by establishing key competencies that residency programs may use to reshape their curricula. Available literature on the implementation of CBME in ophthalmology residency training programs across North America was examined. Ophthalmology-specific residency training objectives and milestones have been proposed within North America in the last 4 years. Curriculum guidelines and implementation blueprints and principles have also been proffered from various sources internationally but have met with some barriers. Assessment tools within ophthalmology have seen the most innovative development within the domain of surgical skills objectives. Competencies outside of the medical expert and patient care roles have proven more challenging to teach and assess. One ophthalmology program in Canada has undergone early implementation of a novel CBME curriculum. There is still considerable work to be done to successfully implement CBME curricula within ophthalmology residency programs in North America. Collaborative efforts to develop customizable curricula, tackle implementation barriers, and create specific assessment modalities will assist programs in meeting the competency mandates of CBME.

Learning curve for endoscopic evaluation of vocal folds lesions with narrow band imaging

Introduction

The endoscopic methods are progressing and becoming more common in routine clinical diagnosis in the field of otorhinolaryngology. Relatively large amount of researches have proved high accuracy of narrow band imaging endoscopy in differentiating benign and malignant lesions within vocal folds. However, little is known about learning curve in narrow band imaging evaluation of laryngeal lesions.

Objective

The aim of this study was to determine the learning curve for the narrow band imaging evaluation of vocal folds pathologies depending on the duration of the procedure.

Methods

Records of 134 narrow band imaging that were analyzed in terms of the duration of the procedure and the accuracy of diagnosis confirmed by histopathological diagnosis were enrolled in the study. The narrow band imaging examinations were performed sequentially by one investigator over a period of 18 months.

Results

The average duration of narrow band imaging recordings was 127.82 s. All 134 studies were divided into subsequent series of several elements. An evident decrease in time of investigation was noticed between 13th and 14th series, when the examinations were divided into 5 elements series, which corresponds to the difference between 65th and 70th subsequent narrow band imaging examination. Parallel groups of 67 examinations were created. Group 1 included 1st to 67th subsequent narrow band imaging examination; Group 2 – 68th to 134th narrow band imaging examinations. The non-parametric U Mann–Whitney test confirmed statistically significant difference between the mean duration of narrow band imaging examination in both groups 160.5 s and 95.1 s, respectively (p < 10⁻⁷). Sensitivity and specificity of narrow band imaging examination in the first group were respectively: 83.7% and 76.7%. In the second group, these indicators amounted 98.1% and 80% respectively.

Conclusions

A minimum of 65th–70th narrow band imaging examinations are required to reach a plateau phase of the learning process in assessment of glottis lesions. Analysis of learning curves is useful for the development of training programs and determination of a mastery level.

Training in Bariatric Surgery: a National Survey of German Bariatric Surgeons

INTRODUCTION

Skill in bariatric surgery has been associated with postoperative outcome. Appropriate surgical training is of paramount importance. In order to continuously improve training strategies, it is necessary to assess current practices.

AIM

To determine how German bariatric surgeons have been trained and to assess current training strategies.

METHODS

Between February 2017 and March 2017, an online census of surgeons registered as members of the German Society for Bariatric and Metabolic Surgery was conducted. A total of three reminders were sent out. Data were analyzed using descriptive statistics. Data was reported as median (interquartile range); percentages were adjusted for completed answers only.

RESULTS

A response rate of 51% (n = 214) was achieved. Surgeons reported a median of 14.5 (8-20) years of surgical experience after initial training, with a specific bariatric experience of 7 (4-13) years. The total cumulative bariatric case volume was 240 (80-500) cases, with an annual case volume of 50 (25-80). The most commonly applied approaches to bariatric skills acquisition were "learning by doing" (71%), "course participation" (70%) and "observerships" (70%). Fellowships and the use of operating videos were less frequently applied strategies (19%/ 47%). Interestingly, observerships (94%) and course participation (89%) were rated as very important/important, whereas "learning by doing" (62%), watching operation videos (59%), and fellowships (48%) were less frequently perceived as important/very important training strategies.

CONCLUSIONS

The majority of surgeons performing bariatric cases were senior surgeons with more than 10 years of post-training experience; nevertheless, the survey revealed a lack of structured approaches to bariatric specialization training.

