Structured and evidence-based training of technical skills in respiratory medicine and thoracic surgery

Effectiveness of Flexible Bronchoscopy Simulation-Based Training: A Systematic Review

BACKGROUND

The implementation of simulation-based training (SBT) to teach flexible bronchoscopy (FB) skills to novice trainees has increased during the last decade. However, it is unknown whether SBT is effective to teach FB to novices and which instructional features contribute to training effectiveness.

RESEARCH QUESTION

How effective is FB SBT and which instructional features contribute to training effectiveness?

STUDY DESIGN AND METHODS

We searched Embase, PubMed, Scopus, and Web of Science for articles on FB SBT for novice trainees, considering all available literature until November 10, 2022. We assessed methodological quality of included studies using a modified version of the Medical Education Research Study Quality Instrument, evaluated risk of bias with relevant tools depending on study design, assessed instructional features, and intended to correlate instructional features to outcome measures.

RESULTS

We identified 14 studies from an initial pool of 544 studies. Eleven studies reported positive effects of FB SBT on most of their outcome measures. However, risk of bias was moderate or high in eight studies, and only six studies were of high quality (modified Medical Education Research Study Quality Instrument score ≥ 12.5). Moreover, instructional features and outcome measures varied highly across studies, and only four studies evaluated intervention effects on behavioral outcome measures in the patient setting. All of the simulation training programs in studies with the highest methodological quality and most relevant outcome measures included curriculum integration and a range in task difficulty.

INTERPRETATION

Although most studies reported positive effects of simulation training programs on their outcome measures, definitive conclusions regarding training effectiveness on actual bronchoscopy performance in patients could not be made because of heterogeneity of training features and the sparse evidence of training effectiveness on validated behavioral outcome measures in a patient setting.

TRIAL REGISTRATION

PROSPERO; No.: CRD42021262853; URL: https://www.crd.york.ac.uk/prospero/.

Objective structured clinical examination in basic thoracic ultrasound: a European study of validity evidence

BACKGROUND

Basic thoracic ultrasound is being used more frequently by clinicians in several settings due to its high diagnostic accuracy for many common causes of respiratory failure and dyspnoea. However, ultrasound examinations are operator-dependent, and sufficient competences are needed to obtain high sensitivity and specificity of examinations. Additionally, it is crucial for ultrasound operators to perceive the competence to interpret the images and integrate them into the patient history and other examinations. This study aims to explore and gather validity evidence for an objective structured clinical examination test of basic thoracic ultrasound competences and establish a pass/fail score.

METHODS

An expert panel created the test which included two theoretical and five practical stations representing cases with different diagnoses that cause respiratory symptoms and which are possible to establish by basic thoracic ultrasound. Twenty-five participants with different levels of experience in basic thoracic ultrasound completed the test. Data of the test scores were used for item analysis, and exploring validity evidence was done according to Messick's framework which is recommended. The contrasting groups' standard setting method was used to establish a pass/fail score.

RESULTS

The summarised internal consistency reliability was high with a Cronbach's alpha of 0.87. The novice group (n = 4) had a mean test score of 42 ± 10.1 points, the intermediate group (n = 8) scored 79.1 ± 8.1 points, and the experienced group (n = 13) 89.0 ± 6.2 points (one-way ANOVA, p < 0.001). A pass/fail score of 71 points was thus derived (maximum test score = 105 points).

CONCLUSION

We developed a test for the assessment of clinical competences in basic thoracic ultrasound with solid validity evidence, and a pass/fail standard with no false positives or false negatives.

