Deliberate practice and acquisition of expert performance: a general overview

Balance control during stance - A comparison between horseback riding athletes and non-athletes

Horseback riding requires the ability to adapt to changes in balance conditions, to maintain equilibrium on the horse and to prevent falls. Postural adaptation involves specific sensorimotor processes integrating visual information and somesthesic information. The objective of this study was to examine this multisensorial integration on postural control, especially the use of visual and plantar information in static (stable) and dynamic (unstable) postures, among a group of expert horse rider women (n = 10) and a group of non-athlete women (n = 12). Postural control was evaluated through the center of pressure measured with a force platform on stable and unstable supports, with the eyes open and the eyes closed, and with the presence of foam on the support or not. Results showed that expert horse rider women had a better postural stability with unstable support in the mediolateral axis compared to non-athletes. Moreover, on the anteroposterior axis, expert horse riders were less visual dependent and more stable in the presence of foam. Results suggested that horseback riding could help developing particular proprioceptive abilities on standing posture as well as better postural muscle tone during particular bipodal dynamic perturbations. These outcomes provide new insights into horseback riding assets and methodological clues to assess the impact of sport practice.

Descriptive Analysis of Pharmacy Students' Impressions on Virtual Interactive Case Software

Objective. To assess students' impressions on whether Virtual Interactive Cases (VICs) contribute to their learning experience. Methods. Ten fourth- year pharmacy students each independently completed the same four VICs followed by a semi-structured interview conducted by VIC project team members. The interviews were audio-recorded, transcribed, and coded for themes using qualitative research methods. Results. All participating students completed all the cases. Overall, students' feedback on VIC was positive. Five main themes emerged from the transcripts: VIC facilitated their skills in information gathering; they learned from the built-in, real-time, formative feedback; they had a fun and positive learning experience; VICs were realistic; and VIC system was user-friendly. Students also recommended that VIC be incorporated into classroom learning. Some students required additional explanation on the concept of time and costs associated with each action they selected, and the associated performance score. Conclusion. Pharmacy students' positive experiences with VICs support its use to bridge classroom learning with clinical practice.

Three-Dimensional Printed Pediatric Airway Model Improves Novice Learners' Flexible Bronchoscopy Skills With Minimal Direct Teaching From Faculty

INTRODUCTION

Training in pediatric flexible bronchoscopy (FB) is predominantly completed on patients. Early trainees are less accurate and slower than experienced bronchoscopists. This report describes the development of a three-dimensional printed airway model and describes how the model was used to teach learners basic FB skills.

METHODS

Postgraduate year two (PGY2) pediatric residents completing a 1-month pediatric pulmonology rotation with minimal previous exposure to FB were randomized into a simulation trainee group (n = 18) or a control resident group (n = 9). The simulation group received four 15-minute practice sessions (3 self-directed, 1 with feedback). Participants completed a bronchoscopy assessment on the model at prestudy, poststudy, and delayed (at least 2 months after the rotation) time points. Outcomes were identification of markers located in the six lung areas and completion time.

RESULTS

There was no difference in prestudy scores between groups. In the poststudy assessment, the simulation participants correctly identified more lung area markers (median = 6 vs 1.5, P < 0.001) and were faster (median = 102 vs 600 seconds, P < 0.001). In the delayed assessment, correct marker identification trended toward improvement in the simulation group compared with controls (median = 4 vs 2, P = 0.077).

CONCLUSIONS

With 1 hour of practice time, requiring 15 minutes of direct teaching, novice resident bronchoscopists are able to more accurately identify and visualize the five lung lobes and lingula via FB and are able to do so in less time than control residents. This anatomically accurate model could be used to train basic FB skills at a low cost compared with other models.

Tending to innovate in Swedish primary health care: a qualitative study

Background

Policymakers in many countries are involved in system reforms that aim to strengthen the primary care sector. Sweden is no exception. Evidence suggests that targeted financial micro-incentives can stimulate change in certain areas of care, but they do not result in more radical change, such as innovation. The study was performed in relation to the introduction of a national health care reform, and conducted in Jönköping County Council, as the region’s handling of health care reforms has attracted significant national and international interest. This study employed success case method to explore what enables primary care innovations.

Methods

Five Primary Health Care Centres (PHCCs) were purposively selected to ensure inclusion of a variety of aspects, such as size, location, ownership and regional success criteria. 48 in-depth interviews with managers and staff at the recruited PHCCs were analysed using content analyses. The COREQ checklist for qualitative studies was used to assure quality standards.

Results

This study identified three types of innovations, which break with previous ways of organizing work at these PHCCs: (1) service innovation; (2) process innovation; and (3) organizational innovation. A learning-oriented culture and climate, comprising entrepreneurial leadership, cross-boundary collaboration, visible and understandable performance measurements and ability to adapt to external pressure were shown to be advantageous for innovativeness.

Conclusions

This qualitative study highlights critical features in practice that support primary care innovation. Managers need to consistently transform and integrate a policy “push” with professionals’ understanding and values to better support primary care innovation. Ultimately, the key to innovation is the professionals’ engagement in the work, that is, their willingness, capability and opportunity to innovate.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3874-y) contains supplementary material, which is available to authorized users.

The Council of Emergency Medicine Residency Directors Academy for Scholarship Coaching Program: Addressing the Needs of Academic Emergency Medicine Educators

Introduction

Didactic lectures remain fundamental in academic medicine; however, many faculty physicians do not receive formal training in instructional delivery. In order to design a program to instill and enhance lecture skills in academic emergency medicine (EM) physicians we must first understand the gap between the current and ideal states.