Self-Controlled Practice to Achieve Neuro-Cognitive Engagement: Underlying Brain Processes to Enhance Cognitive-Motor Learning and Performance

While self-controlled practice has been shown to be an effective practice methodology, the neuro-cognitive correlates of its effectiveness are unclear. We investigated whether learners participating in self-controlled practice exhibit increased neuro-cognitive engagement compared to externally controlled practice. Two groups (self-controlled and yoked) of 16 participants practiced and performed a golf putting task over 3 days. Working memory engagement, central executive activity, and cortical activation were assessed via electroencephalography as indicators of neuro-cognitive engagement. The self-controlled group exhibited more consistent working memory engagement, and greater central executive activity, compared to the yoked group during practice. Relationships were also observed between neuro-cognitive engagement during self-controlled practice and performance improvement, indicating that self-controlled practice uniquely benefitted from increased neuro-cognitive engagement.

A Cognitive Load Theory Simulation Design to Assess and Manage Deteriorating Patients

Background

Cognitive load theory (CLT) uses an understanding of brain architecture for educational design, with implications for simulation. Since working memory is limited, minimising extraneous cognitive load improves learning of new tasks (intrinsic load) and use of existing knowledge (germane load). This study evaluates the effectiveness of low-fidelity simulation (LFS) utilising CLT principles in the assessment and management of the deteriorating patient (AMDP).

Method

CLT design principles informed the choice of LFS and simulation design. The self-rated ability of 13 undergraduate nurses across seven aspects of AMDP was measured in a pre-post design.

Results

Self-rated ability increased from 2.98 (SD = 0.19) to 4.47 (SD = 0.12) (p < 0.001), with improvements across all AMDP aspects.

Conclusion

This study indicates that CLT informed design has benefits for simulation. LFS may be preferred to high fidelity simulation for AMDP teaching and medical simulation for novice learners.

Acquiring and Maintaining Technical Skills Using Simulation: Initial, Maintenance, Booster, and Refresher Training

Simulation-based education has been shown to be an effective tool to mitigate skill decay. However, many of the strategies reported in the literature have overlapping terminology with little consensus on the timing of the strategy to prevent skill decay. In this review, we propose and provide a standardized nomenclature and framework for simulation strategies used to obtain, maintain, or regain skills that are decaying. This framework delineates four types of training: initial, maintenance, booster, and refresher. The framework differentiates these training types based on the learner competency at the time of the training, as well as the frequency and intensity of the training. Initial training is aimed at “novice” learners with the goal to achieve competency. Once competency is achieved, maintenance training prevents skill deterioration through low-dose high-frequency (LDHF) training. Booster training is used when the learner is still proficient, but competency begins to wane. Booster training occurs less frequently than maintenance training but with greater intensity to overcome the skill decay that occurs over time. Refresher training is aimed at re-establishing skill levels after competency has reached unsatisfactory levels. Refresher training is higher intensity than booster and maintenance training. We describe simulation-based strategies reported in the literature that can be used for each type of training. We conclude that there should be an increased emphasis in medical education towards maintenance and booster training in order to preserve skills before competency is lost. 

An observational study using eye tracking to assess resident and senior anesthetists' situation awareness and visual perception in postpartum hemorrhage high fidelity simulation

Background

The postpartum hemorrhage (PPH) is the leading cause of maternal mortality in the world. Human factors and especially situation awareness has primarily responsibility to explain suboptimal cares. Based on eye tracking and behavior analysis in high fidelity simulation of PPH management, the goal of this study is to identify perceptual and cognitive key parameters of the expertise.

Methods

Two groups of fifteen anesthetists (residents and experienced anesthetists) watched the beginning of a severe simulated PPH management. During this first experimental phase, situation awareness was assessed using SAGAT (Situation Awareness Global Assessment Technique) questionnaire and visual behavior was analyzed with eye tracking. In the continuity of the video sequence, they have to step in the PPH situation and to provide care to the simulated patient. Performance of cares was evaluated and self-assessed as well as cognitive load.

Results

No statistical difference between the residents and experienced anesthetists was observed on performance of simulated PPH management. The mean expected practice score was 76.9 ± 13.9%). Assessment of situation awareness (65 ± 7%), cognitive load (74.4 ± 11.3%) and theoretical knowledge of PPH (52.4 ± 3.5%) were also not statistically different between the two groups. Only results of self-assessed performance (respectively 66.1 ± 16.6 and 47.0 ± 20.8 for experts and residents) and eye-tracking data revealed that experts tended to get accurate evaluation of their performance and to monitor more the blood loss of the patient. Experts have in average 8.28% more fixating points than Novices and gazed the blood loss region longer (865 ms ± 439 vs. 717 ms ± 362).

