Beyond "see one, do one, teach one": toward a different training paradigm

Trained to cut? A literature review of veterinary surgical resident training

A surgical residency trains veterinary graduates to a higher level of expertise in surgical procedures than is possible during veterinary school and prepares a resident to pursue board certification in surgery. The education of veterinary surgical residents has changed minimally since its inception in the twentieth century, and there are insufficient studies to determine if residency programs are producing surgeons with competence in each of the necessary procedural categories. The aims of this review were to report the current theory and methods used to provide surgical education to residents, to discuss the training most likely to create a competent, board-certified surgeon and to review assessment methods used during training. Several literature searches using broad terms such as "veterinary surgery residency," "veterinary surgery resident," and "veterinary surgical training" were performed using PubMed, CAB abstracts, and Google Scholar. Literature pertinent to theory, methods, training, and assessment of veterinary surgical residents was included. The reviewed literature demonstrated the need for research-based learning curves for specific procedures. Simulation training is known to facilitate deliberate practice and should be leveraged where possible to reach competency. The creation of validated assessment methods should be pursued as it enables assessment of competency instead of inferring its development from case logs. Understanding and supporting learner cognition and providing sufficient feedback remain important issues in the field. Surgical educators are urged to continue to search for innovative and evidence-based ways to train competent surgical residents.

Interprofessional Differences in Multidimensional Self-Efficacy Associated With Professional Performance in Nephrology During Case-Based Learning

Introduction

Postgraduate medical education assumes rising importance in the rapidly advancing field of medicine. Case-based learning (CBL), a learner-centered pedagogy employing clinical cases to improve decision-making, is widely embraced in postgraduate medical education, including nephrology. Studies suggest that learning self-efficacy (SE) was closely associated with learning motivation and academic performance; however, very few studies examined this association in postgraduate nephrology education. None evaluated whether there were interprofessional differences concerning such association.

Methods

In 2022, we prospectively enrolled physicians and nurses participating in chronic kidney disease (CKD) care from institutions around Taiwan. They completed the Professional Medical Learning Self-efficacy (PMLS) questionnaire after attending >1 CBL session involving CKD care. We undertook confirmatory factor analysis (CFA), followed by structural equation modeling (SEM) to evaluate associations between 5 dimensions of learning SE (conceptual understanding [CU], higher-order cognitive skills [HC], practical work [PW], everyday application [EA], and medical science communication [MSC]) and their professional SE in nephrology according to participants' medical professions.

Results

A total of 513 healthcare providers were surveyed. The convergent and construct validity of our questionnaire were satisfied after analyses. We found that better perceived professional performance in the form of higher professional SE in nephrology was significantly associated with all 5 dimensions of learning SE among physicians and nurses. Only CU and PW were significantly associated with physicians' professional performance; whereas among nurses, only HC and MSC were significantly associated.

Conclusion

We showed that learning SE was an important determinant of nephrology professional performance. Different medical professions posed influences on major SE dimensions.

[Onboarding in intensive care and emergency medicine in Germany]

BACKGROUND

The treatment of acute life-threatening conditions in intensive care and emergency medicine requires in-depth training and education, with initial training playing a key role.

RESEARCH QUESTION

What is the structure and quality of the initial training of physicians and nurses in intensive care units and emergency departments in Germany?

METHODS

With the help of survey software, an online questionnaire comprising 40 questions in German on the aforementioned topic was designed. It was distributed via the website of the German Society for Internal Intensive Care and Emergency Medicine (DGIIN) and via pertinent social media channels.

RESULTS

In total, 103 nurses and 125 physicians participated in the survey. The average work experience of the participating nurses and physicians was 8.5 ± 5.1 and 3.0 ± 3.1 years, respectively. The majority of participants worked primarily in intensive care units (59%) or in emergency departments (22%). On average, the initial training lasted 45 ± 27 and 13 ± 13 days for nurses and physicians, respectively. Only 20% of the initial training comprised seminars or hands-on workshops taught outside of routine clinical care. In all, 47% of the participants stated that they were not able to complete the entire initial training period. Only 49% had been officially certified for usage of the technical equipment in their department. A total of 35% reported feeling confident or somewhat confident in handling predictable tasks after initial training, but only 15% in handling acute emergencies.

DISCUSSION

The present study revealed that initial training in intensive care and emergency medicine is frequently incomplete, unstructured, as well as inadequate and bears both safety and liability risks. New concepts are needed to improve the initial training across clinics.

Effectiveness of simulation-based cesarean section education on improving non-physician clinician midwife's competency in performing cesarean section in Ethiopia: a quasi-experimental study

BACKGROUND

Simulation-based education enhances fundamental and clinical knowledge, procedural abilities, teamwork, and communication skills, as well as quality of care and patient safety. Due to excessive clinical loads and a lack of physicians, even classic teaching methods like bedside instruction are constrained in low-income settings. Thus, this study aimed to ascertain if simulation-based cesarean section education successfully raises non-physician clinician midwives' competency in Ethiopia.

METHODS

A quasi-experimental study design triangulated with a qualitative design was implemented. Sixty Masters Clinical Midwifery students (29 intervention and 31 control) were taken in 5 universities. Three questionnaires (knowledge, confidence levels, and skills) were used. Qualitative data was also collected from 14 participants. The data were analyzed using SPSS version 25. Descriptive and inferential analyses were conducted. P < 0.05 was used for statistical significance. A difference-in-difference with a 95% confidence level was employed to control the potential confounders for knowledge and self-confidence. Multiple linear regression was fitted to identify the independent effect of simulation-based education interventions while controlling for other variables. Thematic analysis was performed using MAXQDA 2020.

RESULT

The age of the respondents varies from 24 to 34 years, with the control group's mean age being 28.8 (± 2.3) years and the intervention group's mean age being 27.2 (± 2.01) years. The intervention and control groups' pre-intervention and post-intervention knowledge scores showed a statistically significant difference. There was a substantial increase in self-confidence mean scores in both the intervention and control groups and between the pre-intervention and post-intervention periods in both the intervention and control groups. Furthermore, there was a substantial improvement in cesarean section skills in the intervention group as compared to the control group (59.6 (3.3) vs. 51.5 (4.8). The qualitative findings supported these.

CONCLUSIONS

The study showed that simulation-based education improved students' procedural knowledge, self-confidence, and skills. As a result, professional care teams can create simulation-based teaching packages to help students prepare for their residency.

Blue-Blood Pig Thorax Model Increases Residents' Confidence in Internal Mammary Dissection

BACKGROUND

 Preparation of the recipient vessels is a crucial step in autologous breast reconstruction, with limited opportunity for resident training intraoperatively. The Blue-Blood-infused porcine chest wall-a cadaveric pig thorax embedded in a mannequin shell, connected to a saline perfusion system-is a novel, cost-effective ($55) simulator of internal mammary artery (IMA) dissection and anastomosis intended to improve resident's comfort, safety, and expertise with all steps of this procedure. The purpose of this study was to assess the effect of the use of this chest wall model on resident's confidence in performing dissection and anastomosis of the IMA, as well as obtain resident's and faculty's perspectives on model realism and utility.

METHODS

 Plastic surgery residents and microsurgery faculty at the University of Wisconsin were invited to participate. One expert microsurgeon led individual training sessions and performed as the microsurgical assistant. Participants anonymously completed surveys prior to and immediately following their training session to assess their change in confidence performing the procedure, as well as their perception of model realism and utility as a formal microsurgical training tool on a five-point scale.

RESULTS

 Every participant saw improvement in confidence after their training session in a minimum of one of seven key procedural steps identified. Of participants who had experience with this procedure in humans, the majority rated model anatomy and performance of key procedural steps as "very" or "extremely" realistic as compared with humans. 100% of participants believed practice with this model would improve residents' ability to perform this operation in the operating room and 100% of participants would recommend this model be incorporated into the microsurgical training curriculum.

CONCLUSION

 The Blue-Blood porcine chest wall simulator increases trainee confidence in performing key steps of IMA dissection and anastomosis and is perceived as valuable to residents and faculty alike.

Sepsis and Clinical Simulation: What Is New? (and Old)

BACKGROUND

Sepsis is a critical and potentially fatal condition affecting millions worldwide, necessitating early intervention for improved patient outcomes. In recent years, clinical simulation has emerged as a valuable tool for healthcare professionals to learn sepsis management skills and enhance them.

