Education Research: Simulation training for neurology residents on acquiring tPA consent

Education Research: A Qualitative Analysis of Communication-Focused Feedback Provided to Child Neurology Residents During an Objective Structured Clinical Examination

Background and Objectives

Child neurology is a specialty with unique challenges in communication. Child neurologists face many complex disorders with a wide array of prognoses and treatments as well as the need to communicate at various developmental levels. Limited literature exists regarding effective communication training during child neurology residency. Our aim was to evaluate feedback provided to child neurology residents by standardized patients (SPs) and faculty during a communication-focused objective structured clinical examination (OSCE) for common themes and identify which elements of communication feedback are most valuable to the residents.

Methods

The child neurology residency at Nationwide Children's Hospital previously developed a set of OSCE cases to assess residents' communication skills. Using a qualitative approach, we used content analysis to identify themes from the feedback residents received from SPs and faculty observers. After themes were identified, we held a focus group with residents to determine which themes contained helpful feedback.

Results

Residents found feedback from both SPs and faculty observers to be important, and how information was delivered was identified as the most impactful type of feedback. Residents appreciated positive feedback from SPs and faculty, especially when aimed at reinforcing a specific behavior that was performed well. Feedback that residents identified as particularly helpful, although not commonly provided, was the recognition of a potential unconscious bias in an encounter. Feedback the residents found less useful was discussing the medical specifics of the case. The most frequently provided types of feedback were not necessarily the most helpful feedback for both SP and faculty feedback.

Discussion

OSCEs can be an effective tool to provide child neurology residents with immediate feedback on their communication skills with difficult conversations in a safe environment. Residents find value in feedback from both the SPs and faculty observers. Certain elements of feedback are more helpful than others. This knowledge could be used to develop an assessment tool to guide feedback from child neurology-specific communication simulation.

Curriculum Innovation: A Standardized Experiential Simulation Curriculum Equips Residents to Face the Challenges of Chief Year

Introduction and Problem Statement

A chief resident's role incorporates administrative, academic, and interpersonal responsibilities essential to managing a successful residency program. However, rising chief residents receive little formal exposure to leadership training.

Objectives

To (1) define leadership styles; (2) understand the effect of cultural competence on leadership styles; (3) learn effective methods to advocate as the chief resident; (4) provide effective peer feedback; (5) provide effective supervisor feedback; (6) learn effective conflict management; (7) ensure psychological safety.

Methods and Curriculum Description

We developed a 1-day curriculum combining didactics and simulation activities for our program's rising chief residents. Implementation of our curricular design included a morning session focusing on small groups and didactic-based lectures on specific topics pertinent to leadership, along with a debriefing of a psychometric evaluation tool administered before the curriculum day. The simulation activity consisted of 3 group objective structured clinical examination (G-OSCE) scenarios: (1) providing a struggling junior trainee with feedback; (2) debriefing an adverse clinical outcome as the team leader; (3) navigating a challenging situation with a supervising physician. Standardized participants were surveyed for specific objectives. Learners completed precurricular and postcurricular surveys on their familiarity and preparedness for their chief year.

Results and Assessment Data

Comparison of preintervention (n = 16) and postintervention (n = 10) data shows improvements in familiarity with leadership models (p = 0.006), cultural competence in leadership (p = 0.027), and team organizational structure (p = 0.010) with notable improvement in report of advocating for the team to 100% of participants in the postcurricular survey. In addition, although not statistically significant, familiarity with specific strategies for feedback delivery improved (p = 0.053), as did learner comfort levels with feedback delivery (comparing 51% of learners were either very or somewhat comfortable precurriculum to 90% postcurriculum). This is further supported by standardized participant data after the G-OSCEs. Although familiarity with wellness resources did improve across learners (p = 0.421), learner-reported use of wellness resources was noted to be reduced after the curricular intervention and remains a result of further interest for exploration.

Discussion and Lessons Learned

A 1-day leadership development curriculum combining didactics and simulation is an effective means of preparing rising chief residents to succeed in their transition to this leadership role.