Conclusions

This study pointed out the limits of classical assessment of performance, and human factors based on questionnaires to identify expertise in simulated PPH care. A neuroscientific approach with new technology like eye tracking could provide new objective and more sensitive insights on human factors in simulated medical emergency situations.

Evaluation of a Mobile Telesimulation Unit to Train Rural and Remote Practitioners on High-Acuity Low-Occurrence Procedures: Pilot Randomized Controlled Trial

Background

The provision of acute medical care in rural and remote areas presents unique challenges for practitioners. Therefore, a tailored approach to training providers would prove beneficial. Although simulation-based medical education (SBME) has been shown to be effective, access to such training can be difficult and costly in rural and remote areas.

Objective

The aim of this study was to evaluate the educational efficacy of simulation-based training of an acute care procedure delivered remotely, using a portable, self-contained unit outfitted with off-the-shelf and low-cost telecommunications equipment (mobile telesimulation unit, MTU), versus the traditional face-to-face approach. A conceptual framework based on a combination of Kirkpatrick’s Learning Evaluation Model and Miller’s Clinical Assessment Framework was used.

Methods

A written procedural skills test was used to assess Miller’s learning level— knows —at 3 points in time: preinstruction, immediately postinstruction, and 1 week later. To assess procedural performance (shows how), participants were video recorded performing chest tube insertion before and after hands-on supervised training. A modified Objective Structured Assessment of Technical Skills (OSATS) checklist and a Global Rating Scale (GRS) of operative performance were used by a blinded rater to assess participants’ performance. Kirkpatrick’s reaction was measured through subject completion of a survey on satisfaction with the learning experiences and an evaluation of training.

Results

A total of 69 medical students participated in the study. Students were randomly assigned to 1 of the following 3 groups: comparison (25/69, 36%), intervention (23/69, 33%), or control (21/69, 31%). For knows, as expected, no significant differences were found between the groups on written knowledge (posttest, P=.13). For shows how, no significant differences were found between the comparison and intervention groups on the procedural skills learning outcomes immediately after the training (OSATS checklist and GRS, P=1.00). However, significant differences were found for the control versus comparison groups (OSATS checklist, P<.001; GRS, P=.02) and the control versus intervention groups (OSATS checklist, P<.001; GRS, P=.01) on the pre- and postprocedural performance. For reaction, there were no statistically significant differences between the intervention and comparison groups on the satisfaction with learning items (P=.65 and P=.79) or the evaluation of the training (P=.79, P=.45, and P=.31).

Conclusions

Our results demonstrate that simulation-based training delivered remotely, applying our MTU concept, can be an effective way to teach procedural skills. Participants trained remotely in the MTU had comparable learning outcomes (shows how) to those trained face-to-face. Both groups received statistically significant higher procedural performance scores than those in the control group. Participants in both instruction groups were equally satisfied with their learning and training (reaction). We believe that mobile telesimulation could be an effective way of providing expert mentorship and overcoming a number of barriers to delivering SBME in rural and remote locations.

Workplace-Based Assessments Using Pediatric Critical Care Entrustable Professional Activities

BACKGROUND

Workplace-based assessment (WBA) is critical to graduating competent physicians. Developing assessment tools that combine the needs of faculty, trainees, and governing bodies is challenging but imperative. Entrustable professional activities (EPAs) are emerging as a clinically oriented framework for trainee assessment.

OBJECTIVE

We sought to develop an EPA-based WBA tool for pediatric critical care medicine (PCCM) fellows. The goals of the tool were to promote learning through benchmarking and tracking entrustment.

METHODS

A single PCCM EPA was iteratively subdivided into observable practice activities (OPAs) based on national and local data. Using a mixed-methods approach following van der Vleuten's conceptual model for assessment tool utility and Messick's unified validity framework, we sought validity evidence for acceptability, content, internal structure, relation to other variables, response process, and consequences.

RESULTS

Evidence was gathered after 1 year of use. Items for assessment were based on correlation between the number of times each item was assessed and the frequency professional activity occurred. Phi-coefficient reliability was 0.65. Narrative comments demonstrated all factors influencing trust, identified by current literature, were cited when determining level of entrustment granted. Mean entrustment levels increased significantly between fellow training years (P = .001). Compliance for once- and twice-weekly tool completion was 50% and 100%, respectively. Average time spent completing the assessment was less than 5 minutes.

