Clinical skills training--practice makes perfect

Description and Validation of an Innovative and Effective Hand-Shaped Suture-Training Model for Medical Students

During medical education, medical students are often frustrated by difficulties in translating theoretical anatomical knowledge and basic surgical skills (suturing, tissue and instrument handling, and local anesthetic administration) into practice. A common etiological factor for this difficulty, among others, is lack of a low-cost and easy-to-assemble low fidelity suturing model. The purpose of this study is the demonstration of a validated, practical, inexpensive, hand-shaped anatomy training model. It is addressed to medical students and graduates that wish to get acquainted with neurovascular anatomy of the hand and improve their basic surgical skills. The model requires only two latex gloves, cotton, and two different color markers per trainee to draw the course of large nerve and vessels. Construction requires less than 15 minutes. For validation, 80 students participated as volunteers in the demonstration course. They evaluated course usefulness and their own confidence after the course. According to the 5-point Likert scale, the participants' confidence increased in a statistically significant way ( p < 0.05). All participants (100%) stated that their skills were "significantly improved" in terms of instrument handling, anatomy studying, performing digital anesthesia, and suturing technique. Overall experience was rated as "satisfactory" or above. The proposed model enables safe gentle soft-tissue handling, and it resembles a realistic human tissue. Low cost, availability, and fast construction are the most important characteristics, making this validated training model appropriate for acquiring fundamental local anesthesia, respect for hand neurovascular anatomy, and suturing skills.

The development and use of a pharmacist-specific Mini-CEX for postgraduate year trainees in Taiwan

BACKGROUND

Clinical pharmacists must have a complex combination of academic knowledge and practical experience that integrates all aspects of practice. Taiwan's Ministry of Health and Welfare in 2007 launched the Postgraduate Year (PGY) training program to increase the standard of pharmaceutical care. This study aims to develop a pharmacist-specific Chinese-language Mini-Clinical Evaluation Exercise (Mini-CEX) to evaluate the professional development of postgraduate year trainees.

METHOD

The specialized Mini-CEX was developed based on the core competencies of pharmacists, published literature, and expert opinion. A pilot test and evaluator workshop were held prior to the administration of the main test. Fifty-three samples were recruited. The main study was conducted at two regional teaching hospitals and a medical center teaching hospital in Taiwan between February and June 2012. The results were analyzed with the kappa statistic (inter-rater reliability) and descriptive statistics, while the Kruskal-Wallis test was used to examine the PGY trainees' Mini-CEX scores based on their performances.

RESULTS

Trainees who had recently completed PGY programs (C-PGY) and 2nd year PGY trainees (PGY2) earned excellent scores, while the 1st year PGY trainees (PGY1) earned satisfactory scores in overall performance. C-PGY and PGY2 trainees also performed significantly better than PGY1 trainees in the organization and efficiency domain, and the communication skills domain.

CONCLUSION

This study demonstrates the feasibility of using the newly developed pharmacist-specific Chinese-language version of the Mini-CEX instrument to evaluate the core competencies of PGY trainees in clinical settings.

Feasibility and Educational Value of a Student-Run Pharmacovigilance Programme: A Prospective Cohort Study

INTRODUCTION

Pharmacovigilance, the monitoring of drug safety after marketing approval, highly depends on the adequate reporting of adverse drug reactions (ADRs). To improve pharmacovigilance awareness and future ADR reporting among medical students, we developed and evaluated a student-run pharmacovigilance programme.

METHODS

In this project, teams of medical students (first- to fifth-year) assessed real ADR reports, as submitted to the national pharmacovigilance centre. After assessment of causality, including identification of a potential pharmacological explanation for the ADR, the students wrote a personalized feedback letter to the reporter, as well as a summary for the European Medicines Agency (EMA) and World Health Organization (WHO) pharmacovigilance databases. This student assessment was then verified and evaluated by staff from The Netherlands Pharmacovigilance Centre Lareb (Lareb), using an e-questionnaire. Student attitudes, intentions, skills, and knowledge of ADR reporting were evaluated using the e-questionnaire, before and after participation in the programme.