METHODS

This review aims to explore the use of clinical simulation in sepsis education and training, as well as its impact on how healthcare professionals acquire knowledge and skills. We conducted a thorough literature review to identify relevant studies, analyzing them to assess the effectiveness of simulation-based training, types of simulation methods employed, and their influence on patient outcomes.

RESULTS

Simulation-based training has proven effective in enhancing sepsis knowledge, skills, and confidence. Simulation modalities vary from low-fidelity exercises to high-fidelity patient simulations, conducted in diverse settings, including simulation centers, hospitals, and field environments. Importantly, simulation-based training has shown to improve patient outcomes, reducing mortality rates and hospital stays.

CONCLUSION

In summary, clinical simulation is a powerful tool used for improving sepsis education and training, significantly impacting patient outcomes. This article emphasizes the importance of ongoing research in this field to further enhance patient care. The shift toward simulation-based training in healthcare provides a safe, controlled environment for professionals to acquire critical skills, fostering confidence and proficiency when caring for real sepsis patients.

Varied Trainee Competence in Cold Snare Polypectomy: Results of the COMPLETE Randomized Controlled Trial

INTRODUCTION

Cold snare polypectomy (CSP) is strongly recommended as the optimal technique for the complete removal of small polyps. Though significant variability in polypectomy technique and quality has been established, the learning curve and impact of targeted training on CSP are unknown. Video feedback has shown promise as an effective pedagogy to improve performance among surgical trainees. We aimed to compare CSP performance between trainees who received video-based feedback and those who received conventional apprentice-based concurrent feedback. We hypothesized that video-based feedback would accelerate competence.

METHODS

We conducted a single-blinded, randomized controlled trial on competence for CSP of polyps <1 cm, comparing video-based feedback with conventional feedback. We randomly assigned deidentified consecutively recorded CSP videos to blinded raters to assess using the CSP Assessment Tool. We shared cumulative sum learning curves every 25 CSP with each trainee. The video feedback trainees also received biweekly individualized terminal feedback. Control trainees received conventional feedback during colonoscopy. The primary outcome was CSP competence. We also assessed competence across domains and change over polypectomy volume.

RESULTS

We enrolled and randomized 22 trainees, 12 to video-based feedback and 10 to conventional feedback, and evaluated 2,339 CSP. The learning curve was long; 2 trainees (16.7%) in the video feedback achieved competence, after a mean of 135 polyps, and no one in the control ( P = 0.481) achieved competence. Overall and in all steps of CSP, a higher percentage of the video feedback group met competence, increasing 3% every 20 CSP ( P = 0.0004).

DISCUSSION

Video feedback aided trainees to competence in CSP. However, the learning curve was long. Our findings strongly suggest that current training methods are not sufficient to support trainees to competency by the completion of their fellowship programs. The impact of new training methods, such as simulation-based mastery learning, should be assessed to determine whether such methods can result in achievement of competence at a faster rate; ClinicalTrials.gov : NCT03115008.

High-fidelity virtual reality simulation training in enhancing competency assessment in orthopaedic training

Surgical competence is the ability to successfully apply academic knowledge, clinical skills and professional behaviour to inpatient care. Along with ensuring patient safety, the ability to communicate effectively, collaborative teamwork and probity, and achieving satisfactory competencies form the fundamental principles of good medical practice. Current strategies to develop surgical competencies include a range of formative and summative assessments. The cancellation of traditional face-to-face meetings and training opportunities during the COVID-19 pandemic had a profound impact on the delivery of medical education and opportunities to achieve surgical competencies. Simulation learning has been used since before the pandemic to deliver surgical training across all grades and specialities, including orthopaedic surgery. Simulation-based training provides a safe, controlled environment to develop skill acquisition. Simulated surgery using virtual reality has evolved following developments in software and hardware. This article explores the role of high-fidelity virtual reality simulation to assess competencies in orthopaedic training in the post-COVID-19 era, and examines whether simulation could be used within the curriculum to augment and improve training.

Perception and knowledge of learners about the use of 3D technologies in manual therapy education - a qualitative study

OBJECTIVES

Manual therapy is a specific hands-on approach used and taught by various professions such as physiotherapy and osteopathy. The current paradigm of teaching manual therapy incorporates the traditional 'See one, do one, teach one' approach. However, this 'teacher centred' approach may not enable learners to develop the complex clinical skills of manual therapy. In this context, 3D technologies such as virtual reality may facilitate the teaching and learning of manual therapy. Hence the aim of the current study was to investigate the perception, knowledge and attitude of manual therapy learners about the use of 3D technologies in manual therapy education.

METHODS

An exploratory qualitative research design using semi-structured interviews was used in this study. A total of ten manual therapy (5 physiotherapy and 5 osteopathic) students (mean age = 32; 80% female) enrolled in an appropriate physiotherapy or osteopathic degree provided by a New Zealand recognized institution (e.g., university or polytechnic) participated in this study. Data saturation was achieved after 10 interviews (average duration: 35 min) that provided thick data. A thematic analysis was used for data analysis.

RESULTS

Six factors were identified which appeared to influence participants' perception of role of technology in manual therapy education. These were (1) the sufficiency of current teaching method; (2) evolution as a learner (a novice to an expert); (3) need for objectivity; (4) tutor feedback; (5) knowledge and (6) barriers and enablers. These six factors influenced the participants' perception about the role of 3D technologies in manual therapy education with participants evidently taking two distinct/polarized positions ('no role' (techstatic) versus a 'complete role' (techsavvy)).

CONCLUSION

Although 3D technology may not replace face-to-face teaching, it may be used to complement the traditional approach of learning/teaching to facilitate the learning of complex skills according to the perceptions of manual therapy learners in our study. The advantage of such an approach is an area of future research.

Training Program for Orthopedic Residents in Forefoot Osteotomy Skills: Transference From a Simulator to a Cadaveric Surgical Scenario

INTRODUCTION

An effective simulation program allows both the acquisition of surgical skills on the simulated model and the transfer of these skills to a surgical scenario. We designed a forefoot osteotomy training program and sought to determine the transferability to a cadaveric surgical scenario.

METHODS

Eleven orthopedic residents and 2 foot and ankle surgeons were included. A foot simulator was used. All residents were instructed on the surgical techniques of Chevron, Akin, and triple Weil osteotomies. Eight junior residents (trainees) were enrolled in a supervised simulation program. Baseline assessment was performed on the simulator with the Objective Structured Assessment of Technical Skills (OSATS) and the Imperial College Surgical Assessment Device (ICSAD). After baseline, trainees completed a training program and had a final evaluation of proficiency on the simulator and on cadaveric specimens. Three senior residents with no simulated training (controls) and experts were assessed for comparison.

RESULTS

All trainees improved from a baseline OSATS score of 11 points (9-20) to a final score of 35 points (33-35) in the simulator and 34 points (32-34) in the cadaveric specimen ( P < 0.01). Compared with baseline, the ICSAD results improved in path length (391 [205-544] to 131 [73-278] meters, P < 0.01) and number of movements (2756 [1258-3338] to 992 [478-1908], P < 0.01). The final OSATS and ICSAD scores did not differ from experts ( P = 0.1) and were significantly different from untrained residents ( P = 0.02).

CONCLUSIONS

Simulated training of Chevron, Akin, and triple Weil osteotomies in orthopedic residents improved procedural proficiency, enabling successful skill transfer to a surgical scenario in cadavers.

LEVEL OF EVIDENCE

II (Prospective Cohort Study).

Cognitive Load Management: An Invaluable Tool for Safe and Effective Surgical Training

This article highlights the importance of considering Cognitive Load (CL) and Cognitive Load Theory (CLT) during surgical training, focusing on the acquisition of intra-operative skills. It describes the basis of CLT with the overarching aim of describing CLT-based techniques to enhance current training strategies and surgical performance, many of which are instinctively already employed in surgical practice. Currently, methods of feedback and assessment are imperfect - typically subjective, unsystematic, opportunistic, or retrospective, and at risk of human bias. Surgical Sabermetrics, the advanced analytics of surgical and audio-visual data, aims to enhance this feedback by providing objective, real-time, digital-based feedback. This article introduces the benefit of real-time measurement of CL to enhance feedback and its applications to surgical performance that follow the ethos of Surgical Sabermetrics.¹ The 2022 theme for ICOSET was "Making it Better." Cognitive Load and Surgical Sabermetrics principles provide tools to make Surgical training better, with the goal of higher quality care for patients.