CONCLUSIONS

Using an EPA-OPA framework, we demonstrated utility and validity evidence supporting the tool's outcomes. In addition, narrative comments about entrustment decisions provide important insights for the training program to improve individual fellow advancement toward autonomy.

A global perspective on implant education: Cluster analysis of the "first dental implant experience" of dentists from 84 nationalities

OBJECTIVES

The aim of this cross-sectional study was to explore the demographic and educational patterns related to the dentists' first implant dental experience.

MATERIAL AND METHODS

Participants of a Massive Open Online Course in implant dentistry who have placed and restored implants completed a 25-item online questionnaire investigating their pathway of education and assessing their experience with the "first implant placement." Exploratory analysis included hierarchical clustering using 9 demographic categorical factors.

RESULTS

A total of 1015 respondents from 84 countries formed 5 distinct clusters. Age and work experience were dominant clustering traits, decreasing from Cluster 1 to Cluster 5. Clusters 1 and 3 represented "senior" and "younger" general dental practitioners, respectively, whilst Clusters 2 and 4 represented post-graduate educated clinicians. Cluster 5 represented recent graduates. Asia, South America and Africa were over-represented in "younger" clusters. Time in practice was a significant determinant of attitudes, followed by completion of post-graduate education. There were significant differences in reported patterns of challenges and complications depending on dentists' time in practice, age and post-graduate education. Challenge in implant positioning was more frequently identified by "young post-graduate" educated dentists. Recent graduates reported having the fewest complications of all clusters. Obtaining implant education in University settings was most frequently recommended by clusters of dentists with post-graduate education.

CONCLUSIONS

Time in practice is a parameter to be considered when designing implant education. The absence of structured education and mentorship might lead to inability to properly assess treatment outcomes and identify complications. Quality-assured and practice-directed education is needed at a global level, to support in particular, recent graduates who now seem to engage with implant dentistry early in their career.

Toward effective feedback: From concept to practice

Feedback is the building block of assessment and an essential component of effective teaching. In this article, we will provide a comprehensive definition of feedback and a relevant conceptual framework for learning to explain how feedback can be used to improve performance. We will discuss the process of providing feedback, and the role teacher and learner can play to make it more effective. We will also examine the misunderstandings and pitfalls around feedback, as well as generational differences that may influence its impact.

Does practice quality mediate the relationship between practice time and outcome in mindfulness-based stress reduction?

Interventions based on mindfulness meditation are increasingly common and evidence exists supporting their use. However, questions remain regarding treatment mechanisms accounting for beneficial effects. The current study examined 1 candidate mechanism-mindfulness practice quality-as a mediator of the link between practice time and outcome within mindfulness-based stress reduction (MBSR). Participants (n = 96) completed measures of mindfulness and psychological symptoms at baseline and posttreatment. A weekly questionnaire assessed practice time and quality over the 8 weeks of MBSR. Multilevel models accounted for nesting within participants, MBSR groups, and instructors. Results generally supported the reliability and validity of a weekly single-item practice quality measure. Greater practice time was associated with improved practice quality (r = .48). Increases in practice quality predicted improvements in self-report mindfulness and psychological symptoms (βs = .35, .30, and -.19, ps < .05), but not behavioral mindfulness (β = -.02, p = .879). In multilevel mediation models, improved practice quality mediated the link between practice time and changes in self-report mindfulness, suggesting improved practice quality functions as a mechanism linking practice time and outcome in MBSR. Future research evaluating practice quality in clinical samples, in tandem with intensive sampling paradigms (e.g., experience sampling) and objective (behavioral, physiological) outcomes may be warranted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Optimizing Performative Skills in Social Interaction: Insights From Embodied Cognition, Music Education, and Sport Psychology

Embodied approaches to cognition conceive of mental life as emerging from the ongoing relationship between neural and extra-neural resources. The latter include, first and foremost, our entire body, but also the activity patterns enacted within a contingent milieu, cultural norms, social factors, and the features of the environment that can be used to enhance our cognitive capacities (e.g., tools, devices, etc.). Recent work in music education and sport psychology has applied general principles of embodiment to a number of social contexts relevant to their respective fields. In particular, both disciplines have contributed fascinating perspectives to our understanding of how skills are acquired and developed in groups; how musicians, athletes, teachers, and coaches experience their interactions; and how empathy and social action participate in shaping effective performance. In this paper, we aim to provide additional grounding for this research by comparing and further developing original themes emerging from this cross-disciplinary literature and empirical works on how performative skills are acquired and optimized. In doing so, our discussion will focus on: (1) the feeling of being together, as meaningfully enacted in collective musical and sport events; (2) the capacity to skillfully adapt to the contextual demands arising from the social environment; and (3) the development of distributed forms of bodily memory. These categories will be discussed from the perspective of embodied cognitive science and with regard to their relevance for music education and sport psychology. It is argued that because they play a key role in the acquisition and development of relevant skills, they can offer important tools to help teachers and coaches develop novel strategies to enhance learning and foster new conceptual and practical research in the domains of music and sport.

