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

Use of an Interactive Online Teaching Module Improved Students' Ability to Write a Clinically Appropriate SOAP Note

The veterinary problem-based medical records lesson (Subjective-Objective-Assessment-Plan [SOAP] notes) at the University of Wisconsin, previously taught in lecture format, provides students little time for reflection. Moreover, evaluation of student-written SOAPs from subsequent courses demonstrates poor knowledge retention and application of the SOAP note structure. This article hypothesized that a virtual, interactive, case-based module would improve student SOAP-writing skills. A second-year student cohort (n = 79) was taught SOAP skills in lecture format (LECTURE-2); 2 years later, another second-year student cohort (n = 73) used the virtual module (MODULE-2). All students wrote SOAPs, which were evaluated using a standardized rubric and the cohorts' scores were compared. SOAPs were then compared between a third-year student cohort who received lecture-based SOAP instruction the year before (LECTURE-3, n = 55) and a third-year student cohort who received the virtual module (MODULE-3, n = 44). SOAP scores were significantly higher in the MODULE-2 group (Mdn = 6.5, range = 1.5-9.0) than in the LECTURE-2 group (Mdn = 5.0, range = 2.0-9.0, p = .006). Similarly, the MODULE-3 students scored higher on the differential diagnosis SOAP component than the LECTURE-3 students (Mdn = 1, range = 0-2, vs. Mdn = 0.5, range = 0-2, p = .041). Student feedback on the online module was positive. An online teaching module improved students' short- and long-term ability to write clinically appropriate SOAP notes. The findings suggest the module encouraged student engagement and reflection, leading to long-term retention and skill application.

Rapid Cycle Deliberate Practice for Pediatric Intern Resuscitation Skills

INTRODUCTION

For pediatric interns, it takes deliberate practice to translate the knowledge of what to do in emergencies into the procedural and communication skills required of a team member or team leader. This curriculum taught interns through simulations with rapid cycle deliberate practice (RCDP). This method focused on teaching time-sensitive team-based activities in simulation. The RCDP structure alternated practice with immediate expert feedback. This alternating pattern gave the learner chances to practice the correct way to perform these skills.

METHODS

The curriculum was developed iteratively based on common gaps in intern skills and knowledge; it was well suited for groups of four to six interns and to be given by one or two instructors over a 6-hour period of time. After an initial warm-up case, a series of simulations used RCDP to move interns through cases focusing on management of respiratory distress, upper airway obstruction, shock, intubation, complications of intubation, and pulseless arrest. Feedback was interspersed throughout the experience with detailed explanations provided as the interns required them to complete the simulations.

RESULTS

This technique was well received by a group of 81 interns who provided positive feedback on the sessions. In particular, when asked if the course "improved my teamwork and leadership skills" they agreed with a mean score of 4.9 out of 5.

DISCUSSION

This curriculum taught and integrated the procedural skills, communication skills, and teamwork needed to participate in pediatric resuscitations. The methods described in this curriculum improved confidence of pediatric interns and merits further study.

Human reliability analysis of bronchoscope-assisted percutaneous dilatational tracheostomy: implications for simulation-based education

BACKGROUND

Teaching and assessing clinical procedures requires a clear delineation of the individual steps required to successfully complete the procedure. For decades, human reliability analysis (HRA) has been used to identify the steps required to complete technical procedures in higher risk industries. However, the use of HRA is uncommon in healthcare. HRA has great potential supporting simulation-based education (SBE) in two ways: (1) to support training through the identification of the steps required to complete a clinical procedure; and (2) to support assessment by providing a framework for evaluating performance of a clinical procedure. The goal of this study was to use HRA to identify the steps (and the risk associated with each of these steps) required to complete a bronchoscope-assisted percutaneous dilatational tracheostomy (BPDT). BPDT is a potentially high-risk minimally invasive procedure used to facilitate tracheostomy placement at the bedside or in the operating theatre.

METHODS

The subgoals, or steps, required to complete the BPDT procedure were identified using hierarchical task analysis. The Systematic Human Error Reduction and Prediction Approach (SHERPA) was then used to identify potential human errors at each subgoal, the level of risk and how these potential errors could be prevented.

RESULTS

The BPDT procedure was broken down into 395 subgoals, of which 18% were determined to be of high-risk. The most commonly identified remediation strategies for reducing the risk of the procedure included: checklist implementation and audit, statutory and mandatory training modules, simulation training, consultant involvement in all procedures, and fostering a safety-focused hospital culture.

CONCLUSION

This study provides an approach for how to systematically identify the steps required to complete a clinical procedure for both training and assessment. An understanding of these steps is the foundation of SBE. HRA can identify 'a correct way' for teaching learners how to complete a technical procedure, and support teachers to give systematic and structured feedback on performance.

Beyond the Surgical Time-Out: A National Needs Assessment of Preoperative Communication in US General Surgery Residency Programs

OBJECTIVE

Perioperative communication is critical for procedural learning. In order to develop a periprocedural faculty development tool, we aimed to characterize the current status of preoperative communication in US General Surgery residency programs.

DESIGN

After Association of Program Directors in Surgery approval, a survey was distributed to general surgery programs. Participants were asked about perioperative communication, including the frequency of preoperative briefings, defined as dedicated educational discussions prior to a procedure. Data were analyzed using descriptive statistics.

SETTING

An anonymous electronic survey was distributed to interested programs in early 2019.

PARTICIPANTS

US General Surgery trainees and attending surgeons.

RESULTS

A total of 348 responses were recorded from 27 programs: 199 (57%) attending surgeons and 149 (43%) surgical trainees. Most respondents (83%) were from a university-affiliated program. Attending surgeons indicated a higher frequency of performing preoperative briefings compared to trainees (p < 0.001). Both trainees and attending surgeons were more likely to select their own group when asked who initiates a preoperative briefing. The majority of respondents (58%) agreed that discussing autonomy preoperatively improves resident autonomy for the case. In regards to the timing of preoperative briefings, most took place in/adjacent to the operating room, with only 60 participants (17%) participating in preoperative briefings the day/night prior to the operation. The most frequent topic discussed during preoperative briefings was "procedural content." Most participants selected "time constraints" as the greatest barrier to preoperative briefings and indicated that attending surgeon engagement was necessary to facilitate their use. Trainees were less likely to report engaging in immediate postoperative feedback, but more likely to report postoperative self-reflection.

CONCLUSIONS

Preoperative briefings are not necessarily routine and attendings and trainees differ on their perceptions related to their content and frequency. Efforts to address timing and scheduling and encourage dual-party engagement in perioperative communication are key to the development of tools to enhance this important aspect of procedural learning.

The Influence of Relationship-Centered Coaching on Physician Perceptions of Peer Review in the Context of Mandated Regulatory Practices

PURPOSE

Medical regulatory authorities are legally mandated to protect patients by monitoring the practice of medicine. While principally a matter of public safety, many pursue this mission by establishing quality improvement initiatives that prioritize professional development for all rather than identification of substandard performers. Engaging practitioners in directed learning opportunities, however, is rife with challenge given inherent social complexities. This study was run to explore whether relationship-centered coaching could improve physicians' perceptions of the value of engaging with College-mandated peer review.

METHOD

A quasi-experimental analysis was performed on physician ratings of the effectiveness of peer assessor interactions and assessment processes during 3 time periods: (1) an historical control (March 2016-December 2016; n = 296); (2) a period after assessors were trained to deliver feedback using relationship-centered coaching (December 2016-March 2017; n = 96); and (3) after physicians were given more capacity to choose patient records for peer review and engage in discussion about multisource feedback results (March 2017-December 2018; n = 448).

RESULTS

Psychometric analyses supported the aggregation of survey items into assessor interaction and assessment process subscores. Training assessors to engage in relationship-centered coaching was related with higher assessor interaction scores (4.64 vs 4.47; P < .05; d = 0.37). Assessment process scores did not increase until after additional program enhancements were made in period 3 (4.33 vs 4.17, P < .05, d = 0.29).

CONCLUSIONS

Despite peer interactions being inherently stressful for physicians when they occur in the context of regulatory authority visits, efforts to establish a quality improvement culture that prioritizes learning can improve physicians' perceptions of peer review.