Quality Improvement Initiative Using Blended In Situ Simulation Training on Procedural Sedation and Analgesia in a Pediatric Emergency Department: Better Patient Care at Lower Costs

INTRODUCTION

There is evidence in the literature for high-fidelity in situ simulation training programs being an effective modality for physicians training. This quality initiative focused on implementation of the procedural sedation and analgesia (PSA) in our pediatric emergency department (PED). The primary outcomes of this study were to evaluate the impact of blended in situ simulation training (BST) program on PSA for closed forearm fracture reduction in the PED and to assess its cost-effectiveness. The secondary outcomes were to estimate this change on PSA's clinical efficacy and safety.

METHODS

Between 2014 and 2018, a single-center, quasi-experimental, uncontrolled before and after study on forearm fracture reduction management was conducted. To assess the impact of our BST-PSA course, both historical control and prospective analyses were performed. Statistical significance was based on Fisher exact test or Pearson χ 2 test.

RESULTS

Eight hundred eighty-five children met inclusion criteria. A significant difference in the number of PSAs performed in the PED, before and after BST, was found (37% vs. 85.3%, P < 0.001). Furthermore, a reduction in the number of hospitalizations for closed fracture reduction was measured (68.2% vs. 31.8%, P < 0.001). The overall cost savings from the BST-enabled increase in PSAs carried out in the PED was €370,714 ($440,838) with a return on investment of 64:1. No significant increase of PSA-related adverse events was found, and no serious adverse events occurred.

CONCLUSIONS

Findings provide evidence of the benefits of implementing BST to enable PSA use in the PED, with an improved patient flow and significant cost savings from avoiding unnecessary hospitalizations.

What's the evidence? A review of current instruction and assessment in veterinary surgical education

Veterinary surgical education is improved by studying the relevant literature. The aim of this literature review was to report the theory and methods used to provide surgical education to veterinary students; to discuss the training most likely to create a competent general practitioner; and to review assessment methods for simulated and live surgeries. The literature reviewed demonstrates that new graduates are expected to perform small animal sterilization, dental extraction, onychectomy, abscess treatment, aural hematoma repair, and mass removal with little or no supervision. Students require repetitive practice to reach competence; some practice can take place in a clinical skills laboratory on models or cadavers. When training novices, distributing practice over a longer time improves retention, but months without practice causes skills to decay. Suturing skills may be taught on models at a ratio of 1 instructor per 10 students. Veterinary students require 6-10 repetitions of each small animal sterilization surgery to reach competence; however, learning curves for other surgeries have not been established. Assessment of surgical skills has been undertaken using objective structured clinical examinations (OSCEs) and observed model and live surgeries. Additional validated rubrics are needed in the field. Surgical educators are urged to continue to search for innovative ways to foster deliberate practice, assess skill, and provide feedback for students.

Transfer of Clinical Decision-Making-Related Learning Outcomes Following Simulation-Based Education in Nursing and Medicine: A Scoping Review

PURPOSE

Simulation is often depicted as an effective tool for clinical decision-making education. Yet, there is a paucity of data regarding transfer of learning related to clinical decision-making following simulation-based education. The authors conducted a scoping review to map the literature regarding transfer of clinical decision-making learning outcomes following simulation-based education in nursing or medicine.

METHOD

Based on the Joanna Briggs Institute methodology, the authors searched 5 databases (CINAHL, ERIC, MEDLINE, PsycINFO, and Web of Science) in May 2020 for quantitative studies in which the clinical decision-making performance of nursing and medical students or professionals was assessed following simulation-based education. Data items were extracted and coded. Codes were organized and hierarchized into patterns to describe conceptualizations and conditions of transfer, as well as learning outcomes related to clinical decision-making and assessment methods.

RESULTS

From 5,969 unique records, 61 articles were included. Only 7 studies (11%) assessed transfer to clinical practice. In the remaining 54 studies (89%), transfer was exclusively assessed in simulations that often included one or more variations in simulation features (e.g., scenarios, modalities, duration, and learner roles; 50, 82%). Learners' clinical decision-making, including data gathering, cue recognition, diagnoses, and/or management of clinical issues, was assessed using checklists, rubrics, and/or nontechnical skills ratings.

CONCLUSIONS

Research on simulation-based education has focused disproportionately on the transfer of learning from one simulation to another, and little evidence exists regarding transfer to clinical practice. The heterogeneity in conditions of transfer observed represents a substantial challenge in evaluating the effect of simulation-based education. The findings suggest that 3 dimensions of clinical decision-making performance are amenable to assessment-execution, accuracy, and speed-and that simulation-based learning related to clinical decision-making is predominantly understood as a gain in generalizable skills that can be easily applied from one context to another.

Prognostication and shared decision making in neurocritical care

Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient's behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.

A Region-Wide All-Hazard Training Program for Prehospital Mass Casualty Incident Management: A Real-World Case Study

OBJECTIVE

We report the development, implementation, and results of a sustainable region-wide mass-casualty management prehospital training program implemented by the Regione Lombardia emergency medical services (EMS) agency AREU in Italy.

METHODS

The educational program learning objectives are: (1) command and control, communications, and resource management; (2) mass casualty triage and the START triage protocol; (3) on-scene management; (4) Regione Lombardia and AREU Mass Casualty standard operating procedures; and (5) inter-agency communications and relations. For each course edition data on participants' summative assessment, participants' feedback and costs were collected.

RESULTS

Between June 26, 2013, and December 31, 2020, a total of 84 editions of the provider training event were delivered, training an overall 1329 prehospital providers; 1239 (93%) passed the summative assessment and were qualified as being operationally "ready." Regarding participant feedback, the overall program was rated 4.4 ± 0.7 out of 5. The overall cost of running the provider program during the study period was €321 510 (circa US $382 000). The average cost per edition was €3828 and €242 per participant.

CONCLUSIONS

We have described a simple yet interactive simulation and blended-learning approach, which has yielded good pass rates, good participant satisfaction, and contained costs to systematically train emergency medical service personnel.

Using Motion Tracking to Analyze Forceps Paths During Simulated Forceps-Assisted Vaginal Deliveries

OBJECTIVE

The purpose of this study was to evaluate the ability of motion tracking to discern variation in forceps paths during standardized simulated forceps-assisted vaginal deliveries among experienced and inexperienced obstetric providers.

METHODS

This is a pilot study involving 24 obstetrics and gynecology residents and 6 faculty at a single institution. Each participant was filmed performing standardized simulated forceps-assisted vaginal deliveries on a high-fidelity model. Motion tracking software (Kinovea, Medoc, France) was used to track the path of the forceps shank. Data were analyzed for total path length, total x-plane displacement, total y-plane displacement, and final forceps angle. One-way analysis of variance was used to evaluate for statistically significant differences between groups based on education year, with Turkey HSD post hoc test to identify interactions.

RESULTS

Statistically significant differences were noted between groups in the total path length (F = 7.57, P < 0.001) and total y-plane displacement (F = 5.79, P < 0.001). On pairwise comparison, significant differences were noted between faculty and postgraduate year 1 as well as faculty and postgraduate year 2 for total y-plane displacement and total path length. Significant differences were not observed between groups for total x-plane displacement (F = 0.89, P = 0.475) and final forceps angle (F = 2.45, P = 0.052).

CONCLUSIONS

Motion tracking of standardized simulated forceps-assisted vaginal deliveries identifies statistically significant differences between experienced and inexperienced obstetric providers. Our findings suggest that motion tracking can be used to design an educational intervention to improve forceps technique among obstetrics and gynecology residents.

Simulation-Based Assessment Identifies Longitudinal Changes in Cognitive Skills in an Anesthesiology Residency Training Program

OBJECTIVES

We describe observed improvements in nontechnical or "higher-order" deficiencies and cognitive performance skills in an anesthesia residency cohort for a 1-year time interval. Our main objectives were to evaluate higher-order, cognitive performance and to demonstrate that simulation can effectively serve as an assessment of cognitive skills and can help detect "higher-order" deficiencies, which are not as well identified through more traditional assessment tools. We hypothesized that simulation can identify longitudinal changes in cognitive skills and that cognitive performance deficiencies can then be remediated over time.

METHODS

We used 50 scenarios evaluating 35 residents during 2 subsequent years, and 18 of those 35 residents were evaluated in both years (post graduate years 3 then 4) in the same or similar scenarios. Individual basic knowledge and cognitive performance during simulation-based scenarios were assessed using a 20- to 27-item scenario-specific checklist. Items were labeled as basic knowledge/technical (lower-order cognition) or advanced cognitive/nontechnical (higher-order cognition). Identical or similar scenarios were repeated annually by a subset of 18 residents during 2 successive academic years. For every scenario and item, we calculated group error scenario rate (frequency) and individual (resident) item success. Grouped individuals' success rates are calculated as mean (SD), and item success grade and group error rates are calculated and presented as proportions. For all analyses, α level is 0.05.