Developmental modulation and predictability of age-dependent vocal plasticity in adult zebra finches

Predicting the nature of behavioral plasticity can provide insight into mechanisms of behavioral expression and control. Songbirds like the zebra finch rely on vocal signals for communication, and the performance of these signals demonstrate considerable plasticity over development. Traditionally, these signals were thought to be fixed in adulthood, but recent studies have revealed significant age-dependent changes to spectral and temporal features of song in adult songbirds. A number of age-dependent changes to song resemble acute changes to adult song performance across social contexts (e.g., when an adult male sings to a female relative to when he sings in isolation). The ability of variation in social context-dependent changes to predict variation in age-dependent plasticity would suggest shared mechanisms, but little is known about this predictability. In addition, although developmental experiences can shape adult plasticity, little is known about the extent to which social interactions during development affect age-dependent change to adult song. To this end, we systematically analyzed age- and context-dependent changes to adult zebra finch song, and then examined the degree to which age-dependent changes varied across birds that were social or non-socially tutored birds and to which social context-dependent changes predicted age-dependent changes. Non-socially tutored birds showed more dramatic changes to the broad structure of their motif over time than socially tutored birds, but non-socially and socially tutored birds did not differ in the extent of changes to various spectral and temporal features of song. Overall, we found that adult zebra finches produced longer and more spectrally stereotyped songs when they were older than when they were younger. Moreover, regardless of developmental tutoring, individual variation in age-dependent changes to song bout duration and syllable repetition were predicted by variation in social context-dependent changes to these features. These data indicate that social experiences during development can shape some aspects of adult plasticity and that acute context-dependent and long-term age-dependent changes to some song features could be mediated by modifications within similar neural substrates.

Assessment of an e-training tool for college students to improve accuracy and reduce effort associated with reading nutrition labels

Objective: Nutrition labels are often underutilized due to the time and effort required to read them. We investigated the impact of label-reading training on effort, as well as accuracy and motivation. Participants: Eighty college students (21 men and 59 women). Methods: The training consisted of a background tutorial on nutrition followed by three blocks of practice reading labels to decide which of two foods was the relatively better choice. Label-reading effort was assessed using an eye tracker and motivation was assessed using a 6-item scale of healthy food-choice empowerment. Results: Students showed increases in label-reading accuracy, decreases in label-reading effort, and increases in empowerment. Conclusions: The nutrition label e-training tool presented here, whether used alone or as part of other wellness and health programs, may be an effective way to boost students' label-reading skills and healthy food choices, before they settle into grocery shopping habits.

Suprapatellar tibial nailing: a learning curve analysis

PURPOSE

The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure.

METHODS

Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the United Kingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning.

RESULTS

Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period.

CONCLUSIONS

Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.

Procedural Experience With Intubation: Results From a National Emergency Medicine Group

STUDY OBJECTIVE

Although intubation is a commonly discussed procedure in emergency medicine, the number of opportunities for emergency physicians to perform it is unknown. We determine the frequency of intubation performed by emergency physicians in a national emergency medicine group.

METHODS

Using data from a national emergency medicine group (135 emergency departments [EDs] in 19 states, 2010 to 2016), we determined intubation incidence per physician, including intubations per year, intubations per 100 clinical hours, and intubations per 1,000 ED patient visits. We report medians and interquartile ranges (IQRs) for estimated intubation rates among emergency physicians working in general EDs (those treating mixed adult and pediatric populations).

RESULTS

We analyzed 53,904 intubations performed by 2,108 emergency physicians in general EDs (53,265 intubations) and pediatric EDs (639 intubations). Intubation incidence varied among general ED emergency physicians (median 10 intubations per year; IQR 5 to 17; minimum 0, maximum 109). Approximately 5% of emergency physicians did not perform any intubations in a given year. During the study, 24.1% of general ED emergency physicians performed fewer than 5 intubations per year (range 21.2% in 2010 to 25.7% in 2016). Emergency physicians working in general EDs performed a median of 0.7 intubations per 100 clinical hours (IQR 0.3 to 1.1) and 2.7 intubations per 1,000 ED patient visits (IQR 1.2 to 4.6).