Methods

In 2012 the Council of Emergency Medicine Residency Directors (CORD) Academy for Scholarship designed a novel coaching program to improve teaching skills and foster career development for medical educators based on literature review and known teaching observation programs. In order to inform the refinement of the program, we performed a needs assessment of participants. Participants’ needs and prior teaching experiences were gathered from self-reflection forms completed prior to engaging in the coaching program. Two independent reviewers qualitatively analyzed data using a thematic approach.

Results

We analyzed data from 12 self-reflection forms. Thematic saturation was reached after nine forms. Overall inter-rater agreement was 91.5%. We categorized emerging themes into three domains: participant strengths and weaknesses; prior feedback with attempts to improve; and areas of desired mentorship. Several overlapping themes and subthemes emerged including factors pertaining to the lecturer, the audience/learner, and the content/delivery.

Conclusion

This study identified several areas of need from EM educators regarding lecture skills. These results may inform faculty development efforts in this area. The authors employed a three-phase, novel, national coaching program to meet these needs.

Designing and implementing asynchronous online deliberate practice to develop interprofessional communication competency

Communicating with healthcare providers is a core tenant in the Quality and Safety Education for Nurses and Institute of Medicine teamwork and collaboration competency but remains a major concern for pre-licensure nursing students and novice nurses. Pre-licensure nursing students rarely have opportunities to practice interprofessional communication skills with other healthcare providers even though lack of this skill competency may lead to patient harm. This article explores the feasibility of using story-guided online deliberate practice sessions as an educational strategy to improve students' interprofessional critical communication competency. The design and testing of asynchronous online deliberate practice session prototypes is described and the implementation and evaluation of two online deliberate practice sessions into a nursing course is reported. The online format provided students with convenient opportunities to develop competency in critical communication skills using SBAR in a safe environment. Results from the prototype testing and student evaluation indicated that students had an overall positive experience. The online deliberate practice sessions provided a low-cost, flexible practice experience to develop critical communication skills and were evaluated as highly satisfactory and easy to navigate. The optimal number of practice sessions needed to attain competency, retain skills, and impact patient outcomes require further longitudinal study.

Long-term social skills group training for children and adolescents with autism spectrum disorder: a randomized controlled trial

Social skills group training (SSGT) is widely used for intellectually able children and adolescents with autism spectrum disorder (ASD). Previous studies indicate small to moderate effects on social communication capacities. The duration of most available programs is relatively short, and extended training might lead to further improvement. This randomized controlled trial compared an extended 24-week version of the SSGT program KONTAKT with standard care. The weekly sessions gradually shifted in content from acquisition of new skills to real-world application of the acquired skills. A total of 50 participants with ASD (15 females; 35 males) aged 8-17 years were included. The study was conducted at two child and adolescent psychiatry outpatient units in Sweden. The primary outcome was the Social Responsiveness Scale-Second Edition (SRS-2) rated by parents and blinded teachers. Secondary outcomes included parent- and teacher-rated adaptive behaviors, trainer-rated global functioning and clinical severity, and self-reported child and caregiver stress. Assessments were made at baseline, posttreatment, and at 3-months follow-up. Parent-rated SRS-2 scores indicated large effects posttreatment [- 19.2; 95% CI - 29.9 to - 8.5; p < .001, effect size (ES) = 0.76], which were maintained at follow-up (- 20.7; 95% CI - 31.7 to - 9.7; p < .0001, ES = 0.82). These estimates indicate substantially larger improvement than previously reported for shorter SSGT. However, the effects on teacher-rated SRS-2 and most secondary outcomes did not reach statistical significance. Our results suggest added benefits of extended SSGT training, implying that service providers might reach better results by optimizing the delivery of SSGT.

Training to Proficiency in the WHO Hand Hygiene Technique

OBJECTIVES

Hand hygiene is critical to patient safety, but low performance in terms of the quantity and quality of hand hygiene is often reported. Training-to-proficiency is common for other clinical skills, but no proficiency-based training program for hand hygiene has been reported in the literature. This study developed a proficiency-based training program to improve hand hygiene quality in line with World Health Organization (WHO) guidelines and assessed the amount of training required to reach proficiency. The training was delivered as part of a 5-day induction for students on the Physician Assistant online program.

METHODS

A total of 42 students used a simulator to objectively measure hand hygiene technique over a 5-day period. Proficiency was achieved when students demonstrated all 6 steps of the WHO technique in less than 42 seconds. The students also completed a postintervention questionnaire.

RESULTS

The average training episode lasted 2.5 minutes and consisted of 4.5 hand hygiene exercises. The average student completed 5 training episodes (1 per day) taking a total of 17 minutes. A total of 40% (17) of the students achieved proficiency within the 5 days. Proficiency was strongly correlated with the number of training exercises completed (r = 0.79, P < .001) and the total time spent training (r = 0.75, P < .001). Linear regression predicted that the 32 hand hygiene exercises or a total of 23-minute training were required to achieve proficiency.

CONCLUSIONS

This is the first study to develop a train-to-proficiency program for hand hygiene quality and estimate the amount of training required. Given the importance of hand hygiene quality to preventing health care-associated infections (HAIs), medical education programs should consider using proficiency-based training in hand hygiene technique.

Moving Toward Milestone-Based Assessment in Osteopathic Manipulative Medicine

Osteopathic medicine is continuing to move toward competency-based education at undergraduate and graduate levels. Competencies and Entrustable Professional Activities (EPAs) have been implemented to guide educators on the skills and abilities that osteopathic medical students and residents should be able to perform as physicians. Unfortunately, many of these skills have not been well described, and the threshold of “competence” or “entrustability” for each of these tasks remains elusive. The author presents an approach to measuring competence in the domain of osteopathic manipulative medicine using a milestone rubric to assess skills related to osteopathic screening, diagnosis, technique, and explanation. This rubric can be applied to all levels of osteopathic training and across many diagnostic and treatment modalities. Clearly defining and assessing the individual skills composing competence in osteopathic manipulative medicine will be increasingly important as medical education continues to evolve and modernize.