RESULTS

Overall PGY4 residents' error rates were lower and success rates higher for the cognitive items compared with technical item performance in the operating room and resuscitation domains. In all 3 clinical domains, the cognitive error rate by PGY4 residents was fairly low (0.00-0.22) and the cognitive success rate by PGY4 residents was high (0.83-1.00) and significantly better compared with previous annual assessments (P < 0.05). Overall, there was an annual decrease in error rates for 2 years, primarily driven by decreases in cognitive errors. The most commonly observed cognitive error types remained anchoring, availability bias, premature closure, and confirmation bias.

CONCLUSIONS

Simulation-based assessments can highlight cognitive performance areas of relative strength, weakness, and progress in a resident or resident cohort. We believe that they can therefore be used to inform curriculum development including activities that require higher-level cognitive processing.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice

BACKGROUND

Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching.

RESEARCH QUESTION

How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety?

STUDY DESIGN AND METHODS

This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias.

RESULTS

We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy.

INTERPRETATION

Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

Applications of 3D printing in critical care medicine: A scoping review

Although a wide range of medical applications for three-dimensional printing technology have been recognised, little has been described about its utility in critical care medicine. The aim of this review was to identify three-dimensional printing applications related to critical care practice. A scoping review of the literature was conducted via a systematic search of three databases. A priori specified themes included airway management, procedural support, and simulation and medical education. The search identified 1544 articles, of which 65 were included. Ranging across many applications, most were published since 2016 in non - critical care discipline-specific journals. Most studies related to the application of three-dimensional printed models of simulation and reported good fidelity; however, several studies reported that the models poorly represented human tissue characteristics. Randomised controlled trials found some models were equivalent to commercial airway-related skills trainers. Several studies relating to the use of three-dimensional printing model simulations for spinal and neuraxial procedures reported a high degree of realism, including ultrasonography applications three-dimensional printing technologies. This scoping review identified several novel applications for three-dimensional printing in critical care medicine. Three-dimensional printing technologies have been under-utilised in critical care and provide opportunities for future research.

Arthroscopic Simulation: The Future of Surgical Training: A Systematic Review

BACKGROUND

Arthroscopic simulation has rapidly evolved recently with the introduction of higher-fidelity simulation models, such as virtual reality simulators, which provide trainees an environment to practice skills without causing undue harm to patients. Simulation training also offers a uniform approach to learn surgical skills with immediate feedback. The aim of this article is to review the recent research investigating the use of arthroscopy simulators in training and the teaching of surgical skills.

METHODS

A systematic review of the Embase, MEDLINE, and Cochrane Library databases for English-language articles published before December 2019 was conducted. The search terms included arthroscopy or arthroscopic in combination with simulation or simulator.

RESULTS

We identified a total of 44 relevant studies involving benchtop or virtually simulated ankle, knee, shoulder, and hip arthroscopy environments. The majority of these studies demonstrated construct and transfer validity; considerably fewer studies demonstrated content and face validity.

CONCLUSIONS

Our review indicates that there is a considerable evidence base regarding the use of arthroscopy simulators for training purposes. Further work should focus on the development of a more uniform simulator training course that can be compared with current intraoperative training in large-scale trials with long-term follow-up at tertiary centers.

Innate Arthroscopic & Laparoscopic Surgical Skills: A Systematic Review of Predictive Performance Indicators Within Novice Surgical Trainees

OBJECTIVE

To query the literature for predictive factors for performance on arthroscopic and laparoscopic surgical simulators in novice surgical trainees. These predictive factors may prove a valuable tool in identifying certain innate potential to becoming a future skilled surgeon that could benefit both surgical residency candidates and program directors alike, while also improving patient care.

DESIGN

Systematic Review.

RESULTS

The initial searches yielded 249 articles. After screening titles/abstracts and implementing inclusion and exclusion criteria, 36 studies were included in the final systematic review.

CONCLUSIONS

Current literature suggests that video game experience/frequency, psychomotor and visuospatial aptitude, and perceptual ability are among the most promising predictive indicators of baseline simulator performance. Study limitations include utilization of different standards for characterizing predictive factors. Future studies should aim to utilize standard guidelines for accurate quantification of innate predictive factors. Future research should also focus on utilizing standardized simulator platforms and aptitude tests to allow for more accurate cross-study comparisons and meta-analyses with larger sample sizes.

Simulation-Based Medical Education Improves Procedural Confidence in Core Invasive Procedures for Military Internal Medicine Residents

Introduction

The American Board of Internal Medicine (ABIM) requires that trainees receive procedural training for certification; however, Internal Medicine (IM) residents perform a variable number of procedures throughout residency training. This results in differences in confidence levels as well as procedural competence. For active-duty military trainees, this is especially problematic, as these procedural skills are often required during deployment soon after residency graduation. This deficit can be improved through standardized simulation-based training.

Methods

All internal medicine residents at our institution were invited to participate in a standardized simulation-based training program for core internal medicine procedures (lumbar puncture, arterial line, central line, thoracentesis, paracentesis, and arthrocentesis). Residents were asked to qualitatively rate their perceived procedural confidence using a Likert scale ranging from 1 (not at all confident) to 5 (extremely confident) in their ability to independently perform core internal medicine procedures prior to the simulation exercise. Experienced senior residents and internal medicine faculty instructed and supervised each resident as they performed the procedures. Following the simulation exercise, the residents repeated the survey and were asked to report whether or not they found the exercise useful. 

Results

Of the 96 residents invited to participate, 49 completed the pre-simulation questionnaire and 36 completed the post-simulation questionnaire. The cumulative mean Likert scale confidence rating for all procedures showed a statistically significant improvement post-simulation as compared to pre-simulation, including lumbar puncture (2.45±1.1 vs. 3.42±0.87, p<0.05), arterial line (2.48±1.06 vs. 3.39±1.04, p < 0.05), central line (2.86±1.08 vs. 3.5±1.02, p < 0.05), thoracentesis (2.67±1.10 vs. 3.64±0.83, p < 0.05), paracentesis (3.1±1.08 vs. 3.82±0.74, p < 0.05), and arthrocentesis (2.56±1.07 vs. 3.67±0.80, p < 0.05). All (36/36) trainees reported that they perceived the simulation exercise as valuable.

Conclusion

Internal medicine residents across all post-graduate year (PGY) levels at our institution lacked confidence to independently perform core internal medicine procedures. Utilizing simulation-based medical education as an adjunct to clinical training is well accepted by internal medicine trainees, and resulted in significantly improved procedural confidence. This intervention was well received by trainees and could feasibly be replicated at other active-duty military internal medicine residency programs to assist with readiness. Research is currently in progress to correlate in-situ competency and evaluate clinical outcomes of this improved confidence.

Predictors of Performance on the Arthrobox Arthroscopy Simulator for Medical Students

Purpose

The purpose of this study was to analyze the effects of past participation in athletics, the playing of musical instruments and video games and other variables on medical students’ performance on an arthroscopic simulator task as well as other assessments of visuospatial ability.

Methods

We assessed 50 medical students by using previously validated tests of manual dexterity and spatial reasoning as well as performance on an arthroscopic surgical simulator. Inclusion criteria were to be 18 years of age or older and to be a student studying in the M.D. program at a single public state university. Exclusion criteria were previous use of an arthroscopic surgery training device or active participation in an actual arthroscopic surgery, defined as participating as a surgeon, resident trainee, physician’s assistant, or other similarly credentialed professional. Students were also assessed by the use of a high-fidelity ultrasound simulator as a marker of visuospatial capacity. Students were then surveyed about lifestyle characteristics and personal attributes hypothesized to predict surgical skill, such as playing sports, instruments or video games.

Results

A total of 49 participants were included in this study. High levels of athletic experience were significantly associated with improved performance on the arthroscopic surgical simulator (P = .008). Participants with higher levels of athletic experience were more likely to achieve competence on the arthroscopic surgical simulator (P = .006). Scores on the arthroscopic simulator task were significantly correlated with both ultrasound simulator shape-identification task scores and masked mirror-tracing task scores, as independent measures of visuospatial ability (P = .015 and P = .013, respectively).