CONCLUSION

These findings provide insights into the frequency with which emergency physicians perform intubations.

Factors influencing patients' hypertension self-management and sustainable self-care practices: a qualitative study

OBJECTIVE

The objective of this study was to explore factors influencing patients with hypertension to participating in a hypertension self-management education (HSME) programme and challenges of sustaining the learnt self-care practices.

STUDY DESIGN

This was a qualitative study with focus group discussions.

METHODS

Focus group discussions using a semistructured moderator guide were conducted among participants who had attended the HSME programme. Data were audio recorded, transcribed verbatim and analysed using a thematic analysis approach.

RESULTS

Three focus groups involving 19 participants were conducted. Four major themes emerged from the data collected. Most participants enjoyed the group-based HSME sessions because sharing experiences with those having similar health problems can reduce their sense of isolation. However, the participants highlighted the difficulty in sustaining self-care practices in the presence of friends and family influences.

CONCLUSION

A number of patient-, family- and community-level motivators and barriers to patients' hypertension self-management have been identified. Efforts to tailor behavioural interventions to sustain daily self-care activities during social and cultural events are imperative.

Gaining or Losing Team Ball Possession: The Dynamics of Momentum Perception and Strategic Choice in Football Coaches

Grounded in the dynamical systems approach, the present research examined the influence of team ball possession (TBP) in soccer on coaches’ perceived psychological momentum (PM) and strategic choice (i.e., game-based “stick” vs. “switch” choices) during a simulated match. Experienced soccer coaches imagined being the coach of the team involved in a highly important match that was displayed on a wall in a lecture hall. The match scenario was manipulated so that the coach was exposed to either a positive momentum sequence (i.e., ascending scenario of TBP) or a negative momentum sequence (i.e., descending scenario of TBP). Results revealed that positive (or negative) momentum sequence increased (or decreased) perceived PM and increased stick (or switch) choices. Perceived PM globally evolved linearly, while strategic choice displayed a dynamical pattern of “critical boundary” (thus showing a nonlinear change). Nonetheless, both variables displayed asymmetrical effects, in the sense that: (1) the strength of positive PM appeared to be easier to decrease than to increase; and (2) the greater the positive PM (or the negative PM), the lesser (or the greater) the coaches’ tendency to make a change in the organization of their teams. This investigation evidences that TBP can powerfully influence coaches’ perceptions and strategic decisions, and that coaches are more likely to be sensitive to negative events than to equivalent positive events.

A helmetless-tackling intervention in American football for decreasing head impact exposure: A randomized controlled trial

OBJECTIVES

To evaluate a behavioral intervention to reduce head impact exposure in youth playing American football.

DESIGN

Nested randomized controlled trial.

METHODS

Participants, ages 14-17 years, wore head impact sensors (SIM-G™) during two seasons of play. Those randomized to the intervention group underwent weekly tackling/blocking drills performed without helmets (WoH) and shoulder pads while the control group trained as normal, matching frequency and duration. Research personnel provided daily oversight to maintain fidelity. Head impact frequency (≥10g) per athlete exposure (ImpAE) was analyzed over time (two 11-week seasons) using mixed effect models or ANCOVA. Secondary outcomes included exposure-type (training, game) and participation level (entry-level versus upper-level secondary education).

RESULTS

One-hundred fifteen participants (59 WoH, 56 control) met compliance criteria, contributing 47,382 head impacts and 10,751 athlete exposures for analysis. WoH had fewer ImpAE during games compared to control participants at weeks 4 (p=0.0001 season 1, p=0.0005 season 2) and 7 (p=0.0001 both seasons). Upper-level WoH participants had less ImpAE during games than their matched controls at weeks 4 (p=0.017 and p=0.026) and 7 (p=0.037 and p=0.014) in both seasons, respectively. Upper-level WoH also had fewer ImpAE during training at week 7 (p=0.015) in season one.

CONCLUSIONS

Tackling and blocking drills performed without a helmet during training reduced the frequency of head impacts during play, especially during games. However, these differences disappeared by the end of the season. Future research should explore the frequency of behavioral intervention and a dose-response relationship considering years of player experience.

TRIAL REGISTRATION

ClinicalTrials.gov # NCT02519478.

Comparison of Personal Video Technology for Teaching and Assessment of Surgical Skills

BACKGROUND

Improvements in personal technology have made video recording for teaching and assessment of surgical skills possible.