High-Fidelity Simulation Education and Crisis Resource Management

This article explores high-fidelity simulation in anesthesiology education and provides strategies for its use to improve management of critical events. Educational theories that underlie the use of simulation are described. High-fidelity simulation is useful in teaching technical (diagnostic and procedural) and nontechnical (communication and professionalism) skills, including crisis resource management (CRM) skills. The practice of CRM is fundamental to ensuring patient safety during critical events and to the safe practice of anesthesiology, and its critical elements are presented. A discussion of the use of high-fidelity simulation to learn to combine highly complex procedural skills and CRM is also provided.

Home Program for Acquisition and Maintenance of Microsurgical Skills During the Coronavirus Disease 2019 Outbreak

BACKGROUND

During the current global crisis unleashed by the severe acute respiratory syndrome coronavirus 2 outbreak, surgical departments have considerably reduced the amount of elective surgeries. This decrease leads to less time in the surgical room to develop and improve the surgical skills of residents. In this study, we developed a training program to obtain and maintain microsurgical skills at home, using a smartphone camera and low-cost materials, affordable for everyone.

METHODS

Using a smartphone camera as a magnification device, 6 participants performed 5 exercises (coloring grids, grouping colors, unraveling of a gauze, knots with suture threads, and tower of Hanoi), both with the dominant and with the nondominant hand, for 4 weeks. We compared performance at the beginning and at the end of the training process. Each participant filled out an anonymous survey.

RESULTS

When we compared the performance at the beginning and at the end of the training process, we found significant improvements (P = 0.05) with the dominant as well as the nondominant hand in all the exercises. All participants were satisfied or very satisfied with the definition of the objectives of the training process, material availability, the exercises performed, the choice of the time to train, and general satisfaction with the training program.

CONCLUSIONS

We developed a microsurgical skills training program to be performed at home, which can be easily reproduced. It allows residents to improve manual coordination skills and is regarded as a feasible adjunct for ongoing training for surgical residents.

Impact of a simulation-based ergonomics training curriculum on work-related musculoskeletal injury risk in colonoscopy

BACKGROUND AND AIMS

Endoscopists are at risk of developing musculoskeletal injuries (MSIs), and few receive training on ergonomics. The aim of this study was to determine the impact of a simulation-based ergonomics training curriculum (ETC) on work-related MSI risk during clinical colonoscopy.

METHODS

Novice endoscopists underwent a simulation-based ETC and were compared with an historical control group who received simulation-based training without ergonomics training. The ETC included a didactic lecture and video on ergonomics in colonoscopy, feedback from supervisors on ergonomics, and an ergonomics checklist to augment feedback and promote self-reflection. Participants were assessed using the rapid entire body assessment (REBA) and rapid upper limb assessment (RULA). The primary outcome was participants' REBA scores during 2 clinical colonoscopies 4 to 6 weeks after training.

RESULTS

In clinical colonoscopy, the ETC group had superior REBA scores (clinical procedure 1: median score, 6 vs 11; P < .001; clinical procedure 2: median score, 6 vs 10; P < .001). In a simulated colonoscopy, the ETC group did not have significantly different REBA or RULA scores between baseline, immediately after training, and 4 to 6 weeks after (REBA: median scores of 5, 5, and 5, respectively; P > .05; RULA: median scores of 6, 6, and 6, respectively; P > .05). The control group had worsening REBA and RULA scores during the study timeline (REBA: median scores of 5 at baseline, 9 immediately after training, and 9 at 4-6 weeks after training; P < .001; RULA: median scores of 6, 7, and 7, respectively; P = .04) during simulated procedures.

CONCLUSIONS

A simulation-based ETC is associated with reduced risk of MSI during endoscopy. Although the REBA score was improved, the intervention group was still within the medium-risk range.

Not Throwing Away My Shot: Leveraging a Peer Vaccination Workshop to Increase Residents' Immunization Skills

OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) requires that pediatric residents demonstrate competence administering immunizations. Despite mandatory simulation training, less than half our residents reported immunization competence. All residents need to receive their influenza vaccination, but schedule restrictions present logistical challenges. We implemented a peer influenza immunization workshop and assessed the impact on resident immunization competence compared to simulation-only training.

METHODS

Prospective cohort study at a pediatric residency program in a tertiary academic center. We implemented an annual influenza immunization workshop including immunization education, simulated practice, and peer influenza immunization. We compared workshop participation to simulation-only training on resident confidence immunizing, number of immunizations logged, and ACGME survey results for immunization skills.

RESULTS

In 2019, 80% (N = 59) of residents participated in the workshop. Participants were more likely to report confidence in immunization skills than nonparticipants (P = .001). Resident-administered immunizations increased from 1 in the 3 years preceding workshop implementation to 74 during the 2019 to 2020 academic year. Significantly, more ACGME survey respondents reported preparedness to immunize after workshop implementation (P = .02).

CONCLUSIONS

Implementation of an influenza immunization workshop provides an innovative opportunity to increase resident preparedness performing an ACGME-required procedure while also helping ensure programs remain compliant with influenza requirements.

How do we teach simulation-based dental education? Time for an evidence-based, best-practice framework

Historically, simulation-based dental education was taught using practical skills and the action of doing. An increased awareness of the importance of patient safety in healthcare education and delivery has seen considerable advances in the application of simulation-based education across several healthcare disciplines including medicine, nursing and anaesthetics. Dental simulation-based education requires improved standards of best-practice, and evidence-based, curriculum design that is based on theoretical frameworks, conceptual frameworks and educational theories. In this commentary, we explore the educational theory and the development of healthcare simulation, including internationally recognised standards of best practice and the simulation-based activity cycle. Given simulation-based education should be fit-for purpose, the components of these standards are examined within the specific context of dental education. We propose an evidence-based, best-practice framework that can be applied in the design and delivery of contemporary simulation-based dental curriculum.

How to agree on what is fundamental to optimal teamwork performance in a situation of postpartum hemorrhage? A multidisciplinary Delphi French study to develop the Obstetric Team Performance Assessment Scale (OTPA Scale)

INTRODUCTION

The objective of this study was to develop a new interdisciplinary teamwork scale, the Obstetric Team Performance Assessment (OTPA), for the management of the post-partum hemorrhage, through consensus agreement of obstetric caregivers. The goal is to provide a reliable tool for teaching and evaluating teams in high-fidelity simulation.

METHODS

This prospective study is based on an expert consensus, using a Delphi method. The authors developed the "OTPA» specifically related to the management of post-partum hemorrhage, using existing recommendations. For the Delphi survey, the scale was distributed to a selected group of experts. After each round of Delphi, authors quantitatively analyzed each element of the scale, based on the percentages of agreement received, and reviewed each comment. This blind examination then led to the modification of the scale. The rounds were continued until 80-100 % agreement with a median overall response score equal to or greater than 8 was obtained for at least 60 % of items. Repeated 3 times, the process led to consensus and to a final version of the OTPA scale.

RESULTS

From February to October 2018, 16 of the 33 invited experts participated in four Delphi cycles. Of the 37 items selected in the first round, only 19 (51.3 %) had an agreement of 80-100% with a median overall response score equal to or greater than 8 in the second round, and a third round was conducted. During this third round, 24 of the 37 items were validated (64.9 %) and 82 of the 88 sub-items obtained 80 %-100 % agreement (93.2 %). The fourth round consisted of proposing a weighting of the different items.

CONCLUSION

Using a structured Delphi method, we provided a new interdisciplinary teamwork scale (OTPA), for the management of the post-partum hemorrhage. Thus, this scale will be able to be used during high-fidelity scenarii to assess performances of various teams facing a scenari of PPH. Moreover, this scale, focusing some crucial aspects of interdisciplinary teamwork will be useful for teaching purpose.

The Simulated Cardiology Clinic: A Standardized Patient Exercise Supporting Medical Students' Biomedical Knowledge and Clinical Skills Integration

INTRODUCTION

Development of cardiac disease-related diagnostic skills-including hypothesis-driven data gathering, heart sound interpretation, and ECG interpretation-is an important component of medical student training. Prior studies indicate trainees' performance of these skills is limited. Simulation provides students with opportunities to practice integrating their developing knowledge in a relevant clinical context. We developed a simulated clinic activity for second-year medical students consisting of standardized patient (SP) cases representing cardiovascular (CV) diseases.