Education Research: Junior Neurology Residents Achieve Competency but Not Mastery After a Brief Acute Ischemic Stroke Simulation Course

Background and Objectives

Simulation bootcamps are used to onboard neurology trainees. It is not known whether these bootcamps result in competency for acute ischemic stroke (AIS).

Methods

For this prospective, single-center pre-post educational intervention study, the Angoff standard setting method was used to determine a Minimum Passing Score (MPS) and Mastery Score for 2 AIS simulations. Junior neurology residents completed precourse knowledge and confidence assessments and had traditional didactic teaching. A week later, each resident completed the first scored AIS simulation. Each resident then practiced stroke care in an unscored simulation. Two to 8 weeks later, each resident was evaluated in an unannounced AIS simulation (the post-test). Postgraduate year (PGY)-3 adult neurology senior residents also completed a knowledge and confidence assessment and were scored on just the AIS post-test case. Using independent and paired t tests, respectively, we compared the junior residents' retention test performance to their baseline assessment and to senior residents' performance.

Results

Thirteen junior residents (9 PGY-2 adult neurology residents and 4 PGY-3 child neurology residents) participated in the course. Only 3 junior residents (23%) initially achieved the MPS in the first AIS simulation. After the simulation course, 9 junior residents (69%) achieved the MPS threshold. Although none achieved mastery, junior residents' mean performance score in the simulation improved (mean score preintervention [SD] = 10.3 [2.8] vs mean score postintervention [SD] = 15.7 [2.6], p < 0.001) and their confidence increased (mean score preintervention [SD] = 3.3 [1.9] vs mean score postintervention [SD] = 4.9 [1.2], p < 0.001, d = 1.7). Eight PGY-3 adult neurology residents were scored on the AIS post-test. Five reached MPS (63%), and 1 demonstrated mastery. The simulation scores of the postcourse juniors and seniors were similar (junior resident mean score [SD] = 15.7 [2.6] vs senior resident mean score [SD] = 16.0 [2.5], p = 0.793).

Discussion

A brief AIS simulation course may improve junior residents' performance and confidence to a level comparable with senior residents, although not to mastery.

Neurology Education in 2035: The Neurology Future Forecasting Series

In the past decade, there have been dramatic changes in all aspects of neurologic care, and along with this, neurology education has transformed. These changes have affected all aspects of education across the educational continuum, including learners, teachers, educators, content, delivery methods, assessments, and outcomes. Health systems science, health humanities, diversity, equity, and inclusion and health disparities are becoming core components of neurology curricula, and, in the future, will be integrated into every aspect of our educational mission. The ways in which material is taught and learned have been influenced by technologic innovations and a growing understanding of the science of learning. We forecast that this trend will continue, with learners choosing from an array of electronic resources to engage with fundamental topics, allowing front-line clinical teachers to spend more time supporting critical reasoning and teaching students how to learn. There has been a growing differentiation of educational roles (i.e., teachers, educators, and scholars). We forecast that these roles will become more distinct, each with an individualized pattern of support and expectations. Assessment has become more aligned with the work of the learners, and there are growing calls to focus more on the impact of educational programs on patient care. We forecast that there will be an increased emphasis on educational outcomes and public accountability for training programs. In this article, we reflect on the history of medical education in neurology and explore the current state to forecast the future of neurology education and discuss ways in which we can prepare.

Simulation-based team training improves door-to-needle time for intravenous thrombolysis

PURPOSE

There is a clinical need for shortened door-to-needle time (DNT) for intravenous thrombolysis, but effective training methods are missing. Simulation training improves teamwork and logistics in numerous fields. Still, it is not clear if simulation improves logistics in stroke.

METHODS

To evaluate the efficiency of a simulation training programme, the DNT of participating centres was compared with the rest of stroke centres in the Czech Republic. Patients' data were prospectively collected from the nationally used Safe Implementation of Treatments in Stroke Registry. The outcome was an improvement in DNT in 2018 as compared with 2015 (after and before the simulation training). Scenarios were based on real clinical cases, and simulation courses were conducted in a standardly equipped simulation centre.