RESULTS

From May 2014 to January 2015, a total of 43 students assessed 100 different ADR reports selected by Lareb staff (n = 3). Student assessments were rated as useful (93%), scientifically substantiated (90%), accurate (92%), and complete (92%), and, on average, did not cost Lareb staff extra time. Medical students were positive about ADR reporting, and their awareness of ADR reporting increased significantly following participation in the programme (p < 0.05). After participation in the programme, the students intended to report serious ADRs in their future practice, and their knowledge of pharmacovigilance and ADR reporting showed they had a high overall level of pharmacological understanding.

CONCLUSION

The student-run pharmacovigilance programme is a win-win venture. It offers students a valuable 'pharmacovigilance experience', creates awareness in future doctors, and has the potential to increase pharmacovigilance skills and knowledge.

Development and Evaluation of Two Canine Low-Fidelity Simulation Models

Two self-made low-fidelity models for simulation of canine intubation and canine female urinary catheterization were developed and evaluated. We used a study design that compares acquired skills of two intervention groups and one control group in a practical examination. Fifty-eight second-year veterinary medicine students received a theoretical introduction to intubation and were randomly divided into three groups. Group I (high-fidelity) was then trained on a commercially available Intubation Training Manikin (item #2006, Veteffects), group II (low-fidelity) was trained on our low-fidelity model, and group III (text) read a text describing intubation of the dog. Forty-seven fifth-year veterinary medicine students followed the same procedure for training urinary catheterization using the commercially available Female Urinary Catheter Training Manikin (Paws 2 Claws), our self-made model, and text. Outcomes were assessed in a practical examination on a cadaver using an Objective Structured Clinical Examination (OSCE) checklist. Considering a value of p≤.05 significant, intervention groups performed significantly better than the text groups. Group I (high-fidelity) and group II (low-fidelity) showed no significant differences (p≤.684, intubation; p≤.901, urinary catheterization). We thereby conclude that low-fidelity models can be as effective as high-fidelity models for clinical skills training.

A facilitative versus directive approach in training clinical skills? Investigating students' clinical performance and perceptions

Over the years, many medical school curricula have started implementing diverse student-centred teaching and learning methodologies. Previous studies, however, have indicated that students prefer more traditional and directive methodologies instead, raising questions on which training approach should be advocated. This study contrasts the effects of a student-centred (i.e. facilitative) training approach on students' clinical skills learning with students' perceptions. More specifically, a quasi-experimental study was set up in which students experienced either a directive or facilitative training approach. Data were collected by means of an OSCE on the one hand, and a questionnaire on students' perceptions of the training sessions, and two open-ended questions about students' likes and dislikes on the other hand. While no general differences were found in terms of clinical knowledge and understanding, and actual clinical performance, an interaction between students' course-specific prior knowledge and the training approach was found. Especially students with low levels of knowledge benefited more from the facilitative training approach in terms of clinical knowledge, while highly knowledgeable students experienced a negative effect of this training approach. Moreover, students' perceptions revealed that facilitative-trained students reported more deep-level learning, while the directive training approach turned out to score higher in terms of quality and perceived effects.

A model for integration of formal knowledge and clinical experience: the advanced doctoring course at Mayo Medical School

Early clinical experiences that are integrated with basic/clinical science content are considered beneficial to medical students, but little has been published concerning how to accomplish this. In this article, the authors describe the yearlong Advanced Doctoring course, a multidisciplinary clinical skills course for second-year students that was implemented at Mayo Medical School in 2006-2007. Of 197 course hours, 163 (83%) are integrated with the basic/clinical science curriculum, which is organized into six blocks (e.g., circulation, oxygen). During most blocks, all second-year students (approximately 50) participate in integrated clinical, surgical, diagnostic, and simulation experiences related to the basic/clinical science block's content. In the circulation block, for example, students complete workups on inpatients with chest pain, examine inpatients and outpatients with heart murmurs, review pediatric presentations of shock, observe valve replacement in the operating room, observe an echocardiogram, and participate in a simulation (i.e., Harvey heart sounds). Student feedback on course evaluation forms is highly positive. Further, on the 2009 Association of American Medical Colleges Graduation Questionnaire, graduating Mayo medical students were twice as likely as U.S. medical students nationally to strongly agree that the basic science content was sufficiently integrated and had sufficient illustrations of clinical relevance. The authors propose that the Advanced Doctoring course may be a useful model for other institutions contemplating curricular reform that targets better integration of formal knowledge and clinical experiences.