METHODS

Student small groups rotated through four SP encounters. For each case, one student performed the history, after which the whole small group listened to audio files of heart sounds, interpreted an ECG, and collaboratively developed a prioritized differential diagnosis. The CV course director met with students for a large-group debrief, highlighting key learning points. We collected learners' evaluations of the event through an online survey.

RESULTS

Of students, 276 participated in this activity over the course of 2 years. Nearly all students assessed the activity as extremely or quite effective for applying learning content from the CV course (97%, 2018; 93%, 2019), and for practicing how to approach chest pain, shortness of breath, palpitations, and fatigue (100%, 2018; 95%, 2019). The most helpful aspects were reinforcement of CV disease illness scripts, hypothesis-driven data gathering practice, ECG interpretation, and applying knowledge and skills in a realistic context.

DISCUSSION

SP encounters representing CV conditions can effectively provide opportunities for students to integrate basic science knowledge and clinical skills. Students assessed the activity as helpful and engaging.

A prospective six-month audit of airway incidents during anaesthesia in twelve tertiary level hospitals across Australia and New Zealand

This audit of airway incidents was conducted over six months in 12 tertiary level hospitals across Australia and New Zealand. During that time, 131,233 patients had airway management and 111 reports were submitted (incidence 0.08%). The airway incidents included a combination of difficult airway management (83), oxygen desaturation (58), aspiration (19), regurgitation (14), laryngospasm (16), airway bleeding (10), bronchospasm (5) and dental injury (4), which gave a total of 209 events in 111 reports. Most incidents occurred during general anaesthesia (GA; 83.8%) and normal working hours (81.1%). Forty-three percent were associated with head and neck surgery and 12.6% with upper abdominal procedures. Of these patients, 52% required further medical treatment or additional procedures and 16.2% required unplanned admission to an intensive care unit or a high dependency unit. A total of 31.5% of patients suffered from temporary harm and 1.8% from permanent harm. There was one death. The factors associated with a high relative risk (RR) of an airway incident included American Society of Anesthesiologists Physical Status (ASA PS) (ASA PS 2 versus 1, RR 1.75; ASA PS 3 versus 1, RR 3.56; ASA PS 4 versus 1, RR 6.1), and emergency surgery (RR 2.16 compared with elective). Sedation and monitored anaesthesia care were associated with lower RRs (RR 0.49 and RR 0.73 versus GA, respectively). Inadequate airway assessment, poor judgement and poor planning appeared to be contributors to these events. Future teaching and research should focus on these areas to further improve airway management and patient safety.

Evolution of an obstetrics and gynecology interprofessional simulation-based education session for medical and nursing students

Simulation and Objective Structured Clinical Examination assessment of learners can teach clinical skills proficiency in a safe environment without risk to patients. Interprofessional simulation-based education (IPSE) contributes to a transformation in students' understanding of teamwork and professional roles. Long term outcomes for stimulation and IPSE sessions, are less well studied. We hypothesized that a progressive interprofessional education simulation program incorporating both faculty and interprofessional student collaboration would improve medical students' knowledge retention, comfort with procedural skills, positive teamwork and respectful interaction between students.An Obstetrics and Gynecology IPSE for medical and nursing students (NS) was developed in collaboration between a school of medicine and a school of nursing from 2014 to 2017. By 2017, content includedFrom 2014 to 2016, medical students completed attitude, knowledge, and perception surveys both pre and immediately post simulation, at 4 months, and 8 months. In 2017; all students completed self-assessments and received faculty-assessments.The program trained 443 medical and 136 NS. Medical students' knowledge, comfort, and interest increased significantly post simulation. Outcome scores decreased but were still significantly improved at 4 months but nearly dissipated by 8 months. There were no significant differences between medical and NS self-assessment or faculty-assessment scores regarding IUD insertion, cervical examination, or contraception quiz scores. Medical students' birth simulation self-assessment versus faculty-assessment scores were 8.6 vs 8.9, P < .001.Simulation improved students' short-term medical knowledge, comfort, and perception with some long-term persistence at 4-8 months. Medical and NS learned obstetrics and gynecology skills in a collaborative environment and in role-specific situations. Medical students had the opportunity to learn from NS. Positive teamwork and respectful interaction occurred between the students.

[Simulation curricular content in postgraduate emergency medicine: A multicentre Delphi study]

OBJECTIVES

There is increasing evidence to support integration of simulation into medical training; however, no national emergency medicine (EM) simulation curriculum exists. Using Delphi methodology, we aimed to identify and establish content validity for adult EM curricular content best suited for simulation-based training, to inform national postgraduate EM training.

METHODS

A national panel of experts in EM simulation iteratively rated potential curricular topics, on a 4-point scale, to determine those best suited for simulation-based training. After each round, responses were analyzed. Topics scoring <2/4 were removed and remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics rated ≥ 3.5/4 were considered "core" curricular topics, while those rated 3.0-3.5 were considered "extended" curricular topics.

RESULTS

Forty-five experts from 13 Canadian centres participated. Two hundred eighty potential curricular topics, in 29 domains, were generated from a systematic literature review, relevant educational documents and Delphi panellists. Three rounds of surveys were completed before consensus was achieved, with response rates ranging from 93-100%. Twenty-eight topics, in eight domains, reached consensus as "core" curricular topics. Thirty-five additional topics, in 14 domains, reached consensus as "extended" curricular topics.

CONCLUSIONS

Delphi methodology allowed for achievement of expert consensus and content validation of EM curricular content best suited for simulation-based training. These results provide a foundation for improved integration of simulation into postgraduate EM training and can be used to inform a national simulation curriculum to supplement clinical training and optimize learning.

[Perspectives of non-university stakeholders on implementing a clinical skills lab in veterinary medicine]

OBJECTIVE

Simulation-based teaching is gaining increasing importance in veterinary education worldwide and is by now an integral part of all German veterinary educational institutions in the form of Skills Labs. Students and teachers of the University of Veterinary Medicine Hannover, Foundation (TiHo) showed a good acceptance for the establishment and curricular use of a Clinical Skills Lab (CSL). This study will now examine the perspectives of non-university stakeholders in order to assess the acceptance of such a facility among clinicians. In addition, experiences in implementing a CSL in veterinary teaching are taken into account by interviewing experts.

MATERIAL AND METHODS

Semi-structured guided interviews were conducted with alumni of the TiHo, senior veterinarians from various German clinics and practices and leading experts from some of the largest veterinary CSLs worldwide.

RESULTS

The interviews revealed a need for improvement in the clinical-practical training of veterinary students among senior veterinarians and alumni. Respondents could imagine that teaching in the CSL may play a major role in this. Overall, the participants pleaded for a mandatory implementation of simulation-based teaching in the curriculum.

CONCLUSION

The study suggests that the training of clinical-practical skills of veterinary students should be continuously adapted to the requirements of the veterinary profession in a clinical environment. Non-university stakeholders seem to support the use of a CSL to improve these skills and encourage its further implementation in the curriculum.

Establishing Objective Measures of Clinical Competence in Undergraduate Medical Education Through Immersive Virtual Reality

OBJECTIVE

The Association of American Medical Colleges defines recognition of the need for urgent or emergent escalation of care as a key Entrustable Professional Activity (EPA) for entering residency (EPA#10). This study pilots the use of an immersive virtual reality (VR) platform for defining objective observable behaviors as standards for evaluation of medical student recognition of impending respiratory failure.

METHODS

A cross-sectional observational study was conducted from July 2018 to December 2019, evaluating student performance during a VR scenario of an infant in impending respiratory failure using the OculusRift VR platform. Video recordings were rated by 2 pair of physician reviewers blinded to student identity. One pair provided a consensus global assessment of performance (not competent, borderline, or competent) while the other used a checklist of observable behaviors to rate performance. Binary discriminant analysis was used to identify the observable behaviors that predicted the global assessment rating.

