Development and validation of a novel ear simulator to teach pneumatic otoscopy

"Seeing inside out": revealing the effectiveness of otoscopy training in virtual reality enhanced practical exams - a randomized controlled trial

BACKGROUND

The study aimed to assess the impact of different training modalities on otoscopy performance during a practical exam using a high-fidelity simulator and to determine if objective evaluation of otoscopy is feasible using a simulator that records insertion depth and tympanic membrane coverage.

METHODS

Participants were assigned to one of four groups: control and three intervention groups with varying training approaches. Participants received otoscopy training and then were assessed through a practical exam on a high-fidelity simulator that uses virtual reality to visualize the ear canal and middle ear. Performance was evaluated using a modified Objective Structured Assessment of Technical Skills checklist and Integrated Procedural Performance Instrument checklist. Insertion depth, tympanic membrane coverage, and correct diagnosis were recorded. Data were tested for normal distribution using the Shapiro-Wilk test. One-way ANOVA and, for non-normally distributed data, Kruskal-Wallis test combined with Dunn's test for multiple comparisons were used. Interrater reliability was assessed using Cohen's κ and Intraclass correlation coefficient.

RESULTS

All groups rated their training sessions positively. Performance on the OSATS checklist was similar among groups. IPPI scores indicated comparable patient handling skills. The feedback group examined larger tympanic membrane areas and had higher rates of correct diagnosis. The correct insertion depth was rarely achieved by all participants. Interrater reliability for OSATS was strong. IPPI reliability showed good correlation.

CONCLUSION

Regardless of training modality, participants perceived learning improvement and skill acquisition. Feedback improved examination performance, indicating simulator-guided training enhances skills. High-fidelity simulator usage in exams provides an objective assessment of performance.

Utilization of Video Otoscopes for Otoscopy Skills Training of Third Year Medical Students

Purpose

Effective teaching and assessment of otologic examinations are challenging. Current methods of teaching otoscopy using traditional otoscopes have significant limitations. We hypothesized that use of all-in-one video otoscopes provides students with an opportunity for real-time faculty feedback and re-practicing of skills, increasing self-reported confidence.

Methods

An otoscopy microskills competency checklist was provided to third-year medical students during their pediatric clerkship to self-assess otoscopy technique during patient examinations, and to clinical preceptors to assess and provide feedback during exams. Over the course of two years, we collected data from students randomly assigned to train on a video otoscope or a traditional otoscope during the clerkship. Pre- and post-clerkship surveys measured confidence in performing otoscopy microskills, making a diagnosis and documentation of findings. For those students who trained on the video otoscope, we solicited post-clerkship feedback on the experience of using a video otoscope.

Results

Pre-clerkship confidence did not differ between the groups, but the video otoscope trained group had significantly higher scores than the traditional otoscope trained group on all self-reported technical and diagnostic microskills confidence questions items post-clerkship. Students trained on video otoscopes had a significant increase in confidence with all microskills items (p-values<0.001), however confidence in the traditional otoscope trained group did not change over time (p-values>0.10). Qualitative feedback from the video otoscope trained group reflected positive experiences regarding "technique/positioning" and "feedback from preceptors.".

Conclusion

Teaching otoscopy skills to pediatric clerkship medical students using a video otoscope significantly enhanced confidence compared to those training on a traditional otoscope by 1. enabling preceptors and students to simultaneously visualize otoscopy findings 2. allowing preceptors to provide real-time feedback and 3. providing opportunity for deliberate practice of microskills. We encourage the use of video otoscopes to augment student confidence and self-efficacy when training in otoscopy.

Face, Content, and Construct Validity of a Virtual Reality Otoscopy Simulator and Applicability to Medical Training

Objective

Otologic diseases are common in all age groups and can significantly impair the function of this important sensory organ. To make a correct diagnosis, the correct handling of the otoscope and a correctly performed examination are essential. A virtual reality simulator could make it easier to teach this difficult-to-teach skill. The aim of this study was to assess the face, content, and construct validity of the novel virtual reality otoscopy simulator and the applicability to otologic training.

Study Design

Face and content validity was assessed with a questionnaire. Construct validity was assessed in a prospectively designed controlled trial.

Setting

Training for medical students at a tertiary referral center.

Method

The questionnaire used a 6-point Likert scale. The otoscopy was rated with a modified Objective Structured Assessment of Technical Skills. Time to complete the task and the percentage of the assessed eardrum surface were recorded.

Results

The realism of the simulator and the applicability to medical training were assessed across several items. The ratings suggested good face and content validity as well as usefulness and functionality of the simulator. The otolaryngologists significantly outperformed the student group in all categories measured (P < .0001), suggesting construct validity of the simulator.