A novel approach for augmenting percutaneous endoscopic gastrostomy tube placement training

INTRODUCTION

Surgical trainees routinely participate in percutaneous endoscopic gastrostomy (PEG) tube placement. Although simulation has gained widespread acceptance, novice trainees continue learning this procedure on real patients. We designed a novel hands-on training model for practicing PEG tube placement with minimal monetary investment (cost<$10).

METHODS

Our portable low-fidelity bench model has a simulated upper gastrointestinal construct made of foam. Seventeen trainees used our model to acquire and practice skills necessary to perform PEG tube placement, for setting up and troubleshooting upper gastrointestinal endoscope, and for using endoscopic instruments in the state-of-the-art simulated operative room. Thirteen trainees completed the course evaluation, using a 5-point Likert scale (5=strongly agree).

RESULTS

The training resulted in a self-reported increase in equipment familiarity (4.23±0.73) and troubleshooting real endoscope (4.69±0.48), and trainees felt better prepared (4.23±0.93) for performing PEG tube placement on real patients. Trainees agreed that this exercise has more educational value than using virtual reality simulator alone (4.38±0.52).

CONCLUSIONS

Procedural training for PEG tube placement using a simple bench training model is perceived as valuable by trainees. Cost and commercial availability can be overcome by innovation in surgical simulation.

Constructing a validity argument for the mini-Clinical Evaluation Exercise: a review of the research

PURPOSE

The mini-Clinical Evaluation Exercise (mCEX) is increasingly being used to assess the clinical skills of medical trainees. Existing mCEX research has typically focused on isolated aspects of the instrument's reliability and validity. A more thorough validity analysis is necessary to inform use of the mCEX, particularly in light of increased interest in high-stakes applications of the methodology.

METHOD

Kane's (2006) validity framework, in which a structured argument is developed to support the intended interpretation(s) of assessment results, was used to evaluate mCEX research published from 1995 to 2009. In this framework, evidence to support the argument is divided into four components (scoring, generalization, extrapolation, and interpretation/decision), each of which relates to different features of the assessment or resulting scores. The strength and limitations of the reviewed research were identified in relation to these components, and the findings were synthesized to highlight overall strengths and weaknesses of existing mCEX research.

RESULTS

The scoring component yielded the most concerns relating to the validity of mCEX score interpretations. More research is needed to determine whether scoring-related issues, such as leniency error and high interitem correlations, limit the utility of the mCEX for providing feedback to trainees. Evidence within the generalization and extrapolation components is generally supportive of the validity of mCEX score interpretations.

CONCLUSIONS

Careful evaluation of the circumstances of mCEX assessment will help to improve the quality of the resulting information. Future research should address issues of rater selection, training, and monitoring which can impact rating accuracy.

They just don't get enough! Variable intern experience in bedside procedural skills

BACKGROUND

Medical school and resident training programmes offer different learning opportunities and outcomes. The aim of the study was to assess medical student and intern experience in common clinical procedures.

METHODS

Interns employed in a metropolitan teaching hospital from 2000 to 2004 completed a survey of experience and confidence in clinical procedures at the beginning and end of their intern year. Attendance at and the contribution to procedural confidence of a voluntary procedural skill-training programme were examined.