RESULTS

Twenty-six fourth year medical students participated. Student performance of 8 observable behaviors was found to be most predictive of a rating of competent, with a 91% probability. Correctly stating that the patient required an escalation of care had the largest contribution toward predicting a rating of competent, followed by commenting on the patient's increased heart rate, low oxygen saturation, increased respiratory rate, and stating that the patient was in respiratory distress.

CONCLUSIONS

This study demonstrates that VR can be used to establish objective and observable performance standards for assessment of EPA attainment - a key step in moving towards competency based medical education.

Child Abuse Recognition Training for Prehospital Providers Using Deliberate Practice

BACKGROUND

In most states, prehospital professionals (PHPs) are mandated reporters of suspected abuse but cite a lack of training as a challenge to recognizing and reporting physical abuse. We developed a learning platform for the visual diagnosis of pediatric abusive versus non-abusive burn and bruise injuries and examined the amount and rate of skill acquisition.

METHODS

This was a prospective cross-sectional study of PHPs participating in an online educational intervention containing 114 case vignettes. PHPs indicated whether they believed a case was concerning for abuse and would report a case to child protection services. Participants received feedback after submitting a response, permitting deliberate practice of the cases. We describe learning curves, overall accuracy, sensitivity (diagnosis of abusive injuries) and specificity (diagnosis of non-abusive injuries) to determine the amount of learning. We performed multivariable regression analysis to identify specific demographic and case variables associated with a correct case interpretation. After completing the educational intervention, PHPs completed a self-efficacy survey on perceived gains in their ability to recognize cutaneous signs of abuse and report to social services.

RESULTS

We enrolled 253 PHPs who completed all the cases; 158 (63.6%) emergency medical technicians (EMT), 95 (36.4%) advanced EMT and paramedics. Learning curves demonstrated that, with one exception, there was an increase in learning for participants throughout the educational intervention. Mean diagnostic accuracy increased by 4.9% (95% CI 3.2, 6.7), and the mean final diagnostic accuracy, sensitivity, and specificity were 82.1%, 75.4%, and 85.2%, respectively. There was an increased odds of getting a case correct for bruise versus burn cases (OR = 1.4; 95% CI 1.3, 1.5); if the PHP was an Advanced EMT/Paramedic (OR = 1.3; 95% CI 1.1, 1.4) ; and, if the learner indicated prior training in child abuse (OR = 1.2; 95% CI 1.0, 1.3). Learners indicated increased comfort in knowing which cases should be reported and interpreting exams in children with cutaneous injuries with a median Likert score of 5 out of 6 (IQR 5, 6).

CONCLUSION

An online module utilizing deliberate practice led to measurable skill improvement among PHPs for differentiating abusive from non-abusive burn and bruise injuries.

How to enhance and assess reflection in specialist training: a mixed method validation study of a new tool for global assessment of reflection ability

BACKGROUND

In Danish GP training we had the ambition to enhance and assess global reflection ability, but since we found no appropriate validated method in the literature, we decided to develop a new assessment tool. This tool is based on individual trainee developed mind maps and structured trainer-trainee discussions related to specific complex competencies. We named the tool Global Assessment of Reflection ability (GAR) and conducted a mixed method validation study. Our goal was to investigate whether it is possible to enhance and assess reflection ability using the tool.

METHODS

In order to investigate acceptability, feasibility, face validity, and construct validity of the tool we conducted a mixed method validation study that combined 1) qualitative data obtained from 750 GP trainers participating in train-the-trainer courses, 2) a questionnaire survey sent to 349 GP trainers and 214 GP trainees and 3) a thorough analysis of eight trainer-trainee discussions.

RESULTS

Our study showed an immediate high acceptance of the GAR tool. Both trainers and trainees found the tool feasible, useful, and relevant with acceptable face validity. Rating of eight audio recordings showed that the tool can demonstrate reflection during assessment of complex competencies.

CONCLUSIONS

We have developed an assessment tool (GAR) to enhance and assess reflection. GAR was found to be acceptable, feasible, relevant and with good face- and construct validity. GAR seems to be able to enhance the trainees' ability to reflect and provide a good basis for assessment in relation to complex competencies.

A think-aloud study to inform the design of radiograph interpretation practice

Models for diagnostic reasoning in radiology have been based on the observed behaviors of experienced radiologists but have not directly focused on the thought processes of novices as they improve their accuracy of image interpretation. By collecting think-aloud verbal reports, the current study was designed to investigate differences in specific thought processes between medical students (novices) as they learn and radiologists (experts), so that we can better design future instructional environments. Seven medical students and four physicians with radiology training were asked to interpret and diagnose pediatric elbow radiographs where fracture is suspected. After reporting their diagnosis of a case, they were given immediate feedback. Participants were asked to verbalize their thoughts while completing the diagnosis and while they reflected on the provided feedback. The protocol analysis of their verbalizations showed that participants used some combination of four processes to interpret the case: gestalt interpretation, purposeful search, rule application, and reasoning from a prior case. All types of processes except reasoning from a prior case were applied significantly more frequently by experts. Further, gestalt interpretation was used with higher frequency in abnormal cases while purposeful search was used more often for normal cases. Our assessment of processes could help guide the design of instructional environments with well-curated image banks and analytics to facilitate the novice's journey to expertise in image interpretation.

Learning Curves and Competences of Vascular Trainees Performing Open Aortic Repair in a Simulation-Based Environment

BACKGROUND

The aim of this study was to analyze learning curves and competency gains of novice vascular trainees when performing open aortic repair in a simulation-based environment.

METHODS

This was a prospective study of 16 vascular trainees performing infrarenal open aortic repair on an inanimate abdominal aortic aneurysm simulator with pulsatile pressure and flow. Each participant performed 4 procedures as a primary surgeon while getting structured feedback by a supervising experienced vascular surgeon. All sessions were video recorded and were anonymously and independently assessed by 3 rater-trained experts on an online platform using the newly validated open abdominal aortic aneurysm repair of technical expertise assessment tool. All supervisor interferences and procedure time was noted.

RESULTS

Reliability between raters was excellent (intraclass correlation coefficient = 0.92). Participants' mean scores almost doubled during the course between the first (13.4, 95% confidence interval [CI], 6.8-20) and fourth session (29.8, 95% CI, 26.3-33.3) with a mean difference of 14.6 (P < 0.001). Supervisor interference also decreased significantly from mean 3.0 (95% CI, 1.5-3.6) in the first to 0.7 (95% CI, 0.4-1.0) in the fourth session (P = 0.004). Procedure time decreased with a mean of 24 minutes: from 81 min (95% CI, 71.8-90.3) to 57 min (95% CI, 51.1-63.2, P < 0.001). There was a significant negative correlation between procedure time and the Open Abdominal Aortic Aneurysm Repair of Technical Expertise score (Pearson's r = -0.72, P < 0.01). Only half of the participants passed the pass/fail score of 27.7 points during the course.

CONCLUSIONS

Novice vascular trainees achieve skills and competencies in open aortic repair in a simulated setting with dedicated supervision and feedback and can become ready for supervised surgery on real patients. Learning rates are individual, and it is important to construct training programs with emphasis on proficiency and not merely attending a course.

Learning to diagnose collaboratively: validating a simulation for medical students

Objectives: Physicians with different professional backgrounds often diagnose a patients' problem collaboratively. In this article, we first introduce a process model for collaborative diagnosing (CDR model), describe the development of a simulation used to empirically examine the facilitation of collaborative diagnostic reasoning. Based on a contemporary validity framework [1], we further suggest indicators for validity and collect initial evidence with respect to the scoring, generalization, extrapolation, and implication inferences to assess the validity of the simulation when used to assess effects of learning interventions. Method: In a quasi-experimental study, we assessed objectivity and reliability of the simulation and compared medical students with low and advanced prior knowledge to practitioners with high prior knowledge with respect to their diagnostic accuracy, diagnostic efficiency, information sharing skills, and their intrinsic cognitive load. Additionally, we obtained authenticity ratings from practitioners with high prior knowledge. Results: The results yielded satisfying initial evidence for the validity of the scoring and the extrapolation inferences as ratings are objective, and the simulation and the collaborative process is perceived as rather authentic. Additionally, participants on different levels of prior knowledge differ with respect to their diagnostic accuracy, diagnostic efficiency, information sharing skills, and their reported intrinsic cognitive load. With one exception (information sharing skills), the generalization inference seems to be valid as well. Conclusions: We conclude that collecting validity evidence for the simulation was an important step towards a better interpretation of the simulation. We found that the simulation is an authentic and valid representation of the chosen collaborative situation and that the collected validity evidence offers sufficient evidence for an initial validation of the simulation. Nevertheless, the validation process highlighted some important gaps that need further consideration. We further conclude that applying a validation model to the context of empirical research is promising and encourage other researchers to follow the example.