FINDINGS

Between 2016 and 2017, 10 courses were conducted for stroke teams from 9 of all 45 stroke centres. DNT data were available both in 2015 and 2018 from 41 (91%) stroke centres. The simulation training improved the DNT in 2018 as compared with 2015 by 30 min (95% CI 25.7 to 34.7) and as compared with 20 min (95% CI 15.8 to 24.3) in stroke centres without the simulation training (p=0.01). Any parenchymal haemorrhage occurred in 5.4% and 3.5% of patients treated in centres without and with simulation training (p=0.054), respectively.

CONCLUSIONS

DNT was considerably shortened nationally. It was feasible to implement simulation as a nationwide training programme. The simulation was associated with improved DNT; however, other studies should confirm that such an association is causal.

Decision-making psychological state and characteristic of proxies of thrombolytic patients: a pilot study

Intravenous thrombolysis is the preferred treatment modality for acute ischemic stroke. In China, written informed consent from patients or proxies must be obtained before intravenous thrombolysis is performed, which always leads to in-hospital delay of thrombolysis. To explore the relationship between characteristics of thrombolysis decision-making and psychological states of proxies of AIS patients. This was a pilot study. 231 proxies of AIS patients were recruited, including 147 males and 84 females. STAI, WFPTS, CAOT, CPS, C-DCS and time-consuming of decision-making were collected by trained nurses during the period from signing informed consent to thrombolysis finished. The general information was collected within 24 h after admission. Pearson correlation analysis and the Ridge regression analysis were used to explore the correlation and causality between psychological indicators (STAI, WFPTS, CAOT, CPS) and decision-making characteristics (C-DCS, Time consuming). Structural equation modeling was used to explore the direct and indirect effect of psychological factors on decision-making characteristics. The mean of anxiety, trust in physicians, and decision conflict were 49.20 ± 9.50, 37.83 ± 6.63 and 30.60 ± 14.77, respectively. The CAOT was associated with C-DCS through the mediation of STAI and WFPTS (p < 0.001). The CAOT was associated with time-consuming through the mediation of STAI, WFPTS and CPS (p < 0.05). The CAOT, STAI and WFPTS were associated with C-DCS (p < 0.05), and STAI, WFPTS and CPS were associated with time-consuming (p < 0.01). The proxy of patients with acute ischemic stroke had severe decision conflict in thrombolysis decision-making. The psychological state was associated with decision conflict and the time-consuming. Medical staff should explore methods to release the anxiety and increase the trust in physicians to reduce the decision-making conflict and time-consuming, which could promote the smooth progress of the informed consent.

Thrombolytic Refusal Over Telestroke

Background

Tissue plasminogen activator (tPA) refusal is 4%-6% for acute ischemic stroke (AIS) in the emergency department. Telestroke (TS) has increased the use of tPA for AIS but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons.

Methods

Patients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA.

Results

Among the 1,242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic Black patients and patients with a prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and were associated with a final diagnosis of stroke mimic (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.15-0.36). Good outcome (90-day modified Rankin Scale 0-2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42-1.54). The most common reasons for refusal were rapidly improving and mild/nondisabling symptoms and concern for potential side effects.

Conclusion

tPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared with those who refused. Sex and racial differences associated with an increased tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.

Practice variation in the informed consent procedure for thrombolysis in acute ischemic stroke: a survey among neurologists and neurology residents

Background

Obtaining informed consent for intravenous thrombolysis in acute ischemic stroke can be challenging, and little is known about if and how the informed consent procedure is performed by neurologists in clinical practice. This study examines the procedure of informed consent for intravenous thrombolysis in acute ischemic stroke in high-volume stroke centers in the Netherlands.

Methods

In four high volume stroke centers, neurology residents and attending neurologists received an online questionnaire concerning informed consent for thrombolysis with tissue-type plasminogen activator (tPA). The respondents were asked to report their usual informed consent practice for tPA treatment and their considerations on whether informed consent should be obtained.