RESULTS

For the 314 interns, clinical experience before and during internship varied for each procedure and between year cohorts as did training programme attendance (44-84%). Student procedural confidence was predicted by pre-intern experience either on patients or by simulation (beta = 0.17, 95% confidence interval (CI) 0.02-0.21, P = 0.03) and age >30 years on commencing internship (beta = 8.44, 95%CI 3.03-14.06, P = 0.003. Adjusted R(2) = 0.08, P = 0.002). Intern procedural confidence by year's end was predicted by attendance at the training programme (beta = 0.48, 95%CI 0.34-0.62, P < 0.001), intern experience with patient procedures (beta = 0.34, 95%CI 0.21-0.47, P < 0.001) and a clear decision to enter a postgraduate training programme (beta = 0.13, 95%CI 0.04-0.22, P = 0.007, Adjusted R(2) = 0.50, P < 0.001).

CONCLUSION

Interns and students receive variable experience to carry out procedural skills on patients. This makes designing training programmes difficult as training needs vary each year. Both mandatory supervision of key skills and opportunities to supplement limited experience are needed during the intern year to ensure a uniform experience.

Simulation in graduate medical education 2008: a review for emergency medicine

Health care simulation includes a variety of educational techniques used to complement actual patient experiences with realistic yet artificial exercises. This field is rapidly growing and is widely used in emergency medicine (EM) graduate medical education (GME) programs. We describe the state of simulation in EM resident education, including its role in learning and assessment. The use of medical simulation in GME is increasing for a number of reasons, including the limitations of the 80-hour resident work week, patient dissatisfaction with being "practiced on," a greater emphasis on patient safety, and the importance of early acquisition of complex clinical skills. Simulation-based assessment (SBA) is advancing to the point where it can revolutionize the way clinical competence is assessed in residency training programs. This article also discusses the design of simulation centers and the resources available for developing simulation programs in graduate EM education. The level of interest in these resources is evident by the numerous national EM organizations with internal working groups focusing on simulation. In the future, the health care system will likely follow the example of the airline industry, nuclear power plants, and the military, making rigorous simulation-based training and evaluation a routine part of education and practice.

Objective assessment of training surgical skills using simulated tissue interface with real-time feedback

OBJECTIVE

We have shown previously that achieving competent performance of basic laparoscopic skills is possible in difficult conditions. We hypothesize that real-time performance feedback adds to the quality of proficiency-based simulator training for performance and forces applied to conventional surgical tools while tying square knots and running suture throws.

DESIGN

A silk suture was preplaced on a simulated skin pad to assess incision closure by tying square knots and in separate trials to evaluate closure with the task of placing a running suture. The order of task performance was assigned randomly, and each task was repeated 5 times before switching to the second task. In all, 10 repetitions per task were performed by each student. After completion of the second surgical task, the cycle was repeated to test adaptation and retention of motor-skill capabilities. Half the participants were provided with a graphic display in dial format to indicate applied force.

SETTING

Bench-top setup of apparatus was performed in a laboratory at Virginia Commonwealth University, Department of Surgery.

PARTICIPANTS

Twelve second-year medical students with no surgical skills background participated in the study.

RESULTS

Results from the knot-tying task indicated that the average force exerted on tissue forceps by the left hand in the blinded group who performed simple knots actually increased over repeated trials, as opposed to what was achieved by the group that had real-time feedback of their forces being applied. For the running suture, the task average force exerted on surgical tools by both hands was greater in the blind group relative to those viewing real-time graphic feedbacks of forces generated over repeated trials.

CONCLUSION

Inclusion of real-time objective assessment in evaluation of surgical skills minimizes subjective evaluation of performance capabilities. A direct correlation between real-time feedback regarding force exerted and extent of surgical task completion was noted.

Perspective: the case for subspecialty clinical learning in early medical education-moving from case-based to patient-based learning