Institution-specific utilization of the American College of Surgeons/Association of Program Directors operative skills curriculum: From needs assessment to implementation

BACKGROUND

The American College of Surgeons/Association of Program Directors in Surgery operative skills curriculum standardizes training. However, simulation resources are variable with curriculum implementation institution dependent. Our aim was to use Kern's six steps of curricular development to demonstrate how to tailor the American College of Surgeons/Association of Program Directors in Surgery Phase 2 curriculum to program specific needs.

METHODS

Problem identification and general needs assessment was performed. Targeted needs assessment of general surgery residents and attendings was conducted to determine perceived importance of operative skills and residents' confidence with these skills and attendings perceptions of deficiencies in technical skills using the Objective Structured Assessment of Technical Skills criteria. Educational strategies were developed dependent on program resources. The program was piloted between 2018 to 2019 and implemented in the 2019 to 2020 academic year. Assessment of resident technical skills and resident or faculty teaching skills was performed for each session. Resident confidence with procedures was assessed using the Zwisch scale before and after modules. Curricular evaluations were completed by residents after each module.

RESULTS

The previous curriculum did not comprehensively cover Phase 2 modules and was not tailored to the needs of residents. Targeted needs assessment revealed differences in prioritization of learning for techniques by seniority (most important operation for faculty: laparoscopic cholecystectomy, postgraduate year 4 and 5: laparoscopic partial colectomy, interns: open inguinal/femoral hernia repair). Faculty identified technical skills on which to focus (ie, interns' knowledge of a specific procedure, postgraduate year 4 and 5 flow of the operation and forward planning). Educational strategies employed included wet and dry lab simulations and online materials. Residents reported increased procedural confidence after curriculum completion.

CONCLUSION

This comprehensive implementation of the American College of Surgeons/Association of Program Directors in Surgery Phase 2 skills curriculum effectively used resources and expertise of an institution and focused on the knowledge and technical deficiencies of the target learners. Improvement in learner confidence was demonstrated by this approach.

Education and training in ultrasound-guided regional anaesthesia and pain medicine

PURPOSE OF REVIEW

Effective and safe regional anaesthesia and pain medicine procedures require clinicians to learn and master complex theoretical knowledge and motor skills. This review aims to summarize articles relevant to education and training in these skill sets in the previous 2 years.

RECENT FINDINGS

Twenty-two articles were identified, investigating nine out of the 13 top-ranked research topics in education and training in regional anaesthesia. Research topics addressed by these articles included prerotation simulation, deliberate practice combined with formative assessment tools, validation of assessment tools, three-dimensional-printed models, and knowledge translation from simulation to clinical practice. Emerging concepts investigated for their applications in regional anaesthesia included eye-tracking as a surrogate metric when evaluating proficiency, and elastography aiding visual salience to distinguish appropriate perineural and inappropriate intraneural injections.

SUMMARY

Research into education and training in regional anaesthesia covered multiple and diverse topics. Methodological limitations were noted in several articles, reflecting the difficulties in designing and conducting medical education studies. Nonetheless, the evidence-base continues to mature and innovations provide exciting future possibilities.

Using Simulation With Deliberate Practice to Improve Pediatric ICU Nurses' Knowledge, Clinical Teamwork, and Confidence

PURPOSE

The purpose of this quality improvement project was to implement an educational intervention involving High-Fidelity Simulation (HFS) with deliberate practice for low-frequency, high-impact events in a Pediatric Intensive Care Unit (PICU), with the goal of improving nurses' crisis management skills.

DESIGN AND METHODS

Four interprofessional simulation education sessions with scenarios were created for this project. A list of knowledge and skills points was used to guide debriefings. All scenarios were based on low-frequency, high-impact events that required the use of Pediatric Advanced Life Support algorithms. Participants included 24 PICU nurses with less than two years of nursing experience. Knowledge and confidence were measured at three timepoints: pre-simulation, one-week post-simulation, and one-month post-simulation series. Clinical teamwork performance was measured twice, during the first and second scenario of each simulation session.

RESULTS

Scores for knowledge, confidence, and clinical teamwork performance improved from pre- to post-simulation, with confidence scores showing the largest increase.

CONCLUSIONS

Regular simulation training with deliberate practice can improve PICU nurses' knowledge, clinical teamwork skills, and confidence when managing low-frequency, high-impact events.

PRACTICE IMPLICATIONS

Regular in-situ simulation training with deliberate practice can improve nursing comfort with managing high-impact, low-frequency events in the PICU. This could lead to improved management of actual events, especially for novice nurses with less than one year of PICU experience.

Quantifying surgeon maneuevers across experience levels through marker-less hand motion kinematics of simulated surgical tasks

This paper compares clinician hand motion for common suturing tasks across a range of experience levels and tissue types. Medical students (32), residents (41), attending surgeons (10), and retirees (2) were recorded on digital video while suturing on one of: foam, pig feet, or porcine bowel. Depending on time in position, each medical student, resident, and attending participant was classified as junior or senior, yielding six experience categories. This work focuses on trends associated with increasing tenure observed from those medical students (10), residents (15), and attendings (10) who sutured on foam, and draws comparison across tissue types where pertinent. Utilizing custom software, the two-dimensional location of each of the participant's hands were automatically recorded in every video frame, producing a rich spatiotemporal feature set. While suturing on foam, increasing clinician experience was associated with conserved path length per cycle of the non-dominant hand, significantly reducing from junior medical students (mean = 73.63 cm, sd = 33.21 cm) to senior residents (mean = 46.16 cm, sd = 14.03 cm, p = 0.015), and again between senior residents and senior attendings (mean = 30.84 cm, sd = 14.51 cm, p = 0.045). Despite similar maneuver rates, attendings also accelerated less with their non-dominant hand (mean = 16.27 cm/s², sd = 81.12 cm/s², p = 0.002) than senior residents (mean = 24.84 cm/s², sd = 68.29 cm/s², p = 0.002). While tying, medical students moved their dominant hands slower (mean = 4.39 cm/s, sd = 1.73 cm/s, p = 0.033) than senior residents (mean = 6.53 cm/s, sd = 2.52 cm/s). These results suggest that increased psychomotor performance during early training manifest through faster dominant hand function, while later increases are characterized by conserving energy and efficiently distributing work between hands. Incorporating this scalable video-based motion analysis into regular formative assessment routines may enable greater quality and consistency of feedback throughout a surgical career.

Learning in the workplace: Use of informal feedback cues in doctor-patient communication

OBJECTIVES

We expect physicians to be lifelong learners. Participation in clinical practice is an important potential source of that learning. To support physicians in this process, a better understanding of how they learn in clinical practice is necessary. This study investigates how physicians recognise and use informal feedback from interactions with patients in outpatient settings as learning cues to adjust their communication behaviours in daily practice.

METHODS

To understand physicians' use of informal feedback, we combined non-participant observations with semi-structured interviews. We enrolled 10 respiratory physicians and observed 100 physician-patient interactions at two teaching hospitals in the Netherlands. Data collection and analysis were performed iteratively according to the principles of constructivist grounded theory.

RESULTS

Following stages of open, axial and selective coding, we were able to conceptualise how physicians use cues to reflect on and adjust their communication. In addition to vast variations within and across patient encounters, we observed recurring adjustments in physicians' communication behaviours in response to specific informal feedback cues. Physicians recognised and used these cues to self-monitor communication performance. They had established 'communication repertoires' based on multiple patient interactions, which many saw as learning opportunities contributing to the development of expertise. Our findings, however, show differences in physicians' individual levels of sensitivity in recognising and using learning opportunities in daily practice, which were further influenced by contextual, personal and interpersonal factors. Whereas some described themselves as having little inclination to change, others used critical incidents to fine-tune their communication repertoires, and yet others constantly reshaped them, seeking learning opportunities in their daily work.