Resident and attending perceptions of direct observation in internal medicine: a qualitative study

OBJECTIVES

Direct observation is the foundation of assessment and learning in competency-based medical education (CBME). Despite its importance, there is significant uncertainty about how to effectively implement frequent and high-quality direct observation. This is particularly true in specialties where observation of non-procedural skills is highly valued and presents unique challenges. It is therefore important to understand perceptions of direct observation to ensure successful acceptance and implementation. In this study, we explored perceptions of direct observation in internal medicine.

METHODS

We interviewed internal medicine attending physicians (n = 9) and residents (n = 8) at the University of Toronto, purposively sampled for diversity. Using a constructivist grounded theory approach, constant comparative analysis was performed to develop a framework to understand perceptions of direct observation on the clinical teaching units.

RESULTS

Participants articulated a narrow perception of what constitutes direct observation, in contrast to their own descriptions of skills that were observed. This resulted in the perception that certain valuable skills that participants felt were routinely observed were nonetheless not 'directly observable', such as clinical reasoning, observed through case presentations and patient care discussions. Differentiating direct observation from informal observation led to overestimation of the time and resource requirements needed to enhance direct observation, which contributed to scepticism and lack of engagement related to CBME implementation.

CONCLUSIONS

In an internal medicine training programme, perceptions of what constitutes direct observation can lead to under-recognition and hinder acceptance in workplace-based assessment and learning. Our results suggest a reframing of 'direct observation' for residents and attending physicians, by explicitly identifying desired skills in non-procedurally-based specialties. These findings may help CBME-based training programmes improve the process of direct observation, leading to enhanced assessment and learning.

Lightly Embalmed Cadavers as a Training Tool for Ultrasound-Guided Procedures Commonly Used in Interventional Radiology

RATIONALE AND OBJECTIVES

Competency in ultrasound (US) imaging and US-guided procedures is often difficult for medical students and residents to master. The use of simulation training has been strongly encouraged but the quality of phantom models available for US-guided procedures is limited. As a feasible alternative, we describe the innovative use of a lightly embalmed cadaver for realistic practice of common interventional radiology (IR) procedures prior to direct patient care.

MATERIALS AND METHODS

Lightly embalmed cadavers were positioned as patients would be in the IR suite: supine, prone, and erect seated position. Lidocaine was injected and visualized under standard percutaneous techniques and sonographic guidance was used to simulate common US-guided procedures performed in IR including liver biopsy, kidney biopsy, thoracentesis, and vascular access.

RESULTS

The ability to position cadavers was a key factor that allowed entire procedures to be simulated. Medical students with very limited exposure to US imaging and diagnostic radiology residents with minimal exposure to US imaging successfully completed common US-guided procedures. Arterial and venous vascular access was obtained. Wires were passed and catheters easily placed via both access sites. The texture of the tissue layers provided realistic feedback for the trainees as they advanced the needle or dilated the tissues. Images from each simulated procedure resembled images expected in a living patient.

CONCLUSION

Lightly embalmed cadavers are an innovative and feasible tool to simulate common IR US-guided procedures in a realistic fashion for deliberate practice in advance of first-attempt encounters with patients.

Neonatal resuscitation experience curves: simulation based mastery learning booster sessions and skill decay patterns among pediatric residents

Background Following neonatal resuscitation program (NRP) training, decay in clinical skills can occur. Simulation-based deliberate practice (SBDP) has been shown to maintain NRP skills to a variable extent. Our study objectives were (a) to determine whether a single 30 min simulation-based intervention that incorporates SBDP and mastery learning (ML) can effectively restore skills and prevent skill decay and (b) to compare different timing options. Methods Following NRP certification, pediatric residents were randomly assigned to receive a video-recorded baseline assessment plus SBDP-ML refresher education at between 6 and 9 months (early) or between 9 and 12 months (late). One year following initial certification, participants had repeat skill retention videotaped evaluations. Participants were scored by blinded NRP instructors using validated criteria scoring tools and assigned a global performance rating score (GRS). Results Twenty-seven participants were included. Residents in both early and late groups showed significant skill decay 7 and 10 months after initial NRP. SBDP-ML booster sessions significantly improved participants' immediate NRP performance scores (p<0.001), which persisted for 2 months, but were again lower 4 months later. Conclusions NRP skills may be boosted to mastery levels after a short SBDP-ML intervention and do not appear to significantly decline after 2 months. Brief booster training could potentially serve as a useful supplement to traditional NRP training for pediatric residents.

A High-fidelity Tactile Hand Simulator as a Training Tool to Develop Competency in Percutaneous Pinning in Residents

Introduction

We developed an economical three-dimensional printed and casted simulator of the hand for the training of percutaneous pinning. This simulator augments the traditional "See one, do one, teach one" training model.

Methods

To evaluate the simulator, five expert orthopaedic surgeons were recruited to perform percutaneous pinning on the simulator and then to complete a questionnaire on its realism and expected usefulness. Evaluation was based on responses to multiple-choice questions and a Likert-type scale.

Results

All subjects expressed that the tactile hand simulator is useful for residency training. They would recommend the simulator to their colleagues and indicated interest in testing future iterations. Subjects rated highly the realism of the material, the purchase of the pin, and the cortical-cancellous bone interface.