Conclusions

This study provides evidence of a statistically significant correlation between increased experience in athletics and single-use test performance on an arthroscopic surgical simulator. Subjects who reported higher levels of experience in athletics were significantly more likely to achieve competence in the arthroscopic surgical simulator task. Finally, statistically significant correlations were found between subjects’ performance scores on tasks assessed by the surgical simulator, masked mirror-trace assessment and ultrasound simulator.

Clinical Relevance

Simulator-based training and education allow for the development of arthroscopic skills prior to operating on a live patient in a clinical situation. This is an area of great interest in orthopaedic education. Our study evaluates parameters in a trainee that may relate to a higher performance level in technical skills on an arthroscopic surgical simulator.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interventional Bronchoscopy

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.

Is Research in Simulation as Accessible as Traditional Clinical Research? A Review of the 'Association for Simulated Practice in Healthcare' Conference

Background Meta-analysis of simulation teaching has shown to be an effective teaching methodology. The Association for Simulated Practice in Healthcare (ASPIH) annual international, multidisciplinary conference is recognised as the leading UK meeting for simulation-based education. We hypothesise that simulation-based research presented at this conference is currently less accessible than more traditional clinical research presentations. Method We reviewed the abstracts of all research presented at the 5th ASPIH Conference, 2014 and then utilised the Bhandari methodology to assess whether an abstract had subsequently been published in a peer review journal. Our secondary aim was to assess for recurring themes that may predict publication. Results Twenty-seven of 197 (14%) abstracts presented at the 2014 meeting were subsequently published. The mean lead time to publication from the conference was 23 (2 - 61) months. Two positive predictive factors for publication were oral presentations (vs poster), and a Kirkpatrick level above 1. Conclusion The publication rate for abstracts from respected clinical conferences is 30%, but the publication rate for ASPIH abstracts is significantly below this. The potential reasons for this may include a lack of simulation specific journals. Authors should aim to publish simulation-based research in peer reviewed publications to help progress the role and the value of simulation in medical education.

Evaluation of a Patient-Specific, Low-Cost, 3-Dimensional-Printed Transesophageal Echocardiography Human Heart Phantom

OBJECTIVE

Currently available 3-dimensional (3D) modeling and printing techniques allow for the creation of patient-specific models based on 3D medical imaging data. The authors hypothesized that a low-cost, patient-specific, cardiac computed tomography-based phantom, created using desktop 3D printing and casting, would have comparable image quality, accuracy, and usability to an existing commercially available echocardiographic phantom.

DESIGN

Blinded comparative study.

SETTING

Simulation laboratory at a single academic institution.

PARTICIPANTS

Voluntary cardiac anesthesiologists at a single academic institution.

INTERVENTIONS

Stage 1 of the study consisted of an online questionnaire in which a set of basic transesophageal echocardiography (TEE) views obtained from the 3D printed phantom and commercial phantom were presented to participants, who had to identify the views and evaluate their fidelity to clinical images on a Likert scale. In stage 2, participants performed an unblinded basic TEE examination on both phantoms.

MEASUREMENTS AND MAIN RESULTS

The time needed to acquire each basic view was recorded. Overall usability of the phantoms was assessed through a questionnaire. The participants could recognize most of the views. Fidelity ratings for both phantoms were similar (p < 0.05), with the exception of a midesophageal 2-chamber view that was observed better on the 3D printed phantom. The time required to obtain the views was shorter for the 3D printed phantom, although not statistically significant for most views. The overall user experience was better for the 3D phantom for all categories examined (p < 0.05).

CONCLUSIONS

The study suggested that a 3D-printed TEE phantom is comparable with the commercially available one with good usability.

The AaLplus near-peer teaching program in Family Medicine strengthens basic medical skills-A five-year retrospective study

Background

Basic medical skills such as history taking and physical examination are essential components of clinical work profiles, but nevertheless have been neglected by conventional preclinical curricula. The near-peer-teaching program AaL^plus [living anatomy plus] teaches basic medical skills, especially history taking, physical examination, and venepuncture, to preclinical students. It is a highly popular compulsory course in the first four semesters (320 students/year, 9h/semester) at Heidelberg University and ends with a formative Objective Structured Clinical Examination (OSCE) during which students receive structured in-depth feedback on their performance. AaL^plus is part of the Department of General Practice’s longitudinal curriculum for Family Medicine.

Objectives

This study aims to assess whether the AaL^plus program has positive effects on students’ clinical skill development and subjective confidence in history taking, physical examination and venepuncture.

Methods

From 2015 to 2019, we asked all AaL^plus participants to rate the program and self-assess their medical skills on 5-point Likert scales (min 1, max 5). In 4-station OSCEs, trained tutors rated the students’ performance in all taught skills using standardized checklists.

Results

From 2015 to 2019 n = 1534 questionnaires returned (response rate = 98.6%, 52.7% females). After course completion, students felt able to take a patient’s history (mean 3.97, SD = 0.75) and perform physical examinations (means range 3.82–4.36, SDs range 0.74–0.89) as well as venepuncture (mean 4.12, SD = 0.88). A large majority of students claimed they acquired these skills in the AaL^plus program. During OSCE, 81.9% passed anamnesis, 93.1% passed physical examination, and 95.4% passed venepuncture (of n = 1556). Students mostly rated the feedback they received during the OSCE as “helpful” or “very helpful” (means for different stations 4.69–4.76, SDs 0.50–0.70).

Conclusions

AaL^plus is a positive example of a peer teaching program in the preclinical stage of medical studies. It successfully trains junior students in essential medical abilities and increases their confidence in their skills. A high percentage of students pass the formative OSCE and evaluate it positively. Consistently high ratings indicate the program’s routine viability. Further studies are needed to analyze if programs like AaL^plus could have an impact on the number of graduates choosing career in Family Medicine.

Objective assessment of obstetrics residents' surgical skills in caesarean: Development and evaluation of a specific rating scale

OBJECTIVE

To develop a modified version of Objective Structured Assessment of Technical Skill (OSATS) rating scale for evaluation of surgical skills specific to caesarean and to assess its relevance in documenting the residents' learning curve during their training. Secondarily, to verify the scale's stability to caesarean's level of difficulty and comparing self-assessment to hetero-assessment in order to propose a practical application of this rating scale during residency.

STUDY DESIGN

We conducted a multicentre observational prospective study, from May 2018 to November 2018. All residents at that time could participate and fill in the rating scale after caesarean. Senior surgeons had to fill in the same rating scale. We analysed correlation between self-assessments and hetero-assessments and sensitivity to change of the rating scale. Analysis of feature's relevance was performed by principal component analysis, factor analysis and reliability analysis.

RESULTS

In total, 234 rating scales were completed evaluating 18 residents. Our study demonstrated that our rating scale could be used to evaluate surgical skills of residents during caesarean and distinguish their year of residency (p < 0.001) with a high correlation between self and hetero-assessment (Intraclass Correlation coefficient for global score: 0.78; 95% CI 0.68-0.86). The principal component analysis revealed two dimensions corresponding to the two parts of the rating scale and the factorial analysis allowed us to confirm distribution of features according to these two dimensions. Cronbach's alpha allowed us to highlight the percentage of representation of the scale's features in relation to all potential theoretical features (0.93, 95% CI 0.82-0.95).

CONCLUSION

Our rating scale could be used for self-assessment during residency and as a hetero-assessment tool for validating defined stages of the internship.

Characteristics of Effective Teachers of Invasive Bedside Procedures: A Multi-institutional Qualitative Study

BACKGROUND

Faculty supervision of invasive bedside procedures (IBPs) in the ICU may enhance procedural education and ensure patient safety. However, there is limited research on teaching effectiveness in the ICU, and there are no best teaching practices regarding the supervision of IBPs.

RESEARCH QUESTION

We conducted a multi-institutional qualitative study of pulmonary and critical care medicine faculty and fellows to better understand characteristics of effective IBP teachers.

STUDY DESIGN AND METHODS

Separate focus groups (FGs) were conducted with fellows and faculty at four large academic institutions that were geographically distributed across the United States. FGs were facilitated by a trained investigator, audio-recorded, and transcribed verbatim for analysis. Themes were identified inductively and compared with constructs from social and situated learning theories. Data were analyzed between and across professional groups. Qualitative research software (NVivo; QSR International) was used to facilitate data organization and create an audit trail of the analysis. A multidisciplinary research team was engaged to minimize interpretive bias.