The subspecialty departments are greatly underutilized for teaching during the first two years of medical school. While second-year students are spending most of their time behind closed doors in the laboratory, lectures, and small groups, the clinical environment is teeming with actual patients whose cases are often directly analogous to the material being learned. Moreover, even in today's environment of increased emphasis on quality of medical care and medical education reform, many U.S. medical students still lack essential exposure to common technologies, tests, and procedures performed within several subspecialties. To remedy this situation, the authors propose that educators develop a system of subspecialty clinical learning for first- and/or second-year students correlated to the classroom study of the pathophysiology of the various organ systems. For example, the second-year cardiology course could be augmented with self-directed, patient-centered learning assignments in the cardiac unit, the pathology lab, the echo lab, and other areas. The authors explain the several advantages of comprehensive subspecialty clinical learning (e.g., it will help prepare physicians to practice distributed care, aid development of competencies within the behavioral and social sciences, foster students' professional development, and encourage creative approaches to issues of health care quality). The authors acknowledge the multiple difficulties of implementing such an approach, and present evidence supporting their argument that with the appropriate vision and leadership, such a living curriculum is important and achievable.

Twelve tips for excellent physical examination teaching

BACKGROUND

Physical examination (PEx) skills are declining among medical trainees, yet many institutions are not teaching these systematically and effectively. Many variables contribute to effective teaching: teachers' confidence in their clinical skills, ability to demonstrate and assess these skills; availability of suitable patients; trainee attitude and fatigue; belief that institutions do not value clinical teachers. Finally, the relevance and significance of a systematic exam must be demonstrated or the teaching degenerates into a 'show-and-tell' exercise.

AIMS

This paper describes twelve practical teaching tips that can be used to promote high quality PEx teaching in 5 minutes or 45 minutes. TEACHING TIPS: (1) Diagnostic hypotheses should guide reflective exam; (2) Teachers with the best clinical skills should be recruited; (3) A longitudinal and systematic curriculum can tailor teaching to multiple learner levels (4) Integration of simulation and bedside teaching can maximise learning; (5) Bedside detective work and games make learning fun; (6) The 6-step approach to teach procedures can be adopted to teach PEx; (7) Clinical teaching at the bedside should be increased; (8) Linking basic sciences to clinical findings will demonstrate relevance; (9) Since assessment drives learning, clinical skills should be systematically assessed; (10) Staff development can target improvement of teachers' clinical skills for effective teaching; (11) Technology should be used to study utility of clinical signs; (12) Institutions should elevate the importance of clinical skills teaching and recognize and reward teachers.

CONCLUSIONS

PEx is important in patient-physician interactions, a valuable contributor to accurate clinical diagnosis and can be taught effectively using practical tips. To reverse the trend of deficient clinical skills, precision of clinical findings should be studied and exam manoeuvres that do not contribute to diagnosis discarded; institutions should value clinical skills teaching, appoint and fund core faculty to teach and provide staff development to improve teaching skills.

Back to the future: teaching medical students clinical procedures

Over the last decade undergraduate training in clinical procedures has moved from 'learning on patients' towards simulation-based training. Simulation was intended to be an adjunct rather than a replacement for experiential learning and several initiatives have emerged to redress this balance. With these initiatives in mind, we evaluated the impact of our undergraduate skills training programme and considered the need to change our teaching and learning strategy in this area. Outcomes-based data was accrued from the performance-based assessment of 64 medical students in four key procedures. Attitudinal data was gleaned from 130 responses to an electronic questionnaire and student self-efficacy ratings taken immediately before assessment. Students performed best in venepuncture. Performance in the other skills revealed 1 in 3 did not reach competence in i.v. cannulation and more than 1 in 2 were below standard when measuring a BM stix and priming an i.v. giving set. The data on self-efficacy and competence was analysed and a Spearman's Rank Correlation coefficient of 0.36 calculated. Students in final year were poor self-assessors and unaware that their skills often fell below standard. These results suggest a need to increase students' self-awareness and promote ward-based learning. This article considers how these objectives might be achieved.

Brief report: Use of the mini-clinical evaluation exercise in internal medicine core clerkships

INTRODUCTION

Direct observation of medical students' clinical skills is important, but occurs infrequently. The mini-clinical evaluation exercise (mCEX) is a tool developed for use with internal medicine (IM) residents that can be used to promote direct observation of medical students' clinical skills. It is unknown how many IM core clerkships in the United States use the mCEX or how it has been implemented.