CONCLUSIONS

There is large variation in how physicians use learning cues from daily practice. To enhance learning in and from daily practice, we propose turning workplace learning into a collaborative effort with the aim of increasing awareness and the use of informal performance-relevant feedback.

Comparison of students' performance of objective structured clinical examination during clinical practice

PURPOSE

Clinical practice for medical students aims to improve their clinical competency. Since students gain experience in clinical practice, it is assumed that their capacity for care is strengthened. This study aimed to verify whether there is a change in the competency of medical students after clinical practice.

METHODS

We assessed the clinical performance of 120 medical students who were enrolled in the fifth year over the academic years 2016-2018. Objective structured clinical examination (OSCE) was used to measure the clinical competency.

RESULTS

The OSCE scores for November fifth grade improved significantly compared to May fifth grade. The scores in September of sixth grade were slightly lower than those of November of fifth grade, but there was no statistically significant difference.

CONCLUSION

It was confirmed that the clinical practice of fifth-year students improved their clinical competency, but it did not show any significant shift in the clinical competency of sixth-year students. The results of this study suggest that it is very important to organize the curriculum so that students can continue to experience patient-facing care throughout the entire clinical practice course to produce highly qualified physicians.

More Is Not Always Better in Simulation. Learners' Evaluation of a "Chest Model"

Background: Fidelity in simulation is an important design feature. Although it is typically seen as bipolar (i.e., "high" or "low"), fidelity is actually multidimensional. There are concerns that "low fidelity" might impede the immersion of learners during simulation training. "Locally built models" are characterized by decreased cost and reduced "structural" fidelity (how the simulator looks) while satisfying "functional" fidelity (what the simulator does). Objective: To 1) describe the use of a locally built chest tube model in building a mastery-based simulation curriculum and 2) describe evaluation of the model from learners in different stages and contexts. Methods: The model was built on the basis of key functional features of the assigned training task. A curriculum that combined progressive difficulty and opportunities for deliberate practice and mastery was developed. An analysis of the learner's survey responses was performed using SAS studio (SAS Software). Results: We describe the process of creating the chest tube model and a curriculum in which the model is used for increasing levels of difficulty to reach skill mastery. Learners at different stages and in different contexts, such as practicing physicians and trainees from developed and developing countries, evaluated the model similarly. We provide validity evidence for the content, response process, and relationship with other variables when using the model in the assessment of chest tube insertion skills. Conclusion: As demonstrated in our chest tube critical care medicine curriculum, the locally built models are simple to build and feasible to use. Contrary to current thinking that low-fidelity models might impede immersion in simulation training for experienced learners, the survey results show that different learners provide very similar evaluations after practicing with the model.

Quantitating skill acquisition with optical ultrasound simulation

Objective

To investigate and compare the effect of simulator training on quantitative scores for ultrasound-related skills for trainees with novice level ultrasound experience and expert ultrasound operators.

Methods

Three novice (comprising of 11, 32, 23 participants) and one expert (10 participants) subgroups undertook an ultrasound simulation training session. Pre- and post-training test scores were collected for each subgroup. Outcome measures were as follows: mean accuracy score for obtaining the correct anatomical plane, percentage of correctly acquired target planes, mean number of movements, time to achieve image, distance travelled by probe and accumulated angling of the probe.

Results

The novices showed improvement in image acquisition after completion of the simulation training session with an improvement in the rate of correctly acquired target planes from 28-57% to 39-83%. This was not replicated in the experts. The novice's individual ratios based on pre- vs. post-training metrics improved between 1.7- and 4.3-fold for number of movements, 1.9- and 6.7-fold for distance, 2.0- and 5.2-fold for time taken and 1.8- and 7.3-fold for accumulated angling. Among the experts, there was no relationship between pre-training simulator metrics and years of ultrasound experience.

Conclusions

The individual simulation metrics suggest the sessions were delivered at an appropriate level for basic training as novice trainees were able to show demonstrable improvements in both efficiency and accuracy on the simulator. Experts did not improve after the simulation modules, and the novice scores post-training were similar to those of experts, suggesting the exercises were valid in testing ultrasound skills at novice but not expert level.

Clinical Reasoning as a Core Competency

Diagnostic error is a challenging problem; addressing it effectively will require innovation across multiple domains of health care, including medical education. Diagnostic errors often relate to problems with clinical reasoning, which involves the cognitive and relational steps up to and including establishing a diagnostic and therapeutic plan with a patient. However, despite a call from the National Academies of Sciences for medical educators to improve the teaching and assessment of clinical reasoning, the creation of explicit, theory-informed clinical reasoning curricula, faculty development resources, and assessment tools has proceeded slowly in both undergraduate and graduate medical education. To accelerate the development of this critical element of health professions education and to promote needed research and innovation in clinical reasoning education, the Accreditation Council for Graduate Medical Education (ACGME) should revise its core competencies to include clinical reasoning. The core competencies have proven to be an effective means of expanding educational innovation across the United States and ensuring buy-in across a diverse array of institutions and disciplines. Reformulating the ACGME core competencies to include clinical reasoning would spark much-needed educational innovation and scholarship in graduate medical education, as well as collaboration across institutions in this vital aspect of physicianship, and ultimately, could contribute to a reduction of patient suffering by better preparing trainees to build individual, team-based, and system-based tools to monitor for and avoid diagnostic error.

Medical Students' Progress in Detecting and Interpreting Visual and Auditory Clinical Findings

Phenomenon: Detection of visual and auditory clinical findings is part of medical students' core clinical performance abilities that a medical education curriculum should teach, assess, and remediate. However, there is a limited understanding of how students develop these skills. While training physical exam technical skills has received significant attention and emphasis, teaching and assessing medical students' ability to detect and interpret visual and auditory clinical findings skills has been less systematic. Therefore, the purpose of this study is to investigate how medical students' visual and auditory clinical findings skills progress and develop over their four years of undergraduate medical education. This study will provide educators insights that can guide curriculum refinements that lead to improving students' abilities in this area. Approach: A computer-based progress exam was created to measure the longitudinal development of students' abilities to detect and interpret visual and auditory findings. After pilot testing, sixty test items were developed in collaboration with six clinical faculty members and two medical education researchers. The exam includes detection and description of ECG, x-ray, heart sounds, breath sounds, skin lesions, and movement findings. The exam was administered to students at the beginning of each training year since 2014. Additionally, the exam was administered to the Class of 2017 prior to their graduation. Measurement validity and reliability tests were conducted. Descriptive statistics and ANOVA were used to determine progress. Findings: More than 98% of students in four years of training completed the exam each year. The exam instrument had high reliabilities and demonstrated acceptable concurrent validity when compared with other academic performance data. Findings showed that students' visual and auditory clinical findings skills increased each training year until their fourth year. There was no performance improvement between incoming Year 4 students and graduating Year 4 students. While group means increased, class performance did not become more homogeneous across four years. Longitudinal data showed the same performance patterns as the cross-sectional data. Performance of the bottom quartile of graduating fourth-year students was not significantly higher than the performance of the top quartile of incoming first-year students who had not had formal medical training. Insights: A longitudinal study to follow learners' performance in detecting and interpreting visual and auditory clinical findings can provide meaningful insights regarding the effects of medical training programs on performance growth. The present study suggests that our medical curriculum is not effective in bringing all students to a higher level of performance in detecting and interpreting visual and auditory clinical findings. This study calls for further investigation how medical students can develop visual and auditory detection and interpretation skills in undergraduate medical education. There is a need for planned curriculum and assessment of medical students' skills in detecting and interpreting visual and auditory clinical findings.

Preventing Readmissions Through Effective Partnerships—Communication and Palliative Care (PREP-CPC): A Multisite Intervention for Encouraging Goals of Care Conversations for Hospitalized Patients Facing Serious Illness

Background:

Despite evidence showing that goals of care (GOC) conversations increase the likelihood that patients facing a serious illness receive care that is concordant with their wishes, only a minority of at-risk patients receive the opportunity to engage in such conversations.