Conclusion

The learning of tactile skills in addition to visual cues on a tactile simulator is expected to benefit residents. It provides a low-cost and low-risk environment outside the operating room for residents to hone their skills.

Communication Course for Pediatric Providers Improves Self-efficacy

BACKGROUND

Communication is essential to building a trusting, clinician-patient relationship. Multiple studies have demonstrated the effects of experiential communication training on patient experience and provider well-being and resiliency. To date, no studies have described an organization-wide communication training program for pediatric clinicians. The objective of this study was to evaluate the impact of a pediatric-focused communication course on provider satisfaction, self-efficacy, and burnout.

METHODS

Texas Children's Hospital, in collaboration with the Academy on Communication in Healthcare, designed and implemented a pediatric focused communication course entitled Breakthrough Communication. Pre, immediate-post, and 3-month postcourse completion online surveys were sent to participants 1 day before, 1 day after, and 3 months after course completion. Participant demographic information, self-assessment of communication skills, the Maslach Burnout Inventory Human Services Survey, and postcourse satisfaction data were collected.

RESULTS

Participants reported high course satisfaction and improved self-efficacy in all measured skill sets both following and 3 months after course completion. Trends indicating a reduction in provider burnout improved in 2 of the 3 Maslach Burnout Inventory domains; however, statistical significance was not achieved.

CONCLUSIONS

A pediatric-focused communication course was well received by multi-specialty clinicians within a large, academic health care organization. This course enhanced clinician self-efficacy with newly learned pediatric encounter specific communication skills.

Factors Important to Top Clinical Performance in Emergency Medicine Residency: Results of an Ideation Survey and Delphi Panel

OBJECTIVES

We explore attributes, traits, background, skills, and behavioral factors important to top clinical performance in emergency medicine (EM) residency.

METHODS

We used a two-step process-an ideation survey with the Council of Emergency Medicine Residency Directors and a modified Delphi technique-to identify: 1) factors important to top performance, 2) preresidency factors that predict it, and 3) the best ways to measure it. In the Delphi, six expert educators in emergency care assessed the presence of the factors from the ideation survey results in their top clinical performers. Consensus on important factors that were exemplified in >60% of top performers were retained in three Delphi rounds as well as predictors and measures of top performance.

RESULTS

The ideation survey generated 81 responses with ideas for each factor. These were combined into 89 separate factors in seven categories: attributes, personal traits, emergency department (ED)-specific skills and behaviors, general skill set, background, preresidency predictors, and ways to measure top performance. After three Delphi rounds, the panel achieved consensus on 20 factors important to top clinical performance. This included two attributes, seven traits, one general skill set, and 10 ED-specific skills and behaviors. Interview performance was considered the sole important preresidency predictor and clinical competency committee results the sole important measure of top performance.

CONCLUSION

Our expert panel identified 20 factors important to top clinical performance in EM residency. Future work is needed to further explore how individuals learn and develop these factors.

Reducing Lethal Force Errors by Modulating Police Physiology

OBJECTIVES

The aim of this study was to test an intervention modifying officer physiology to reduce lethal force errors and improve health.

METHODS

A longitudinal, within-subjects intervention study was conducted with urban front-line police officers (n = 57). The physiological intervention applied an empirically validated method of enhancing parasympathetic engagement (ie, heart rate variability biofeedback) during stressful training that required lethal force decision-making.

RESULTS

Significant post-intervention reductions in lethal force errors, and in the extent and duration of autonomic arousal, were maintained across 12 months. Results at 18 months begin to return to pre-intervention levels.

CONCLUSION

We provide objective evidence for a physiologically focused intervention in reducing errors in lethal force decision-making, improving health and safety for both police and the public. Results provide a timeline of skill retention, suggesting annual retraining to maintain health and safety gains.

Workplace mentoring of residents in generic competencies by an independent coach

INTRODUCTION

During postgraduate education in pulmonology, supervisors are responsible for training residents in generic competencies such as communication, professionalism and collaboration, but their focus commonly lies more on medical-technical competencies. As an alternative approach to supporting residents to develop generic skills, we developed a personal mentoring program with a non-medical professional as mentor. In this study, the residents' experiences with the mentoring program were evaluated.

METHODS

After an introductory session in which individual learning goals were established, pulmonology residents received at least six, 60-90-minute, individual, mentoring sessions largely consisting of feedback after being observed during daily clinical activities, over a period of 9 months. The residents' experiences with mentoring were explored through in-depth interviews followed by a qualitative content analysis.

RESULTS

From March to November 2016, ten residents in pulmonology completed the program. Despite initial scepticism, mentoring encouraged residents to reflect deeply on their professional interactions. This caused an increased awareness of the effects of their communication and behaviour on patients. Experimenting with communication and different behaviours in subsequent interactions felt rewarding and contributed to further development, resulting in increased self-confidence and job satisfaction.

DISCUSSION

Mentoring residents by non-medical coaching was associated with improved residents' proficiency in generic competencies.

Communicating medication risk to cardiovascular patients in Qatar

Purpose

Patient safety is gaining prominence in health professional curricula. Patient safety must be complemented by teaching and skill development in practice settings. The purpose of this paper is to explore how experienced pharmacists identify, prioritize and communicate adverse drug effects to patients.

Design/methodology/approach

A focus group discussion was conducted with cardiology pharmacy specialists working in a Doha hospital, Qatar. The topic guide sought to explore participants’ views, experiences and approaches to educating patients regarding specific cardiovascular therapy safety and tolerability. Discussions were audio-recorded and transcribed verbatim. Data were coded and organized around identified themes and sub-themes. Working theories were developed by the three authors based on relevant topic characteristics associated with the means in which pharmacists prioritize and choose adverse effect information to communicate to patients.