Results

From the 203 invited clinicians, 50% (n = 101) completed the questionnaire. One-third of the neurology residents (n = 21) and 21% of the neurologists (n = 8) reported that they always obtain informed consent for tPA treatment. If a patient is not capable of providing informed consent, 30% of the residents (n = 19) reported that they start tPA treatment without informed consent. In these circumstances, 53% of the neurologists (n = 20) reported that the resident under their supervision would start tPA treatment without informed consent. Most neurologists (n = 21; 55%) and neurology residents (n = 45; 72%) obtained informed consent within one minute. None of the respondents used more than five minutes for informed consent. Important themes regarding obtaining informed consent for treatment were patients’ capacity, and medical, ethical and legal considerations.

Conclusion

The current practice of informed consent for thrombolysis in acute ischemic stroke varies among neurologists and neurology residents. If informed consent is obtained, most clinicians stated to obtain informed consent within one minute. In the future, a shortened information provision process may be applied, making a shift from informed consent to informed refusal, while still considering the patient’s capacity, stroke severity, and possible treatment delays.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00684-6.

Simulation for Neurology training: Acute setting and beyond

Simulation-based training is adapted for teaching neurology, and it can offer multiple programs for general and specialized neurologists. Indeed, simulation training is "learner-centered", assuring sessions tailored to each learner level, and provides a realistic, safe, controlled and reproducible environment to improve knowledge, technical and non-technical skills, including situational awareness, communication, teamwork and leadership. Indeed, simulation tools allow multidisciplinary sessions with different team members (nurses, physician associates, specialist trainees, technicians) participating with their experiences. Multidisciplinary scenarios maximize awareness on the "human factors" and contribute to the safety of future patients. Simulation sessions require clear learning objectives and debriefing points tailored to the learning groups, but instructors may vary the scenarios in real time according to learners' actions. Different simulation techniques are applied according to learning objectives. The simulation session always includes a briefing, a simulation scenario and a structured debriefing, driven by the instructor, which is crucial for learning consolidation. In neurology training, simulation methods are applicable for: i) training on emergency situations, where the neurologist team has to manage in frontline a specific medical emergency (stroke, status epilepticus, coma, neuromuscular respiratory failure); ii) improving technical skills (lumbar puncture, electroencephalography (EEG), cervical ultrasound and transcranial Doppler, endovascular thrombectomy procedures, neuroradiological investigations); iii) improving procedures and patient pathways (stroke pathway, telemedicine); and iv) training non-technical skills (communication, teamwork, leadership). This manuscript provides a brief overview on the general principles of simulation techniques and their potential application in neurology training, in the acute setting and beyond.

Objective Structured Clinical Exams (OSCE) are a feasible method of teaching how to discuss a nonepileptic seizure diagnosis

OBJECTIVE

Presenting the diagnosis of psychogenic nonepileptic seizures (PNES) can be a difficult task, but disclosing this information effectively is important to optimize patient outcomes. We sought to develop a standardized method to teach neurology residents how to introduce the diagnosis of PNES via an objective structured clinical examination (OSCE) with a standardized patient (SP).

METHODS

In conjunction with the New York University School of Medicine Simulation Center (NYSIM), we designed an OSCE in which a resident had to inform a SP of her diagnosis of PNES and discuss a treatment plan. The SP was provided with details to gradually disclose depending on what the resident said about the history of her episodes, triggers for her episodes and her history of sexual abuse. Each encounter was observed by an attending physician who provided real-time feedback to the resident after the session. Additionally, the SP completed an objective written checklist of items the resident should have covered in the session and gave them verbal feedback.

RESULTS

Twenty-six adult neurology (n = 22), child neurology (n = 3), and neuropsychiatry (n = 1) residents participated in this OSCE in 2018 and 2019, with full data available for 25 participants. Residents reported the OSCE was very useful (mean Likert score of 4.9/5). They felt moderately prepared (mean Likert score 3.8/5) and rated their performance as a mean of 3.3/5. On the SP's checklist, most residents were rated as Well Done in the domains of information gathering, relationship development, and education and counseling. Only in the domain of psychosocial assessment were most residents rated as Not Done (only 7/25 inquired about past trauma as a risk factor for PNES).

SIGNIFICANCE

The OSCEs are a feasible and useful way to teach neurology residents about discussing PNES, as they allow for provision of real-time practice and feedback in a safe environment without real patients.