Objective:

The Preventing Readmissions through Effective Partnerships—Communication and Palliative Care (PREP-CPC) intervention was designed to increase the frequency of GOC conversations for hospitalized patients facing serious illness.

Methods:

The PREP-CPC employed a sequential, multicohort design using a yearlong mentored implementation approach to support nonpalliative care health-care professionals at participating hospitals to implement quality improvement projects focused on GOC conversations.

Results:

Over the 3-year study period, 134 clinicians from 29 hospital teams were trained to facilitate GOC conversations. After the kickoff conference, participants reported improvements in their confidence in facilitating GOC conversations. The hospital teams then instituted site-specific pilot interventions to promote GOC conversations, identifying essential elements required for ongoing improvement. Since projects varied by hospital, results did as well, but reported positive outcomes included increased GOC conversations, increased Practitioner Orders for Life-Sustaining Treatment form completion rates, new screening and documentation methods, and increased support from leadership.

Conclusions:

The PREP-CPC pilot successfully engaged a diverse set of hospitals to participate in quality improvement collaborative promoting primary palliative care and more frequent GOC conversations. This initiative revealed several lessons that should guide future interventions.

The student is key: A realist review of educational interventions to develop analytical and non-analytical clinical reasoning ability

OBJECTIVES

Clinical reasoning refers to the cognitive processes used by individuals as they formulate a diagnosis or treatment plan. Clinical reasoning is dependent on formal and experiential knowledge. Developing the ability to acquire and recall knowledge effectively for both analytical and non-analytical cognitive processing has patient safety implications. This realist review examines the way educational interventions develop analytical and non-analytical reasoning ability in undergraduate education. A realist review is theory-driven, seeking not only to identify if an intervention works, but also understand the reasons why, for whom, and in what circumstances. The aim of this study is to develop understanding about the way educational interventions develop effective analytical and non-analytical clinical reasoning ability, when they do, for whom and in what circumstances.

METHODS

Literature from a scoping search, combined with expert opinion and researcher experience was synthesised to generate an initial programme theory (IPT). Four databases were searched and articles relevant to the developing theory were selected as appropriate. Factors affecting educational outcomes at the individual student, teacher and wider organisational levels were investigated in order to further refine the IPT.

RESULTS

A total of 28 papers contributed to the overall programme theory. The review predominantly identified evidence of mechanisms for interventions at the individual student level. Key student level factors influencing the effectiveness of interventions included an individual's self-confidence, self-efficacy and pre-existing level of knowledge. These contexts influenced a variety of educational interventions, impacting both positively and negatively on educational outcomes.

CONCLUSIONS

Development of analytical and non-analytical clinical reasoning ability requires activities that enhance knowledge acquisition and recall alongside the accumulation of clinical experience and opportunities to practise reasoning in real or simulated clinical environments. However, factors such as pre-existing knowledge and self-confidence influence their effectiveness, especially amongst individuals with 'low knowledge.' Promoting non-analytical reasoning once novices acquire more clinical knowledge is important for the development of clinical reasoning in undergraduate education.

Novel Simulation Model with Pulsatile Flow System for Microvascular Training, Research, and Improving Patient Surgical Outcomes

BACKGROUND

Simulation allows surgical trainees to acquire surgical skills in a safe environment. With the aim of reducing the use of animal experimentation, different alternative nonliving models have been pursued. However, one of the main disadvantages of these nonliving models has been the absence of arterial flow, pulsation, and the ability to integrate both during a procedure on a blood vessel. In the present report, we have introduced a microvascular surgery simulation training model that uses a fiscally responsible and replicable pulsatile flow system.

METHODS

We connected 30 human placentas to a pulsatile flow system and used them to simulate aneurysm clipping and vascular anastomosis.

RESULTS

The presence of the pulsatile flow system allowed for the simulation of a hydrodynamic mechanism similar to that found in real life. In the aneurysm simulation, the arterial flow could be evaluated before and after clipping the aneurysm using a Doppler ultrasound system. When practicing anastomosis, the use of the pulsatile flow system allowed us to assess the vascular flow through the anastomosis, with verification using the Doppler ultrasound system. Leaks were manifested as "blood" pulsatile ejections and were more frequent at the beginning of the surgical practice, showing a learning curve.

CONCLUSIONS

We have provided a step-by-step guide for the assembly of a replicable and inexpensive pulsatile flow system and its use in placentas for the simulation of, and training in, performing different types of anastomoses and intracranial aneurysms surgery.

Combined Gaze Metrics as Stress-Sensitive Indicators of Microsurgical Proficiency

Background. Evaluation of microsurgical proficiency is conventionally subjective, time consuming, and unreliable. Eye movement–based metrics have been promising not only in detection of surgical expertise but also in identifying actual cognitive stress and workload. We investigated if pupil dilations and blinks could be utilized in parallel to accurately classify microsurgical proficiency and its moderating features, especially task-related stress. Methods. Participants (n = 11) were divided into groups based on prior experience in microsurgery: novices (n = 6) with no experience and trained microsurgeons (n = 5). All participants conducted standardized suturing tasks with authentic instruments and a surgical microscope. A support vector machine classifier was used to classify features of microsurgical expertise based on percentage changes in pupil size. Results. A total of 109 successful sutures with 1090 segments were recorded. Classification of expertise from sutures achieved accuracies between 74.3% and 76.0%. Classification from individual segments based on these same features was not feasible. Conclusions. Combined gaze metrics are applicable for classifying surgical proficiency during a defined task. Pupil dilation is also sensitive to external stress factors; however, the usefulness of blinks is impaired by low blink rates. The results can be translated to surgical education to improve feedback and should be investigated individually in the context of actual performance and in real patient operations. Combined gaze metrics may be ultimately utilized to help microsurgeons monitor their performance and workload in real time—which may lead to prevention of errors.

TEACH and repeat: Deliberate practice for teaching

BACKGROUND

Deliberate practice facilitates skill mastery. We aimed to create a novel resident-as-teacher rotation, leveraging a deliberate practice framework with repeated practice in real-life teaching settings, with feedback from dedicated faculty member coaches.

METHODS

A resident-as-teacher rotation was designed for 35 Postgraduate Year-2 (PGY2) paediatric residents. To facilitate deliberate practice, teaching experiences were observed by faculty member coaches and were repeated with different audiences. Participating residents received pre-rotation, post-rotation and follow-up surveys on their confidence and comfort with teaching, supervision and feedback skills. All residents were also surveyed the year before and the year after implementation on their perceptions of their teaching, supervision and feedback skills, and whether the residency provided adequate training on these topics.

RESULTS

Survey response rates varied from 40 to 71%. The rotation was highly valued, and deliberate practice was a most valued aspect. Mean scores in comfort and confidence significantly increased from pre- to post-rotation, with these increases sustained months later. Prior to implementation, residents' perceptions of their teaching skills and the adequacy of their training increased incrementally with each postgraduate year. After the inaugural year of the rotation, the PGY2 class rated their teaching skills and training as higher than more experienced residents.

DISCUSSION

A novel resident-as-teacher rotation successfully incorporated deliberate practice in real-life settings by repeating teaching activities with feedback from dedicated coaches. The rotation led to sustained increases in residents' confidence in their teaching, supervising and feedback skills, and improved perceptions of their teaching training during residency.

Experience of Practicing Veterinarians with Supervising Final-Year Students and New Graduates in Performing Desexing Surgeries

With increasing pressure on university teaching hospital caseloads, veterinary students are increasingly being taught basic desexing skills during their final-year extramural rotations or as new graduates in practice. A cross-sectional survey of New Zealand veterinarians was conducted to elicit information about their experiences supervising these cohorts. Of the 162 respondents who had supervised at least one final-year veterinary student, only 95 (58.6%) allowed students to perform desexing surgeries and the most common procedures they allowed students to perform were cat neuters (96%) followed by cat spays (64%), dog neuters (63%), and dog spays (24%). The time needed to supervise students, the liability of students operating on client-owned animals, and students' poor basic instrument, tissue, and suture handling skills were cited as major deterrents. Breaks in sterility and dropped pedicles were the most frequently reported complications, although these still occurred only occasionally or rarely. Of the 101 respondents who had supervised at least one new graduate, all but one provided surgical mentoring. It took an average of 3.3 dog neuters, 8 dog spays, 2.4 cat neuters, and 4.7 cat spays before respondents were comfortable letting new graduates perform surgery unassisted. Respondents generally expected new graduates to perform dog spays in under 60 minutes, cats spays and dog neuters in under 30 minutes, and cat neuters in under 10 minutes. Although most respondents agreed that students needed more hands-on experience with live animal surgery, the main clinical skills deficiencies identified were ones that could easily be trained and practiced on simulated models.