Findings

Nine pharmacists participated in the discussion. The specific adverse effects prioritized were consistent with the reported highest prevalence. Concepts and connections to three main themes described how pharmacists further tailored patient counseling: potential adverse effects and their perceived importance; patient encounter; and cultural factors. Pharmacists relied on initial patient dialogue to judge an individual’s needs and capabilities to digest safety information, and drew heavily upon experience with other counseling encounters to further prioritize this information, processes dependent upon development and accessing exemplar cases.

Originality/value

The findings underscore practical experience as a critical instructional element of undergraduate health professional patient safety curricula and for developing associated clinical reasoning.

Learning curves in surgery: variables, analysis and applications

Learning curves graphically represent the relationship between learning effort and learning outcome. Learning curves are increasingly used in research, the design of randomised controlled trials, the assessment of competency, healthcare education and training programme design. In this review we have outlined the principles behind plotting learning curves, described the common methods used to analyse learning curves, how to interpret learning curves, the multitude of learning models, their applications and potential pitfalls, and the importance of a mathematically rigorous approach to learning curve analytics.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes

STUDY OBJECTIVE

Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications.

DESIGN

Retrospective, multicenter, cohort study (Canadian Task Force classification II-2).

SETTING

Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites.

PATIENTS

Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012.

INTERVENTION

ACS-NSQIP database.

MEASUREMENTS AND MAIN RESULTS

Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality.

CONCLUSION

Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Study habits and academic achievement among medical students: A comparison between male and female subjects

PURPOSE

Study habits of medical students contribute to better understanding learner achievement and success. This study examines the relationship between study habits, including gender and nonacademic factors that affect learning, to investigate their relationship with performance outcomes.

METHODS

This study was conducted in March 2015 at the College of Medicine and Applied Medical Science at Taif University. A survey was administered, measuring study habits such as study time, study partners, source of study, breaks, study interruptions, difficulty concentrating, study activity, and delayed study. Comparisons were examined by high and low grade point average (GPA) and by gender.

RESULTS

A total of 257 students completed the questionnaire (59% high GPA and 41% low GPA; 50% males and 50% females). Results indicated significant differences for time of study, study materials, study interruptions, study enjoyment between students of high and low GPAs. Gender differences were found for study time, study methods, study breaks, student activity, and delayed study time.

CONCLUSIONS

This study found that study habits differ by gender and also have significant impact on performance outcomes of learners. Given that students' academic success is an important outcome for medical schools, these findings call for implementing these results to enhance curricular changes and promote better learning outcomes.

Paracentesis Simulation: A Comprehensive Approach to Procedural Education

INTRODUCTION

Structured procedural education and assessment of competency are growing needs for residency and fellowship programs. Simulation is a useful way to learn, experience, and practice procedural skills with competence. Paracentesis is a common procedure encountered in internal medicine. This educational resource for paracentesis education includes didactics, cases, and assessments to address cognitive skills, a simulation experience to address psychomotor procedural skills, and an entrustment-based assessment tool.

METHODS

Prior to the simulation, learners completed preprocedural didactics and self-assessments. Utilizing a paracentesis trainer, ultrasound, and paracentesis kit, the case of a 46-year-old male with ascites in need of a paracentesis was presented. During the simulation, learners initially performed a paracentesis step by step, with assistance and feedback from the case instructor. This was immediately followed by paracentesis without assistance, where the instructor evaluated the learners with an assessment tool encompassing a procedural checklist, global skill assessment scale, and entrustment scale. Afterwards, learners completed case-based reviews and returned to the simulation lab several months later to repeat an unassisted paracentesis.

RESULTS

The curriculum was used with internal medicine and medicine-pediatric residents of all training levels. To date, over 120 residents have completed the curriculum. Residents reported an increase in self-confidence and competence using ultrasound to identify ascites and performing a paracentesis. Learners provided positive feedback.

DISCUSSION

This curriculum offers the opportunity for both cognitive and psychomotor paracentesis education in a low-risk simulation environment. The comprehensive strategy with didactics, cases, and multiple simulations is designed to promote knowledge and skill retention.

Improving diagnosis by improving education: a policy brief on education in healthcare professions

Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative strategy for improving diagnosis, centered on future healthcare providers, to improve the education and training of clinicians in every health care profession. The hypothesis is that we can improve diagnosis by improving education. A literature search was first conducted to understand the relationship of education and training to diagnosis and diagnostic error in different health care professions. Based on the findings from this search we present the justification for focusing on education and training, recommendations for specific content that should be incorporated to improve diagnosis, and recommendations on educational approaches that should be used. Using an iterative, consensus-based process, we then developed a driver diagram that categorizes the key content into five areas. Learners should: 1) Acquire and effectively use a relevant knowledge base, 2) Optimize clinical reasoning to reduce cognitive error, 3) Understand system-related aspects of care, 4) Effectively engage patients and the diagnostic team, and 5) Acquire appropriate perspectives and attitudes about diagnosis. These domains echo recommendations in the National Academy of Medicine’s report Improving Diagnosis in Health Care. The National Academy report suggests that true interprofessional education and training, incorporating recent advances in understanding diagnostic error, and improving clinical reasoning and other aspects of education, can ultimately improve diagnosis by improving the knowledge, skills, and attitudes of all health care professionals.

Struggling Medical Learners: A Competency-Based Approach to Improving Performance

INTRODUCTION

Faculty must be trained to recognize, analyze, and provide feedback and resources to struggling medical learners. Training programs must be equipped to intervene when necessary with individualized remediation efforts to ensure learner success.