RESULTS

Thirty-three faculty and 30 fellows participated. Inductive analysis revealed three categories of themes among successful IBP teachers: traits, behaviors, and context. Traits included calm demeanor, trust, procedural competence, and effective communication. Behaviors included leading preprocedure huddles to assess learners' experiences and define expectations; debriefing to provide feedback; and allowing appropriate autonomy. Context included learning climate, levels of distraction, patient acuity, and institutional culture.

INTERPRETATION

We identified specific traits and behaviors of effective IBP teachers that intersect with the practice environment, which highlights the challenge of teaching IBPs. Notably, FG participants emphasized interpersonal, more than technical, aspects of successful IBP teachers. These findings should inform future curricula on teaching IBPs in the ICU, standardize IBP teaching for pulmonary and critical care medicine fellows, and reduce patient injury from procedural complications.

Developing Neuraxial and Regional Pain Procedural Skills Through Innovative 3-Dimensional Printing Technology

Context

Various forms of simulation-based training, including training models, increase training opportunities and help assess performance of a task. However, commercial training models for lumbar puncture and epidural procedures are costly.

Objective

To assess medical students’ and residents’ perception of 3-dimensional (3D)-printed lumbar, cervical, and pelvic models for mastering joint injection techniques and to determine the utility of ultrasonography-guided needle procedure training.

Methods

Osteopathic medical students and residents used in-house 3D-printed gel joint models during an injection ultrasonography laboratory for mastering lumbar epidural, caudal epidural, sacroiliac, and facet joint injection techniques. After the laboratory, they answered a 17-item survey about their perception of the importance of the models in medical education and future practice. The survey also evaluated comfort levels with performing joint injections after using the models, overall satisfaction with the models, and likelihood of using models in the future.

Results

Thirty-six medical students and residents participated. Both students and residents agreed that 3D-printed models were easy to use, aided understanding of corresponding procedures, and increased comfort with performing joint injections (all P<.001). Most participants (35 [97.2%]) believed that the models were reasonable alternatives to commercial models. Over half felt capable of successfully performing cervical or pelvic (22 [61.1%]) and lumbar epidural (23 [63.9%]) injections. The majority of participants (34 [94.4%]) would like to use the models in the future for personal training purposes. Overall, 100% believed that the 3D-printed models were a useful tool for injection training.

Conclusions

Results suggest that 3D-printed models provided realistic training experience for injection procedures and seemed to allow participants to quickly master new injection techniques. These models offer a visual representation of human anatomy and could be a cost-saving alternative to commercial trainers.

Orthopaedic Residents' Transfer of Knee Arthroscopic Abilities from the Simulator to the Operating Room

INTRODUCTION

The ultimate goal for any surgical simulation program is to prove the capability of transferring the skills learned to real-life surgical scenarios. We designed an arthroscopic partial meniscectomy (APM) training program and sought to determine its ability to transfer skills to real patients.

METHODS

Eleven junior orthopaedic residents and three expert knee surgeons were included. A low-fidelity knee simulator was used. Trainees had two baseline assessments of completing APM on a supervised real patient and on the simulator, measured using the Arthroscopic Surgical Skill Evaluation Tool (ASSET). After baseline, the trainees completed an APM training program and had a final evaluation of proficiency on the simulator and in real patients. Experts were also assessed for comparison. Statistical analysis was performed, assuming nonparametric behavior of variables.

RESULTS

All trainees improved from a base score of 14 points in real patients and 10 points on the simulator to a final score of 39 points and 36 points, respectively (P < 0.01). The final trainee simulator score did not differ from experts on the simulator and was lower in real patients (36 versus 39 points, respectively, P ≤ 0.01), which resulted in a 92% transfer ratio for the simulator.

DISCUSSION

Simulated training of APM in orthopaedic residents using a low-fidelity knee simulator proved to not only improve simulated proficiency but also successfully transfer skills to a real clinical scenario with a high model transfer ratio.

LEVEL OF EVIDENCE

Level II (Prospective Cohort Study).

Development and Validation of a Canine Castration Model and Rubric

Veterinary educators use models to allow repetitive practice of surgical skills leading to clinical competence. Canine castration is a commonly performed procedure that is considered a Day One competency for a veterinarian. In this study, we sought to create and evaluate a canine pre-scrotal closed castration model and grading rubric using a validation framework of content evidence, internal structure evidence, and relationship with other variables. Veterinarians (n = 8) and students (n = 32) were recorded while they performed a castration on the model and provided survey feedback. A subset of the students (n = 7) then performed a live canine castration, and their scores were compared with their model scores. One hundred percent of the veterinarians and 91% of the students reported that the model was helpful in training for canine castration. They highlighted several areas for continued improvement. Veterinarians' model performance scores were significantly higher than students', indicating that the model had adequate features to differentiate expert from novice performance. Students' performance on the model strongly correlated with their performance of live castration (r = .82). Surgical time was also strongly correlated (r = .70). The internal consistency of model and live rubric scores were good at .85 and .94, respectively. The framework supported validation of the model and rubric. The canine castration model facilitated cost-efficient practice in a safe environment in which students received instructor feedback and learned through experience without the risk of negatively affecting a patient's well-being. The strong correlation between model and live animal performance scores suggests that the model could be useful for mastery learning.

Using simulation to explore the impact of device design on the learning and performance of peripheral intravenous cannulation

BACKGROUND

The design of medical devices impacts upon the performance of healthcare professionals and patient safety. However, multiple devices serving the same function are often available. The purpose of this study was to use simulation as a means of examining the impact of differences in device design on (1) learning of, or attainment of behavioral fluency in, peripheral intravenous cannulation (PIVC); and (2) the generalization, or transfer, of learning on one device to performance of PIVC using an untrained device.

METHODS

A total of 25 final cycle medical students participated in this study which used a randomized two-group design. Participants were randomly assigned to learn PIVC using either a closed PIVC device (a single device which consists of an intravenous cannula with a pre-attached extension tube; n = 14) or an open PIVC device (a two-piece device made up of an intravenous cannula and a separate extension tube which is attached following insertion of the cannula; n = 11). Task analyses were developed for the performance of PIVC using each device. Subsequently, simulation-based fluency training was delivered to both groups using their assigned PIVC device, and continued for each participant until the fluency criterion was achieved. Following achievement of fluency, participants were asked to perform PIVC using the untrained device (i.e., the PIVC device that they had not been trained on).

RESULTS

All participants in both groups met the fluency criterion, and no significant differences were observed in the number of trials or total training required by groups to achieve fluency. Participants in both groups improved significantly from baseline (M = 11.69) to final training trial (M = 100). However, a significant decrement in performance (M = 81.5) was observed when participants were required to perform PIVC using the untrained device.

CONCLUSIONS

Participants achieved fluency in PIVC regardless of the device used. However, significant decrements in performance were observed when participants were required to perform PIVC using a novel device. This finding supports the need for careful consideration of devices purchased and supplied in the clinical setting, and the need for training prior to the introduction of novel devices or for new staff members.

Implementing Motivational Interviewing for Substance Misuse on Medical Inpatient Units: a Randomized Controlled Trial

BACKGROUND

General medical hospitals provide care for a disproportionate share of patients who misuse substances. Hospitalization provides a unique opportunity to identify and motivate patients to address their substance misuse.

OBJECTIVE

To determine the effectiveness of three strategies for implementing motivational interviewing for substance misuse with general medical inpatients.

DESIGN

Type 3 hybrid effectiveness-implementation randomized controlled trial (Clinical Trials.gov: NCT01825057).

PARTICIPANTS

Thirty-eight providers (physicians, physician assistants, nurses) from 13 general medical inpatient services, and 1173 of their patients admitted to an academically affiliated acute care hospital.

INTERVENTIONS

Implementation strategies included (1) a continuing medical education workshop on detection of substance misuse and provision of a motivational interview; (2) workshop plus bedside supervision (apprenticeship condition); and (3) a workshop plus ability to place a medical order for an interview from a consultation-liaison service (consult condition).

MAIN MEASURES

Primary outcomes were the percentage of study-eligible patients who received an interview for substance misuse and the integrity (adherence, competence) of the interviews. The secondary outcome was the percent of patient statements within the interviews that indicated motivation for reducing substance misuse.

KEY RESULTS

20.5% of patients in the consult condition received an interview, compared to 0.8% (Hedge's g = 1.49) and 3.0% (Hedge's g = 1.26) in the respective workshop only and apprenticeship conditions (p < 0.001). Motivational interviews in the consult condition were performed with more fundamental motivational interviewing adherence and competence than the other conditions. Most statements made by patients during the interviews favored reducing substance misuse, with no differences between conditions.