Entwicklung der akademischen Thoraxchirurgie in Deutschland

Die Thoraxchirurgie ist in Deutschland vornehmlich an außeruniversitären thoraxchirurgischen Kliniken abgebildet und nur an verhältnismäßig wenigen Universitätskliniken klinisch als eigenständige Abteilung oder Klinik und wissenschaftlich als W2- oder W3-Professur etabliert. Infolgedessen ist die Gewinnung von fachärztlichem Nachwuchs und insbesondere die Generierung von akademisch tätigen Thoraxchirurgen als Kontaktpersonen für Forschende aus den unterschiedlichen Bereichen der Lebens- und Ingenieurwissenschaften sowie für die Weiterentwicklung des Fachgebiets Thoraxchirurgie deutlich schwieriger als in anderen chirurgischen Fächern. In den medizinischen Fakultäten stehen die Lehre, Forschung und Patientenversorgung gleichberechtigt nebeneinander. Für die Übernahme dieser Aufgaben durch Thoraxchirurgen werden Konzepte zum Ausbau und der Förderung der akademischen Thoraxchirurgie in der deutschen Hochschulmedizin benötigt. Ein strukturiertes Curriculum Akademische Thoraxchirurgie kann zusätzlich zu Mentorenprogrammen, Fördermöglichkeiten und zusätzlichen Freiräumen für die Forschung bzw. Lehre die akademische Karriere in der Thoraxchirurgie unterstützen.

Pulmonologists' work and clinical life during the COVID-19 pandemic: a society-led survey

The continuous and ongoing coronavirus disease 2019 (COVID-19) pandemic has highly affected pulmonologists and pulmonology residents worldwide. To identify where additional work and resources must be focused, it is important to explore on what parameters the pulmonologists and residents are challenged. We present the results of a society-led survey on pulmonologists' and pulmonology residents' work and clinical life during the pandemic. A total of 579 pulmonologists and pulmonology residents completed the survey (5.9% of the European Respiratory Society's physician members) and most respondents answered that they have had sufficient training on how to handle patients with COVID-19 (e.g. how to handle patients to prevent virus spread). However, more than a third of the respondents (n=210, 36.3%) had performed procedures they did not feel competent in due to the pandemic and, for example, relocation to COVID-19 units. We must strive for investment in research on medical education and potentially simulation-based training in technical procedures to ensure competence and decrease the insecurity about new procedures, especially in the setting of worldwide pandemics or acute critical situations.

Quality of focused thoracic ultrasound performed by emergency medical technicians and paramedics in a prehospital setting: a feasibility study

BACKGROUND

In a prehospital setting, the severity of respiratory symptoms in patients calling for an ambulance differ. The initial evaluation, diagnosing, and thereby management can be challenging because respiratory symptoms can be caused by disease in many organs. Ultrasound examinations can contribute with important information and support the clinical decision-making. However, ultrasound is user-dependent and requires sufficient knowledge and training. The aim of this study was to explore the quality of thoracic ultrasound examinations performed on patients by emergency medical technicians and paramedics in a prehospital, clinical setting.

METHODS

From November 2018 - April 2020, Danish emergency medical technicians and paramedics (n = 100) performed thoracic ultrasound examinations on patients with respiratory symptoms using a portable ultrasound device. The ultrasound examinations were stored and retrospectively assessed by a reviewer blinded to the patients' symptoms and history, as well as the emergency medical technicians' and paramedics' findings. The image quality was scored from 1 to 5. The findings determined by the reviewer was then correlated with a questionnaire filled out by the emergency medical technicians and paramedics regarding ultrasonic findings and potential change in treatment or management of the patient. The agreement in percentage and as Cohen's kappa was explored.

RESULTS

A total of 590 ultrasound examinations were assessed, resulting in a median image quality score of 3 (IQ1 = 4, IQ3 = 3). The overall agreement in percentage between the emergency medical technicians and paramedics and reviewer was high (87.7% for a normal scan, 89.9% for interstitial syndrome, 97.3% for possible pneumothorax, and 96.3% for pleural effusion). Cohen's kappa varied from 0.01 for possible pneumothorax to 0.69 for pleural effusion. Based on the questionnaires (n = 406), the ultrasound examination entailed a change in treatment or visitation in 48 cases (11.7%) which in this study population encompasses a number-needed-to-scan of 8.5.

CONCLUSION

Emergency medical technicians and paramedics perform focused thoracic ultrasound examinations with adequate image quality sufficient to determine if pathology is present or not. The emergency medical technicians' and paramedics' assessment correlates to some extent with an experienced reviewer and their findings are most reliable for the inclusion of a normal scan or inclusion of pleural effusion. Implementation could possibly impact the number of patients receiving correct prehospital treatment and optimal choice of receiving facility.