METHODS

This 90-minute interactive faculty development workshop provides a foundational competency-based framework for identifying and assisting the struggling medical learner. The workshop uses a mock academic promotions committee meeting addressing the case of a struggling undergraduate learner. The workshop was presented at two regional conferences, and participants completed an anonymous evaluation form containing 10 items on a 5-point Likert scale and two open-ended questions. Data were analyzed and a subgroup analysis performed using an independent t test and correlation. Qualitative data were read and coded for representative themes by two authors.

RESULTS

Fifty-five participants completed an evaluation form. The quality of the workshop was high (M = 4.5, SD = 0.6); participants agreed that the learning objectives were achieved and relevant to their educational needs (M = 4.4, SD = 0.7). A significant positive correlation existed between perceived quality and the interactive elements (.70, p < .05) as well as the intention to apply learning (.60, p < .05). Written comments revealed six themes: role-play, resources, interaction with colleagues, modeling, relevant content, and the process of learning.

DISCUSSION

The workshop's quality, relevance, and applicability were rated excellent among medical educators. Participants felt the interactive nature of the workshop was its most useful aspect, and a majority intended to apply the learning to their practice.

Coaching Residents in the Ambulatory Setting: Faculty Direct Observation and Resident Reflection

BACKGROUND

Direct observation can be valuable for learners' skill development in graduate medical education, but it is done infrequently. Information on how to optimize trainee learning from, and best practices of, direct observation interventions in the ambulatory setting is limited.

OBJECTIVE

We explored the impact of a focused outpatient direct observation and coaching intervention on internal medicine residents.

METHODS

Using a behavior checklist based on tenets of clinical excellence, 2 faculty preceptors observed outpatient primary care visits with 96% (46 of 48) of the internal medicine residents in 2017. Residents self-assessed their performance after the visit using the same checklist. Next, a focused coaching feedback session, emphasizing reflection, was structured to highlight areas of discrepancy between resident self-assessment and coach observation (blind spots), and residents were asked to identify goals for practice improvement.

RESULTS

Common blind spots in resident self-assessment related to collaborating with patients while using the electronic health record (48%, 21 of 44), hand washing (43%, 20 of 46), and asking thoughtful questions (40%, 18 of 45). At 1-month follow-up, 93% (43 of 46) of responding residents reported change in practice toward goals often or sometimes. All residents reported that the intervention felt comfortable, and 98% (45 of 46) noted that it helped them identify new behaviors to incorporate into clinical practice.

CONCLUSIONS

Structured episodes of direct observation and coaching in the outpatient setting, with a behavior checklist, appear acceptable and useful for internal medicine residents' learning and development.

Quantitative Analysis of Needle Navigation under Ultrasound Guidance in a Simulated Central Venous Line Procedure

Complications in ultrasound-guided central line insertions are associated with the expertise level of the operator. However, a lack of standards for teaching, training and evaluation of ultrasound guidance results in various levels of competency during training. To address such shortcomings, there has been a paradigm shift in medical education toward competency-based training, promoting the use of simulators and quantitative skills assessment. It is therefore necessary to develop reliable quantitative metrics to establish standards for the attainment and maintenance of competence. This work identifies such a metric for simulated central line procedures. The distance between the needle tip and ultrasound image plane was quantified as a metric of efficacy in ultrasound guidance implementation. In a simulated procedure, performed by experienced physicians, this distance was significantly greater in unsuccessful procedures (p = 0.04). The use of this metric has the potential to enhance the teaching, training and skills assessment of ultrasound-guided central line insertions.

What's the headline on your mind right now? How reflection guides simulation-based faculty development in a master class

Introduction

The demand for highly skilled simulation-based healthcare educators (SBEs) is growing. SBEs charged with developing other SBEs need to be able to model and conduct high-quality feedback conversations and 'debrief the debriefing'. Direct, non-threatening feedback is one of the strongest predictors of improved performance in health professions education. However, it is a difficult skill to develop. Developing SBEs who can coach and support other SBEs is an important part of the faculty development pipeline. Yet we know little about how they get better at skilled feedback and the ability to reflect on it. There is scant evidence about their thoughts, feelings and dilemmas about this advanced learning process. To address this gap, we examined advanced SBE's subjective experience as they grappled with challenges in a 4-day advanced SBE course. Their reflections will help target faculty development efforts.

Methods

Using a repeated, identical free-writing task, we asked "What is the headline for what is on your mind right now?"

Results

A five-theme mosaic of self-guiding reflections emerged: (1) metacognitions about one's learning process, (2) evaluations of sessions or tools, (3) notes to self, (4) anticipations of applying the new skills in the future, and (5) tolerating the tension between pleasant and unpleasant emotions.

Conclusions

The results extend simulation-based education science by advocating the motivational role of noting inconsistencies between one's intention and impact and the central role of self-regulation, emotion, and experiencing feedback and debriefing from multiple perspectives for improving advanced skills of SBEs. Recommendations for faculty development are discussed.

The R2C2 Model in Residency Education: How Does It Foster Coaching and Promote Feedback Use?

PURPOSE

The authors previously developed and tested a reflective model for facilitating performance feedback for practice improvement, the R2C2 model. It consists of four phases: relationship building, exploring reactions, exploring content, and coaching. This research studied the use and effectiveness of the model across different residency programs and the factors that influenced its effectiveness and use.

METHOD

From July 2014-October 2016, case study methodology was used to study R2C2 model use and the influence of context on use within and across five cases. Five residency programs (family medicine, psychiatry, internal medicine, surgery, and anesthesia) from three countries (Canada, the United States, and the Netherlands) were recruited. Data collection included audiotaped site assessment interviews, feedback sessions, and debriefing interviews with residents and supervisors, and completed learning change plans (LCPs). Content, thematic, template, and cross-case analysis were conducted.