METHODS

Questions about use of the mCEX were incorporated into an online annual survey distributed to the 114 IM clerkships belonging to Clerkship Directors in Internal Medicine, a national organization of individuals responsible for teaching IM to medical students.

RESULTS

The survey response rate was 83%. Twenty-eight percent (N=27) of respondents use the mCEX in their clerkship. The mean number of required mCEX encounters is 2.3 (SD 1.6). The mCEX is used for formative assessment (68%) more than summative assessment (11%). Ward attendings are the most common mCEX evaluators (72%).

DISCUSSION

The mCEX is being used to promote direct observation of medical students' clinical skills in a significant minority of IM core clerkships. The mCEX is 1 tool for facilitating feedback from both faculty and residents on trainees' developing skills.

The impact of preclinical preceptorships on learning the fundamentals of clinical medicine and physical diagnosis skills

PURPOSE

To learn whether preclinical primary care preceptorships resulted in demonstrable clinical performance benefits to medical students.

METHOD

This was a retrospective cohort study of 267 medical students who elected and 310 students who did not elect to take a four-week primary care preceptorship following the first year of training at the University of Texas Medical School at Houston in 2001-2003. Outcome variables were the students' performances on a written examination testing their integration of basic science and fundamentals of clinical medicine and performances on a comprehensive objective structured clinical examination (OSCE). After adjusting for factors that might have explained differences in the students' performances, logistic regression models were used to assess the association of the outcome variables with participation in a preceptorship.

RESULTS

Students who participated in any one of the preceptorships performed better on the OSCE and on the fundamentals of clinical medicine examination than students who did not participate (p < .01). Students who participated in the family medicine or pediatric preceptorship scored higher on an OSCE (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.01-2.78 and OR, 2.26; 95% CI, 1.18-4.36, respectively) than those students who did not participate in a preceptorship. Students who participated in the internal medicine preceptorship scored higher on the fundamentals of clinical medicine examination (OR, 3.18; 95% CI, 1.92-5.23).

CONCLUSIONS

Preliminary evidence indicates that a short preclinical primary care preceptorship can help medical students to consolidate and integrate the fundamental cognitive and clinical skills they will apply during the clinical years of medical training.

Basic life support skills training in a first year medical curriculum: six years' experience with two cognitive-constructivist designs

RATIONALE

Although the Basic Life Support (BLS) ability of a medical student is a crucial competence, poor BLS training programs have been documented worldwide. Better training designs are needed. This study aims to share detailed descriptions and the test results of two cognitive-constructivist training models for the BLS skills in the first year of medical curriculum.

METHOD

A BLS skills training module was implemented in the first year curriculum in the course of 6 years (1997-2003). The content was derived from the European Resuscitation Council Guidelines. Initially, a competence-based model was used and was upgraded to a cognitive apprenticeship model in 2000. The main performance-content type that was expected at the end of the course was: competent application of BLS procedures on manikins and peers at an OSCE as well as 60% achievement in a test consisting of 25 MCQ items. A retrospective cohort survey design using exam results and a self-completed anonymous student ratings' questionnaire were used in order to test models.

RESULTS

Training time for individual students varied from 21 to 29 hours. One thousand seven hundred and sixty students were trained. Fail rates were very low (1.0-2.2%). The students were highly satisfied with the module during the 6 years.

CONCLUSION

In the first year of the medical curriculum, a competence-based or cognitive apprenticeship model using cognitive-constructivist designs of skills training with 9 hours theoretical and 12-20 hours long practical sessions took place in groups of 12-17 students; medical students reached a degree of competence to sufficiently perform BLS skills on the manikins and their peers. The cognitive-constructivist designs for skills training are associated with high student satisfaction. However, the lack of controls limits the extrapolation of this conclusion.

Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students?

INTRODUCTION

The transition to full-time clinical studies holds anxieties for most medical students. While graduate entry medical education has only recently begun in the UK, the parallel undergraduate and graduate entry MBBS courses taught at our school allowed us to study how 2 differently prepared groups perceived this vital time at a comparable stage in their training.