A Comparison of Guided Video Reflection versus Self-Regulated Learning to Teach Knot Tying to Medical Students: A Pilot Randomized Controlled Trial

OBJECTIVES

Self-regulated learning has been proposed as a resource saving alternative for learning knot tying. However, this may be hindered by the Dunning-Kruger effect. A potential alternative is guided video reflection. The objectives of this study are to compare the performance and self-assessment abilities amongst medical students learning knot tying using either a traditional self-regulated approach versus guided video reflection.

DESIGN

This randomized, single-blinded, controlled trial used a pre-post-retention test design. All knot tying performances were video recorded and assessed nonsequentially by blinded evaluators using a modified Objective Structured Assessment of Technical Skills tool.

PARTICIPANTS

This study recruited 31 first- and second-year medical students and 6 senior urology residents from Western University in Canada.

RESULTS

At baseline, the performances of the experts were significantly higher than the experimental groups (F_3,85 = 9.080, p < 0.001). After the intervention, there was a significant increase in the performance for both experimental groups compared to the pretest period (p < 0.001). The scores between the experimental groups were not significantly different (p = 0.338). The improved performances of both groups were sustained on retention testing (p < 0.001). The self-assessment abilities were accurate for both experimental groups at baseline. However, at the post-test period the accuracy was poor (interclass correlation 0.361) for the self-regulated group, while remaining moderately (interclass correlation 0.685) accurate for the reflection group.

CONCLUSIONS

Students using guided video reflection were able to achieve competency and maintained their knot tying skills to the same degree as those who used the self-regulated approach. These results may be due to the positive effects of reflection on self-assessment abilities and subsequent improvement in goal setting for further practice.

Learning Conversations: An Analysis of the Theoretical Roots and Their Manifestations of Feedback and Debriefing in Medical Education

Feedback and debriefing are experience-informed dialogues upon which experiential models of learning often depend. Efforts to understand each have largely been independent of each other, thus splitting them into potentially problematic and less productive factions. Given their shared purpose of improving future performance, the authors asked whether efforts to understand these dialogues are, for theoretical and pragmatic reasons, best advanced by keeping these concepts unique or whether some unifying conceptual framework could better support educational contributions and advancements in medical education.The authors identified seminal works and foundational concepts to formulate a purposeful review and analysis exploring these dialogues' theoretical roots and their manifestations. They considered conceptual and theoretical details within and across feedback and debriefing literatures and traced developmental paths to discover underlying and foundational conceptual approaches and theoretical similarities and differences.Findings suggest that each of these strategies was derived from distinct theoretical roots, leading to variations in how they have been studied, advanced, and enacted; both now draw on multiple (often similar) educational theories, also positioning themselves as ways of operationalizing similar educational frameworks. Considerable commonality now exists; those studying and advancing feedback and debriefing are leveraging similar cognitive and social theories to refine and structure their approaches. As such, there may be room to merge these educational strategies as learning conversations because of their conceptual and theoretical consistency. Future scholarly work should further delineate the theoretical, educational, and practical relevance of integrating feedback and debriefing.

Maintaining competence in airway management

BACKGROUND

Airway management is a defining skill for anaesthesiologists. Anaesthesiologists must maintain and update these crucial skills throughout their career, but how this is best achieved remains unclear. This study aimed to clarify anaesthesiologists' procedural volume, confidence in airway management and their current and preferred future educational strategies.

METHODS

A questionnaire was developed consisting of 28 items exploring essential skills in airway management. All anaesthesiologists in the Capital Region of Denmark were invited to participate.

RESULTS

The response rate was 84% (240/285). Most anaesthesiologists felt competent to a high or very high degree in basic airway management. Anaesthesiologists from anaesthesia felt confident to a significantly higher degree than those working in the intensive care unit (ICU) regarding the practical aspects of airway management in both the anticipated difficult airway (93% vs 73%, P < .001) and the unanticipated difficult airway (81% vs 61%, P = .002). Both groups performed most of the key advanced techniques ≤4 times yearly, whereas anaesthesiologists from the ICU had a lower and less diverse procedural volume than those working in anaesthesia. The anaesthesiologists preferred training through their daily clinical work, hands-on workshops, and scenario-based simulation training. However, a large discrepancy was identified between the current and the desired level of training.

CONCLUSION

The anaesthesiologists felt competent to a high or very high degree in basic airway management but the current procedural volume in advanced airway management causes concern for skill maintenance. Furthermore, we found a gap between the current and the desired level of supplemental training.

Comparison of a Silicon Skin Pad and a Tea Towel as Models for Learning a Simple Interrupted Suture

There has been rapid growth in the range of models available for teaching veterinary clinical skills. To promote further uptake, particularly in lower-income settings and for students to practice at home, factors to consider include cost, availability of materials and ease of construction of the model. Two models were developed to teach suturing: a silicon skin pad, and a tea towel (with a check pattern) folded and stapled to represent an incision. The models were reviewed by seven veterinarians, all of whom considered both suitable for teaching, with silicon rated as more realistic. The learning outcome of each model was compared after students trained to perform a simple interrupted suture. Thirty-two second-year veterinary students with no prior suturing experience were randomly assigned to three training groups: silicon skin pad or tea towel (both self-directed with an instruction booklet), or watching a video. Following training, all students undertook an Objective Structured Clinical Examination (OSCE), placing a simple interrupted suture in piglet cadaver skin. The OSCE pass rates of the three groups were silicon skin pad, 10/11; tea towel, 9/10; and video, 1/11. There was no significant difference between the model groups, but the model groups were significantly different from the video group (p < .017). In conclusion, the tea towel was as effective as the silicon skin pad, but it was cheaper, simpler to make, and the materials were more readily available. In addition, both models were used effectively with an instruction booklet illustrating the value of self-directed learning to complement taught classes.

Implementation and Effectiveness of Coaching for Surgeons in Practice - A Mixed Studies Systematic Review

INTRODUCTION

Despite recent changes to medical education, surgical training remains largely based on the apprenticeship model. However, after completing training, there are few structured learning opportunities available for surgeons in practice to refine their skills or acquire new skills. Personalized observation with feedback is rarely a feature of traditional continuing medical education learning. Coaching has recently been proposed as a modality to meet these educational gaps; however, data are limited, and few coaching programs presently exist. The purpose of this study is to summarize the characteristics of coaching programs for surgeons in practice including participant satisfaction, program outcomes, and barriers to implementation, in the published literature.

METHODS

A mixed studies systematic review was conducted according to PRISMA guidelines to identify all original studies describing or investigating coaching for practicing surgeons up to 06/2019. Quantitative analysis was used to summarize numerical data, and qualitative analysis using grounded theory methodology for descriptive data was used to summarize the results into themes across studies.

RESULTS

After identification of articles, 27 were included in the final synthesis. Twenty-six articles described execution of a coaching program. Programs varied widely with 18/26 focusing on teaching new skills, and the remainder on refinement of skills. Thematic analysis identified 2 major data categories that guided deeper analysis: outcomes of and barriers to coaching. Of the 16 (62%) programs that reported outcomes of coaching, 42% to 100% of participants reported changes in clinical practice directly associated with coaching. Positive satisfaction after completion of a program was reported by 82% to 100% of participants. Reported barriers to participating in a coaching program emerged along 3 main themes: logistical constraints, surgical culture, and perceived lack of need.

CONCLUSIONS

Coaching for surgeons in practice is highly rated by participants and often results in clinical practice changes, while cultural and logistical issues were identified as barriers to implementation. A better understanding of these factors is required to guide coaching program development and implementation.