OBJECTIVE

This study compared 5 personal video-recording devices based on their utility (image quality, hardware, mounting options, and accessibility) in recording open surgical procedures.

METHODS

Open procedures in a simulated setting were recorded using smartphones and tablets (MOB), laptops (LAP), sports cameras such as GoPro (SC), single-lens reflex cameras (DSLR), and spy camera glasses (SPY). Utility was rated by consensus between 2 investigators trained in observation of technology using a 5-point Likert scale (1, poor, to 5, excellent).

RESULTS

A total of 150 hours of muted video were reviewed with a minimum 1 hour for each device. Image quality was good (3.8) across all devices, although this was influenced by the device-mounting requirements (4.2) and its proximity to the area of interest. Device hardware (battery life and storage capacity) was problematic for long procedures (3.8). Availability of devices was high (4.2).

CONCLUSIONS

Personal video-recording technology can be used for assessment and teaching of open surgical skills. DSLR and SC provide the best images. DSLR provides the best zoom capability from an offset position, while SC can be placed closer to the operative field without impairing sterility. Laptops provide best overall utility for long procedures due to video file size. All devices require stable recording platforms (eg, bench space, dedicated mounting accessories). Head harnesses (SC, SPY) provide opportunities for "point-of-view" recordings. MOB and LAP can be used for multiple concurrent recordings.

LearnOvation: an intervention to foster exploration and exploitation behaviour in health care management in daily practice

Background

Innovation has been identified as an important engine for improving the quality, productivity and efficiency of health care. Little is known about how to stimulate innovation capacity in primary health care in general; even less is known about how specific interventions should be designed to support managements’ work with practice-based innovations. Research has shown that if managers and teams are excellent at handling the challenges of production (exploitation) and development (exploration), they are better at innovation. The aim of the study is to develop a dynamic management support programme to increase innovation leadership skills in daily practice.

Methods

The study has an interactive approach that allows the need for empirical and theoretical knowledge to emerge and merge, and a quasi-experimental cross-over design. Eight primary health care centres will participate in the study. In the first phase, the management teams at four health care centres will participate in the intervention, and the other four centres will serve as a control group. Thereafter, the units will switch places and the control group will experience the intervention. All staff at the 8 units will answer questionnaires at four points in time (before, during, after, 6 months later) to evaluate the effects of the intervention.

Discussion

The study will contribute to knowledge on how to organize processes of innovation and support exploitation and exploration behaviours by co-producing and testing a tailor-made management support programme for innovation work in primary health care. An expected long-term effect is that the support system will be disseminated to other centres both within and beyond the participating organizations.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4152-8) contains supplementary material, which is available to authorized users.

Using deliberate practice framework to assess the quality of feedback in undergraduate clinical skills training

BACKGROUND

In this research paper we report on the quality of feedback provided in the logbooks of pre-clinical undergraduate students based on a model of 'actionable feedback'. Feedback to clinical learners about their performance is crucial to their learning, which ultimately impacts on their development into competent clinicians. Due to students' concerns regarding the inconsistency and quality of feedback provided by clinicians, a structured feedback improvement strategy to move feedback forward was added to the clinical skills logbook. The instrument was also extended for peer assessment. This study aims to assess the quality of feedback using the deliberate practice framework.

METHODS

A feedback scoring system was used to retrospectively assess the quality of tutor and peer logbook feedback provided to second and third year medical students to identify deliberate practice components i.e. task, performance gap and action plan. The sample consisted of 425 second year and 600 third year feedback responses over a year.

RESULTS

All three deliberate practice components were observed in the majority of the written feedback for both classes. The frequency was higher in peer (83%, 89%) than tutor logbook assessments (51%, 67%) in both classes respectively. Average tutor and peer task, gap and action feedback scores ranged from 1.84-2.07 and 1.93-2.21 respectively. The overall quality of feedback provided by the tutor and peer was moderate and less specific (average score < or = 2). The absence of the three components was noted in only 1% of the feedback responses in both 2nd and 3rd year.

CONCLUSION

This study found that adding in a feed-forward strategy to the logbooks increased the overall quality of tutor and peer feedback as the task, gap and action plans were described. Deliberate practice framework provides an objective assessment of tutor and peer feedback quality and can be used for faculty development and training. The findings from our study suggest that the ratings from the tool can also be used as guidelines to provide feedback providers with feedback on the quality of feedback they provided. This includes specifically describing a task, performance gap and providing a learning plan as feed-forward to enhance feedback given.