RESULTS

An average of nine resident-supervisor dyads per site were recruited. The R2C2 feedback model, used with an LCP, was reported to be effective in engaging residents in a reflective, goal-oriented discussion about performance data, supporting coaching, and enabling collaborative development of a change plan. Use varied across cases, influenced by six general factors: supervisor characteristics, resident characteristics, qualities of the resident-supervisor relationship, assessment approaches, program culture and context, and supports provided by the authors.

CONCLUSIONS

The R2C2 model was reported to be effective in fostering a productive, reflective feedback conversation focused on resident development and in facilitating collaborative development of a change plan. Factors contributing to successful use were identified.

Ear Disease Knowledge and Otoscopy Skills Transfer to Real Patients: A Randomized Controlled Trial

OBJECTIVE

To determine which teaching method-otoscopy simulation (OS), web-based module (WM), or standard classroom instruction (SI)-produced greater translation of knowledge and otoscopy examination skills to real patients.

DESIGN

In a prospective randomized controlled nonclinical trial, medical students were randomized to 1 of 3 interventional arms: (1) OS, (2) WM, or (3) SI. Students were assessed at baseline for diagnostic accuracy and otoscopy skills on 5 volunteer patients (total of 10 ears), followed by the intervention. Testing was repeated immediately after intervention on the same patients. Student reported confidence in diagnostic accuracy and otoscopy examination were also captured. Assessors were blinded to the intervention group, and whether students were pre- or post-intervention.

SETTING

Clinical Teaching Centre, Queen's University.

PARTICIPANTS

Twenty-nine participants were initially randomized. Two students were unable to attend their specific intervention sessions and withdrew. Final group sizes were: OS-10, WM-9, SI-8. Five patients with external/middle ear pathologies were voluntarily recruited to participate as testing subjects.

RESULTS

Baseline diagnostic accuracy and otoscopy clinical skills did not differ across the groups. Post-intervention, there were improvements in diagnostic accuracy from all groups: OS (127.78%, 2.30 ± 1.42, p = 0.0006), WM (76.40%, 1.44 ± 1.88, p = 0.0499), and SI (100.00%, 1.50 ± 1.20, p = 0.0093). For otoscopy skills, post-intervention improvements were noted from OS (77.00%, 3.85 ± 2.55, p < 0.0001) and SI (22.20%, 1.25 ± 1.20, p = 0.0011), with no significant improvement from WM (13.46%, 0.78 ± 1.92, p = 0.1050). Students across all groups reported significantly improved confidence in diagnostic accuracy (p < 0.0001) and otoscopy skill (p < 0.0001) after the intervention.

CONCLUSION

All 3 teaching modalities showed an improvement in diagnostic accuracy immediately post-intervention. Otoscopy clinical skills were found to have increased only in OS and SI, with the OS group demonstrating the largest improvement. Simulation-based medical education in Otolaryngology may provide the greatest transfer of medical knowledge and technical skills when evaluated with real patients.

Improving Surgical Safety and Nontechnical Skills in Variable-Resource Contexts: A Novel Educational Curriculum

OBJECTIVE

A substantial proportion of adverse intraoperative events are attributed to failures in nontechnical skills. To strengthen these skills and improve surgical safety, the Non-Technical Skills for Surgeons (NOTSS) taxonomy was developed as a common framework. The NOTSS taxonomy was adapted for low- and middle-income countries, where variable resources pose a significant challenge to safe surgery. The NOTSS for variable-resource contexts (VRC) curriculum was developed and implemented in Rwanda, with the aim of enhancing knowledge and attitudes about nontechnical skills and promoting surgical safety.

DESIGN

The NOTSS-VRC curriculum was developed through a rigorous process of integrating contextually appropriate values. It was implemented as a 1-day training course for surgical and anesthesia postgraduate trainees. The curriculum comprises lectures, videos, and group discussions. A pretraining and posttraining questionnaire was administered to compare knowledge and attitudes regarding nontechnical skills, and their potential to improve surgical safety.

SETTING

The setting of this study was in the tertiary teaching hospital of Kigali, Rwanda.

PARTICIPANTS

Participants were residents of the University of Kigali. A total of 55 residents participated from general surgery (31.4%), obstetrics (25.5%), anesthesia (17.6%), and other surgical specialties (25.5%).

RESULTS

In a paired analysis, understanding of NOTSS improved significantly (55.6% precourse, 80.9% postcourse, p<0.01). All residents reported that the course would improve their ability to provide safer patient care, and 97.4% believed developing nontechnical skills would improve patient outcomes.

CONCLUSIONS

Nontechnical skills must be highlighted in surgical training in low- and middle-income countries. The NOTSS-VRC curriculum can be implemented without additional technology or significant financial cost. Its deliberate design for resource-constrained settings allows it to be used both as an educational course and a quality improvement strategy. Our research demonstrates it is feasible to improve knowledge and attitudes about NOTSS through a 1-day course, and represents a novel approach to improving global surgical safety.

Comparison of faculty versus structured peer-feedback for acquisitions of basic and intermediate-level surgical skills

PURPOSE

Video feedback and faculty feedback has been shown to improve surgical performance; however, consistent access to faculty is challenging. We studied the utility of structured peer-feedback (PF) compared to faculty-feedback (FF) during acquisition of basic and intermediate surgical skills.

METHODOLOGY

Two randomized non-inferiority trials were conducted with 1st (n = 30) and 2nd year (n = 29) medical students learning skin-lesion excision and closure (S), and single-layer hand-sewn bowel anastomosis (B), respectively. Five attempts were performed. PF participants used an Objective Structured Assessment of Technical Skills tool to guide feedback. Blinded raters assessed video-recorded performance, time and Integrity of the completed task were also assessed.