METHOD

An anonymous questionnaire collected demographic data and graded anxiety in 13 statements relating to starting full-time clinical attachments. Two open questions allowed free text comment on the most positive and negative influences perceived during this time. Both a statistical analysis and a qualitative assessment were performed to compare the 2 groups of students.

RESULTS

The 2 groups were similar with respect to gender but the graduate entry students were significantly older. The graduate entry students were significantly less anxious about most aspects of the transition period compared to the undergraduates. These course differences remained after adjusting for age and sex. When adjusted for course and age, male students expressed less anxiety. The main positive qualitative statements related to continual clinical and communication skills training in the graduate entry group. The main qualitative concerns in both groups related to 'fitting in' and perceived lack of factual knowledge.

DISCUSSION

These data support the early introduction of clinical skills teaching, backed up by a fully integrated clinically relevant curriculum with continued assessment, in preparing students and reducing levels of anxiety before they start full-time clinical attachments. These course design differences appear to be more important than any differences in maturity between the 2 groups.

Good wine may need to mature: a critique of accelerated higher specialist training. Evidence from cognitive neuroscience

CONTEXT

Higher specialist training in the UK is to be further shortened in the absence of any valid educational evidence for the wisdom of this move. Some practitioners/teachers are becoming increasingly concerned at this.

THESIS AND DISCUSSION

Whereas the optimum length of time for such training is as yet undetermined, there is much in medical practice that resonates with the thinking of recent authors, who recommend slow incubation and facilitated reflection on experience, which steeps the learner in a hidden curriculum of practice, and entrains intuitive, "slow mode" thinking. This engagement necessarily takes time. The author has surveyed some of the recent literature on problem solving, cognitive neuroscience, artificial intelligence and learning for practice, and discusses his conclusions. These are unsettling.

CONCLUSION

Further truncation of the length of higher specialist training must be supported by robust educational evidence that supports this reduction. The author advises caution.

Monitoring the development of clinical skills during training in a clinical placement

BACKGROUND

The education and training of health care practitioners has undergone recent reform, and indicate that curricula should place emphasis on the development of clinical skills and attitude. The purpose of this study was two-fold: to define the key skills necessary for a competent dietetic student practitioner and to devise a reliable assessment tool to measure and track performance in these key skill areas throughout the period of clinical placement.

METHODS

Key clinical skills were identified by a concensus group of experienced dietitians and academic practitioners. An assessment tool was then developed to measure these attributes in 43 students undertaking clinical placement at a number of training centres in Scotland. Development of skills was tracked for the entire duration of placements using the novel assessment tool. The assessment tool used a visual analogue scale (VAS) as the measuring score.

RESULTS

A high level of skill attainment was equated with high VAS scores. Performance in three of the four key skills (written skills: r = 0.762, P </= 0.001; interviewing skills: r = 0.697, P < 0.001; and dietary assessment technique: r = 0.697, P </= 0.001) showed impressive correlation co-efficients, indicating a striking and significant positive correlation with the length of training. A high skill performance level attainment was achieved by week 16/17 of training.

CONCLUSION

The authors are confident that the assessment tool is valid and reliable and measures skill performance objectively. A high level of skill attainment was observed in most students by about the mid-point in training: this allows the student to consolidate these skills in the latter stages of training which is in keeping with educational and practice philosophy of placement learning outcomes.

Low- to high-fidelity simulation - a continuum of medical education?

CONTEXT

Changes in medical training and culture have reduced the acceptability of the traditional apprenticeship style training in medicine and influenced the growth of clinical skills training. Simulation is an educational technique that allows interactive, and at times immersive, activity by recreating all or part of a clinical experience without exposing patients to the associated risks. The number and range of commercially available technologies used in simulation for education of health care professionals is growing exponentially. These range from simple part-task training models to highly sophisticated computer driven models.

AIM

This paper will review the range of currently available simulators and the educational processes that underpin simulation training. The use of different levels of simulation in a continuum of training will be discussed. Although simulation is relatively new to medicine, simulators have been used extensively for training and assessment in many other domains, most notably the aviation industry. Some parallels and differences will be highlighted.