Perfecting practice: a protocol for assessing simulation-based mastery learning and deliberate practice versus self-guided practice for bougie-assisted cricothyroidotomy performance

BACKGROUND

Simulation-based medical education (SBME) is a cornerstone for procedural skill training in residency education. Multiple studies have concluded that SBME is highly effective, superior to traditional clinical education, and translates to improved patient outcomes. Additionally it is widely accepted that mastery learning, which comprises deliberate practice, is essential for expert level performance for routine skills; however, given that highly structured practice is more time and resource-intensive, it is important to assess its value for the acquisition of rarely performed technical skills. The bougie-assisted cricothyroidotomy (BAC), a rarely performed, lifesaving procedure, is an ideal skill for evaluating the utility of highly structured practice as it is relevant across many acute care specialties and rare - making it unlikely for learners to have had significant previous training or clinical experience. The purpose of this study is to compare a modified mastery learning approach with deliberate practice versus self-guided practice on technical skill performance using a bougie-assisted cricothyroidotomy model.

METHODS

A multi-centre, randomized study will be conducted at four Canadian and one American residency programs with 160 residents assigned to either mastery learning and deliberate practice (ML + DP), or self-guided practice for BAC. Skill performance, using a global rating scale, will be assessed before, immediately after practice, and 6 months later. The two groups will be compared to assess whether the type of practice impacts performance and skill retention.

DISCUSSION

Mastery learning coupled with deliberate practice provides systematic and focused feedback during skill acquisition. However, it is resource-intensive and its efficacy is not fully defined. This multi-centre study will provide generalizable data about the utility of highly structured practice for technical skill acquisition of a rare, lifesaving procedure within postgraduate medical education. Study findings will guide educators in the selection of an optimal training strategy, addressing both short and long term performance.

Deliberate Practice as an Effective Remediation Strategy for Underperforming Medical Students Focused on Clinical Skills: a Prospective Longitudinal Study

BACKGROUND

It is critical to develop remedial education for underperforming medical students, but little is known about how to create an effective remediation program. Deliberate practice (DP) is a structured and reflective activity that is designed to optimize performance. Here we applied the concept of DP to create remedial education to improve the clinical practices of medical students. We also analyzed the effectiveness of the remediation program.

METHODS

Based on the expert performance approach of DP, we designed a 4-week remedial program for clinical performance that included feedback and reflection. There were 74 student participants in this program from 2014 to 2017. Their clinical performance was re-evaluated after completion, and changes in their clinical performance scores were analyzed.

RESULTS

Students who completed the remediation program showed significant improvements in clinical performance scores (P < 0.001). Most students found the program to be instructive and helpful for improving their clinical performance. They reported that role play with peers was the most helpful for improving their skills.

CONCLUSION

The DP-based remediation program improved the clinical performance of failing medical students. This remediation program should continue to be offered to underperforming students to ensure that medical school graduates are competent.

Exploring the challenges of task-centred training in obstetric anaesthesia in the operating theatre environment

BACKGROUND

Task-centred learning forms the basis of procedural training in obstetric anaesthesia. We observed that our residents were not building their competence from experiential practice in the operating theatre. We used a broad-based framework to explore the challenges encountered by the residents and clinical supervisors in the learning and teaching of obstetric anaesthesia.

METHODS

The study was conducted at the KK Women's and Children's Hospital, Singapore, from 1 December 2016 to 30 June 2017. A semi-structured interview format was used in the focus group and individual interviews. Information collection continued until data saturation was reached. The interviews were analysed and the challenges were identified. Fourteen residents and five clinical supervisors participated in the focus group and individual interviews respectively.

FINDINGS

The operating theatre constituted a stressful learning and teaching environment for the participants. Five categories of challenges were identified: (1) clinical conditions, (2) concerns about maternal risk and outcomes, (3) reluctance of the residents to vocalise their learning needs, (4) poor feedback, and (5) lack of opportunities for inter-professional practice. These collective challenges reduced the quality of task-centred learning and the effectiveness of supervisor teaching. We described some strategies to overcome these challenges (dedicated trainee lists, obstetric anaesthesia reflective diary, active mentoring system and in-situ simulation).

CONCLUSIONS

Our study described the challenges of obstetric anaesthesia training in the operating theatre environment in an Asian healthcare setting. Research is needed on the influence of supervisors' concern about maternal risks and their teaching behaviours.