CONCLUSIONS

Providers' ability to place an order to have experts from the consultation-liaison service deliver a motivational interview was a more effective implementation strategy than a workshop or apprenticeship method for ensuring motivational interviewing is available to medical inpatients who misuse substances.

TRIAL REGISTRY

NCT01825057.

Review of the effect of 3D medical printing and virtual reality on urology training with ‘MedTRain3DModsim’ Erasmus + European Union Project

Background/aim

It is necessary to incorporate novel training modalities in medical education, especially in surgical fields, because of the limitations of cadaveric training. Traditional medical education has many drawbacks, such as residency working hour restrictions, patient safety conflicts with the learning needs, and the lack of hands-on workshops. The MedTRain3DModsim Project aimed to produce 3-dimensional (3D) medical printed models, simulations, and innovative applications for every level of medical training using novel worldwide technologies. It was aimed herein to improve the interdisciplinary and transnational approaches, and accumulate existing experience for medical education, postgraduate studies, and specialty training.

Materials and methods

This project focused on models of solid organs and the urinary system, including the kidney, prostate, ureter, and liver. With 3D medical printing, it is possible to produce a body part from inert materials in just a few hours with the standardization of medical 3D modeling.

Results

The target groups of this project included medical students and residents, graduate students from engineering departments who needed medical education and surgical training, and medical researchers interested in health technology or clinical and surgical an atomy.

Conclusion

It was also intended to develop a novel imaging platform for education and training by reevaluating the existing data using new software and 3D modalities. Therefore, it was believed that our methodology could be implemented in all related medical fields.

Theories of learning and teaching methods used in postgraduate education in the health sciences: a scoping review

OBJECTIVE

The objective of this scoping review was to determine the theories of learning and methods used in teaching in postgraduate education in the health sciences. The longer-term objective was to use the information gathered to design a workshop for teachers of postgraduate students.

INTRODUCTION

Whilst undergraduate teaching in the health sciences has received considerable attention in the literature in terms of methods used, innovative ideas and outcomes, the same cannot be said of postgraduate education. A considerable amount of postgraduate teaching takes place in the workplace and often in the form of informal teaching. The increasing complexity of health problems calls for innovative teaching.

INCLUSION CRITERIA

Papers included in this review were those that considered postgraduate education in the health science disciplines, including but not limited to medicine, nursing, occupational therapy, physiotherapy, pharmacy and dentistry, and that described theories of learning and/or teaching methods used in teaching.

METHODS

Five databases were searched for the period 2001 through 2016. PubMed yielded the most records (3142). No relevant papers were identified through hand searching of the references of the included papers. A data extraction table was developed and used to extract relevant information from included papers.

RESULTS

Sixty-one papers were included in the review. Most of the included papers were from the USA, with 17 published in 2015. Descriptive study designs were the most frequently identified study design. Most of the papers were from the medical disciplines. Twenty-seven papers did not refer to a teaching and learning theory, a further group referred to a theory but often towards the end of the paper, and seven papers had as their focus the importance of theories in medical education. The theories named were of a wide variety. Likewise, a wide range of teaching methods were identified.

CONCLUSIONS

It is clear that a range of theories and teaching methods are used in postgraduate health science education, with educators feeling the need to explore more innovative methods.

Simulation-Based Assessment of Critical Care "Front-Line" Providers

OBJECTIVES

Develop a standardized simulation method to assess clinical skills of ICU providers.

DESIGN

Simulation assessment.

SETTING

Simulation laboratory.

SUBJECTS

Residents, Critical Care Medicine fellows, acute care nurse practitioner students.

INTERVENTIONS

Performance scoring in scenarios from multiple Critical Care Medicine competency domains.

MEASUREMENTS AND MAIN RESULTS

Three-hundred eighty-four performances by 48 participants were scored using checklists (% correct) and holistic "global" ratings (1 [unprepared] to 9 [expert]). One-hundred eighty were scored by two raters. Mean checklist and global scores (± SD) ranged from 65.0% (± 16.3%) to 84.5% (± 17.3%) and 4.7 (± 1.4) to 7.2 (± 1.2). Checklist and global scores for Critical Care Medicine fellows and senior acute care nurse practitioner students (Experienced group, n = 26) were significantly higher than those for the Novice acute care nurse practitioner students (Novice group, n = 14) (75.6% ± 15.6% vs 68.8% ± 21.0% and 6.1 ± 1.6 vs 5.4 ± 1.5, respectively; p < 0.05). Residents (Intermediate group, n = 8) scored between the two (75.4% ± 18.3% and 5.7 ± 1.7). 38.5% of the Experienced group scored in the top quartile for mean global score, compared with 12.5% of the Intermediate and 7.1% of the Novice groups. Conversely, 50% of the Novice group scored in the lower quartile (< 5.3), compared with 37.5% of the Intermediate and 11.5% of the Experienced groups. Psychometric analyses yielded discrimination values greater than 0.3 for most scenarios and reliability for the eight-scenario assessments of 0.51 and 0.60, with interrater reliability of 0.71 and 0.75, for checklist and global scoring, respectively.

CONCLUSIONS

The simulation assessments yielded reasonably reliable measures of Critical Care Medicine decision-making skills. Despite a wide range of performance, those with more ICU training and experience performed better, providing evidence to support the validity of the scores. Simulation-based assessments may ultimately prove useful to determine readiness to assume decision-making roles in the ICU.

Use of a Refresher Course Increases Confidence in Point-of-Care Ultrasound Skills in Emergency Medicine Faculty

Introduction All practicing emergency medicine (EM) physicians need to maintain a skillset in emergency ultrasound (US) after their initial training. EM physicians in academic practice may be supervising trainees performing ultrasound applications that they aren't comfortable with. This study investigates the effectiveness of a US refresher course. The hypothesis was that a series of short courses would increase confidence in performing and supervising US applications. Methods Nine basic emergency ultrasound applications were taught over the course of one year by ultrasound fellowship-trained EM faculty in a simulation center at a single academic institution. Each session included 30-minutes of didactics/image review and 30-minutes of hands-on practice on normal volunteers and was followed by an anonymous questionnaire evaluating comfort level performing and supervising the ultrasound application before and after the course using a Likert scale from 1 "not at all confident" to 5 "very confident". Results Thirty-six of 60 EM physicians participated in at least 1 of the 9 sessions (median 3, interquartile range 2-4). Faculty who attended had a median of 10 (interquartile range 7-15) years in practice and 61% work at both academic and community sites. For all sessions combined, confidence in performing US increased from a mean score on the Likert scale of 3.3 to 4.4 (difference 1.1, confidence interval (CI) (0.94, 1.29), p < 0.001) and confidence in supervising trainees increased from a mean of 3.4 to 4.5 (difference 1.1, CI (0.88, 1.23), p < 0.001). The largest increases were seen in musculoskeletal (MSK), nerve, and pelvic applications and the least increase was seen with the session focused on intravenous access, but confidence was increased in all sessions. Physicians in practice ≥10 years increased in confidence in performing and supervising the applications by 1.4 (CI (1.11, 1.60), p < 0.001) and 1.3, (CI (1.01, 1.49), p < 0.001), respectively. Physicians in practice <10 years increased 0.8 (CI (0.57, 1.03), p < 0.001) and 0.8 (CI (0.55, 1.05), p < 0.001), respectively. Conclusion An emergency ultrasound refresher course for EM physicians at a single institution improved self-reported confidence in both performing and supervising trainees in all applications reviewed. Those in practice ≥10 years showed the largest increases.