RESULTS

For both tasks performance by PF was comparable to FF (P = 0.111). Both groups improved significantly: performance (B:P < 0.0001, S:P = 0.035), time (B:P = 0.043, S:P < 0.0001) and integrity (B:P < 0.0001, S:P < 0.032).

CONCLUSION

Structured peer-feedback is equivalent to faculty-feedback in the acquisition of basic and intermediate surgical skills, giving students freedom to practice independently.

Initiating a Robotic Thyroidectomy Program in India

Robotic surgery has been successfully used for many surgical indications in head and neck surgery. Robotic thyroidectomy is getting accepted worldwide, but the majority of the literature is from South Korea. The purpose of the paper is to review and give a personal perspective on how a robotic thyroidectomy program was initiated in a tertiary care academic medical institution in India. Advantages of robotic approaches are the three-dimensional visualization, precision, dexterity, and surgeon ergonomics. Cost is an important concern. Training includes basic robotics skill training, cadaveric training, observership, and hands-on training. Sufficient preclinical and clinical training is essential before embarking onto the newer surgical modality. Surgeon credentialing, though institution dependent, has specific guidelines. Case selection is the key, especially in the initial learning curve. The authors prefer the retroauricular approach for robotic thyroidectomy, and our initial experience in the first ten cases of total thyroidectomy was encouraging.

A Multi-Institutional Simulation Boot Camp for Pediatric Cardiac Critical Care Nurse Practitioners

OBJECTIVES

Assess the effect of a simulation "boot camp" on the ability of pediatric nurse practitioners to identify and treat a low cardiac output state in postoperative patients with congenital heart disease. Additionally, assess the pediatric nurse practitioners' confidence and satisfaction with simulation training.

DESIGN

Prospective pre/post interventional pilot study.

SETTING

University simulation center.

SUBJECTS

Thirty acute care pediatric nurse practitioners from 13 academic medical centers in North America.

INTERVENTIONS

We conducted an expert opinion survey to guide curriculum development. The curriculum included didactic sessions, case studies, and high-fidelity simulation, based on high-complexity cases, congenital heart disease benchmark procedures, and a mix of lesion-specific postoperative complications. To cover multiple, high-complexity cases, we implemented Rapid Cycle Deliberate Practice method of teaching for selected simulation scenarios using an expert driven checklist.

MEASUREMENTS AND MAIN RESULTS

Knowledge was assessed with a pre-/posttest format (maximum score, 100%). A paired-sample t test showed a statistically significant increase in the posttest scores (mean [SD], pre test, 36.8% [14.3%] vs post test, 56.0% [15.8%]; p < 0.001). Time to recognize and treat an acute deterioration was evaluated through the use of selected high-fidelity simulation. Median time improved overall "time to task" across these scenarios. There was a significant increase in the proportion of clinically time-sensitive tasks completed within 5 minutes (pre, 60% [30/50] vs post, 86% [43/50]; p = 0.003] Confidence and satisfaction were evaluated with a validated tool ("Student Satisfaction and Self-Confidence in Learning"). Using a five-point Likert scale, the participants reported a high level of satisfaction (4.7 ± 0.30) and performance confidence (4.8 ± 0.31) with the simulation experience.

CONCLUSIONS

Although simulation boot camps have been used effectively for training physicians and educating critical care providers, this was a novel approach to educating pediatric nurse practitioners from multiple academic centers. The course improved overall knowledge, and the pediatric nurse practitioners reported satisfaction and confidence in the simulation experience.

Cognitive processing differences of experts and novices when correlating anatomy and cross-sectional imaging

The ability to correlate anatomical knowledge and medical imaging is crucial to radiology and as such, should be a critical component of medical education. However, we are hindered in our ability to teach this skill because we know very little about what expert practice looks like, and even less about novices' understanding. Using a unique simulation tool, this research conducted cognitive clinical interviews with experts and novices to explore differences in how they engage in this correlation and the underlying cognitive processes involved in doing so. This research supported what has been known in the literature, that experts are significantly faster at making decisions on medical imaging than novices. It also offers insight into the spatial ability and reasoning that is involved in the correlation of anatomy to medical imaging. There are differences in the cognitive processing of experts and novices with respect to meaningful patterns, organized content knowledge, and the flexibility of retrieval. Presented are some novice-expert similarities and differences in image processing. This study investigated extremes, opening an opportunity to investigate the sequential knowledge acquisition from student to resident to expert, and where educators can help intervene in this learning process.

Parkour as a Donor Sport for Athletic Development in Youth Team Sports: Insights Through an Ecological Dynamics Lens

Analyses of talent development in sport have identified that skill can be enhanced through early and continued involvement in donor sports which share affordances (opportunities for action) with a performer’s main target sport. Aligning key ideas of the Athletic Skills Model and ecological dynamics theory, we propose how the sport of parkour could provide a representative and adaptive platform for developing athletic skill (e.g. coordination, timing, balance, agility, spatial awareness and muscular strength). We discuss how youth sport development programmes could be (re) designed to include parkour-style activities, in order to develop general athletic skills in affordance-rich environments. It is proposed that team sports development programmes could particularly benefit from parkour-style training since it is exploratory and adaptive nature shapes utilisation of affordances for innovative and autonomous performance by athletes. Early introduction to varied, relevant activities for development of athleticism and skill, in a diversified training programme, would provide impetus for a fundamental shift away from the early specialisation approach favoured by traditional theories of skill acquisition and expertise in sport.