SASS: South African Simulation Survey – a review of simulation-based education

Background: Simulation-based education (SBE) has been shown to be an effective and reproducible learning tool. SBE is used widely internationally. The current state of SBE in South Africa is unknown. To the best of our knowledge this is the first survey that describes the use and attitudes towards SBE within South Africa. Methods: An online survey tool was distributed by email to: i) the South African Society of Anaesthesiologists (SASA) members; and ii) known simulation education providers in South Africa. The respondents were grouped into anaesthesia and non-anaesthesia participants. Descriptive statistics were used to analyse the data. Ethics approval was obtained: HREC REF 157/2017. Results: The majority of the respondents provide SBE and integrate it into formal teaching programmes. There is a will amongst respondents to grow SBE in South Africa, with it being recognised as a valuable educational tool. The user groups mainly targeted by SBE, were undergraduate students, medical interns, registrars and nurses. Learning objectives targeted include practical skills, medical knowledge, critical thinking and integrated management. Amongst anaesthesia respondents: the tool most commonly used to assess the quality of learner performance during SBE, for summative assessment, was ‘expert opinion’ (33%); the most frequent methods of evaluating SBE quality were participant feedback (42%) and peer evaluation (22%); the impact of SBE was most frequently assessed by informal discussion (42%) and learner feedback (39%). In anaesthesia SBE largely takes place within dedicated simulation facilities on site (47%). Most respondents report access to a range of SBE equipment. The main reported barriers to SBE were: finance, lack of trained educators, lack of equipment and lack of protected time. A limited number of respondents report engaging in SBE research. There is a willingness in both anaesthesia and non-anaesthesia groups (96% and 89% respectively) to collaborate with other centres. Conclusion: To the best of our knowledge this publication provides us with the first cross-sectional survey of SBE in anaesthesia and a selection of non-anaesthetic respondents within South Africa. The majority of respondents indicate that SBE is a valuable education tool. A number of barriers have been identified that limit the growth of SBE within South Africa. It is hoped that with a commitment to ongoing SBE research and evaluation, SBE can be grown in South Africa.

Surveying, shoring, strengthening: rebuilding medical morale from its foundations

Significant uncertainty surrounds the sustainability of healthcare services in which junior doctors work. It is essential that student and foundation doctors (SFDs) are actively engaged if workforce morale is rebuilt. This narrative review explores the evidence driving the individual work-streams of the Royal College of Physicians' newly formed Student and Foundation Doctor Network. Undergraduate and postgraduate training reform has coincided with concerning feedback from newly qualified doctors. System-level efforts to address this include a focus on extra-contractual matters, where small, sustainable changes could address training and work issues.Fewer foundation year-2 doctors are entering specialty training immediately after the foundation programme. Providing dedicated careers guidance and highlighting opportunities within traditional placements and other career paths can support doctors who undertake non-traditional career routes, including those who take time out of programme.Disseminating these resources through an effective peer-to-peer framework and a well-established mentoring scheme could be the most appropriate way to spread good practice.

Trainee colonoscopy quality is influenced by the independent and unobserved performance characteristics of supervising physicians

Background  Endoscopy training remains an apprenticeship, and the characteristics that facilitate transfer of high quality procedural skills from role models to trainees are unknown. We sought to determine whether unobserved supervisor performance influences the quality of colonoscopy performed by trainees, by studying how supervisors perform alone and how trainees perform while under those same supervisors. Methods  This was a retrospective cross-sectional study conducted among ambulatory adults ≥ 50 years old who underwent colonoscopy for cancer screening or polyp surveillance from 2006 to 2015 at one academic medical center. The primary exposures were the colonoscopy withdrawal time (WT) and adenoma detection rate (ADR) of supervisors while performing colonoscopies alone. The primary outcomes were the WT and ADR of trainees performing colonoscopies under supervision. Results  Data were included from 22 attending gastroenterologist supervisors, 56 gastroenterology fellow trainees, and 2777 adults undergoing 3094 colonoscopy procedures. Among all supervised colonoscopies, mean trainee WT was 12.7 minutes (SD 4.9) and trainee ADR was 33.5 %. The trainee WT was 0.42 minutes longer (standard error = 0.16, P  = 0.01) per minute increase in supervisor WT. Similarly, trainee ADR was higher under a high ADR supervisor, and the odds ratio of high compared to low supervisor ADR category was 1.28 (95 %CI 1.01 - 1.62, P  = 0.04) after adjusting for other factors. Conclusions  The unobserved performance characteristics of supervising endoscopists may influence the quality of colonoscopy performed by trainees.

Simulation centres in German hospitals and their organisational aspects: Expert survey on drivers and obstacles

Background: Simulation trainings offer the opportunity to replicate parts of or entire processes of medical care in a controlled environment. Some hospitals operate simulation centres dedicated to training their staff. Which organisational factors support or impede the implementation of such units in hospitals? Methods: In an exploratory survey experts and decision makers in German hospitals were interviewed. The answers were evaluated qualitatively in order to identify patterns in argumentation. Among the eleven participants were practitioners heading simulation centres (n=4), managers or executives in charge of finances (n=2), medical directors or head physicians with disciplinary responsibility for medical personnel (n=3), and researchers who deal with simulation trainings in medicine (n=2). The interview partners were guaranteed confidentiality in order to allow for them to speak freely about the obstacles and weaknesses in their respective organisations. Results: The interviewees showed a very heterogeneous picture of the simulation trainings in their respective hospitals in terms of content as well as target groups. Asked about purpose and benefit of simulation centres, subgroups of the interviewees gave various arguments. Financing is comprised of subsidies, fees from external participants, and of vocational training budgets. Several obstacles for the implementation were mentioned such as insufficient error culture, deficient interaction of quality and risk management, high equipment costs, or staffing levels that are too low to schedule entire teams for vocational trainings. Conclusions: Patterns in argumentation could be identified that support the implementation and operation of simulation centres in hospitals. Yet strikingly enough there were no coherent arguments i.e. there was no uniform reasoning of aim and purpose of simulation centres. Furthermore, the survey indicated the need to approach quality- and risk management more holistically wherefore simulation centres could offer laboratory environments. All in all, the survey indicates that the assessment of success and economic benefits of simulation centres haven't yet been examined thoroughly.

Haptic, Physical, and Web-Based Simulators: Are They Underused in Maxillofacial Surgery Training?

PURPOSE

Surgical residencies have increasingly incorporated both digital and mannequin simulation into their training programs. The aim of our review was to identify all digital and mannequin maxillofacial simulators available for education and training, highlight their benefit, and critically assess the evidence in support of these educational resources.

MATERIALS AND METHODS

We performed a comprehensive literature review of all peer-reviewed publications of digital and mannequin simulators that met the inclusion criteria, defined as any simulator used in education or training. All simulators used in surgical planning were excluded. Before the query, it was hypothesized that most studies would be descriptive in nature and supported by low levels of evidence. Literature search strategies included the use of multiple combinations of key search terms, review of titles and abstracts, and precise identification of the use of the simulator described. All statistics were descriptive.

RESULTS

The primary search yielded 259 results, from which 22 total simulators published on from 2001 to 2016 were identified using the inclusion and exclusion criteria: 10 virtual reality haptic-based simulators, 6 physical model simulators, and 6 Web-based simulators used for a variety of procedures such as dental skills, instrument handling, orthognathic surgery (Le Fort I osteotomy, vertical ramus osteotomy, bilateral sagittal split ramus osteotomy), genioplasty, bone grafting, sinus surgery, cleft lip repair, orbital floor repair, and oral biopsy. Only 9 formalized studies were completed; these were classified as low-level evidence-based cohort studies (Levels IV and V). All other simulator reports were descriptive in nature. There were no studies with high levels of evidence completed (Level I to III).

CONCLUSIONS

The results of this review suggest that, although seemingly beneficial to the trainee in maxillofacial surgery, simulation in education in this field is an underused commodity because of the significant lack of scientific and validated study designs reported on in the literature thus far. The maxillofacial and simulation communities would benefit from studies on utility and efficacy with higher levels of evidence.

Low-cost three-dimensional printed phantom for neuraxial anesthesia training: Development and comparison to a commercial model

METHODS

Anonymized CT DICOM data was segmented to create a 3D model of the lumbar spine. The 3D model was modified, placed inside a digitally designed housing unit and fabricated on a desktop 3D printer using polylactic acid (PLA) filament. The model was filled with an echogenic solution of gelatin with psyllium fiber. Twenty-two staff anesthesiologists performed a spinal and epidural on the 3D printed simulator and a commercially available Simulab phantom. Participants evaluated the tactile and ultrasound imaging fidelity of both phantoms via Likert-scale questionnaire.

RESULTS

The 3D printed neuraxial phantom cost $13 to print and required 25 hours of non-supervised printing and 2 hours of assembly time. The 3D printed phantom was found to be less realistic to surface palpation than the Simulab phantom due to fragility of the silicone but had significantly better fidelity for loss of resistance, dural puncture and ultrasound imaging than the Simulab phantom.

CONCLUSION

Low-cost neuraxial phantoms with fidelity comparable to commercial models can be produced using CT data and low-cost infrastructure consisting of FLOS software and desktop 3D printers.