Conclusion

In this study, we could demonstrate face, content, and construct validity for a novel high-fidelity virtual reality otoscopy simulator. The results encourage the use of the otoscopy simulator as a complementary tool to traditional teaching methods in a curriculum for medical students.

Current Status of Handheld Otoscopy Training: A Systematic Review

OBJECTIVE

Otoscopy is a frequently performed procedure and competency in this skill is important across many specialties. We aim to systematically review current medical educational evidence for training of handheld otoscopy skills.

METHODS

Following the PRISMA guideline, studies reporting on training and/or assessment of handheld otoscopy were identified searching the following databases: PubMed, Embase, OVID, the Cochrane Library, PloS Medicine, Directory of Open Access Journal (DOAJ), and Web of Science. Two reviewers extracted data on study design, training intervention, educational outcomes, and results. Quality of educational evidence was assessed along with classification according to Kirkpatrick's model of educational outcomes.

RESULTS

The searches yielded a total of 6064 studies with a final inclusion of 33 studies for the qualitative synthesis. Handheld otoscopy training could be divided into workshops, physical simulators, web-based training/e-learning, and smartphone-enabled otoscopy. Workshops were the most commonly described educational intervention and typically consisted of lectures, hands-on demonstrations, and training on peers. Almost all studies reported a favorable effect on either learner attitude, knowledge, or skills. The educational quality of the studies was reasonable but the educational outcomes were mostly evaluated on the lower Kirkpatrick levels with only a single study determining the effects of training on actual change in the learner behavior.

CONCLUSION

Overall, it seems that any systematic approach to training of handheld otoscopy is beneficial in training regardless of learner level, but the heterogeneity of the studies makes comparisons between studies difficult and the relative effect sizes of the interventions could not be determined.

Low-fidelity otoscopy simulation and anatomy training: A randomized controlled trial

OBJECTIVES

To evaluate whether the use of low-fidelity otoscopy simulation improved medical students' theoretical knowledge of middle ear anatomy and pathologies compared to traditional teaching methods.

METHODS

This was a randomized controlled trial. Simulation workshops were conducted in April 2019 in the Lyon Sud University medical faculty, France. Students were randomly assigned to the simulation group (n=105) or to the control group (n=95). The students in the control group answered a questionnaire evaluating theoretical knowledge (25 true-false questions) before the simulation tutorial, while the students in the simulation group answered the same questions after the tutorial. Both groups also filled out a satisfaction questionnaire for feedback.

RESULTS

196 of the 200 students who participated in the study completed the knowledge assessment questionnaire. Scores were 32.0% higher in the simulation group than in the control group (mean scores, 12.0/20 vs. 9.1/20; P<0.0001). 184 of the 191 students who completed the satisfaction questionnaire (96.3%) were satisfied or very satisfied with the workshop, and all but one (99.5%) recommended keeping it in the curriculum. In the free comments fields, students highlighted the educational value of learning without the stress of patient discomfort.

CONCLUSION

Otoscopy simulation is an effective training method, improving theoretical knowledge compared with conventional theoretical training.

Development of video otoscopy quiz using a smartphone adaptable otoscope

Background

Otoscopy examination can be challenging. Traditional teaching uses still image illustrations. Newer attempts use video samples to simulate the otoscopy exam which is a dynamic process.

Aims/Objective: To assess whether recorded otoscopy videos from a smartphone adaptable otoscope can be used to develop a video-based otoscopy quiz which may be used for instructing and familiarizing participants to normal anatomy and pathologic ear conditions. To use this quiz to assess current pediatric residents’ competency of common otoscopy diagnosis.

Method and materials

This study was conducted in 2018. Video samples of ear pathology were collected at the Albany Medical Center using a smartphone adaptable otoscope- Cellscope. The videos were used to create a video otoscopy quiz (VOQ) without clinical vignettes. 45 pediatric residents from 3 academic institutions were evaluated with the quiz.

Results

The weighted mean for the VOQ was 66.90% (95%CI 58.89%–68.42%). The breakdown by questions are: myringosclerosis 72.88%, retraction pocket 80.65%, cholesteatoma 42.22%, hemotympanum 75.04%, tympanic membrane perforation 79.62%, cerumen impaction 95.46%, otitis externa 52.54%, otitis media with effusion 63.30%, acute otitis media 75.55%, normal ear 36.39%.

Conclusion

We found that videos of otoscopy exams can be obtained with a smartphone adaptable otoscope and validated to develop a video-based quiz, which may be used to supplement otoscopic instruction. Following our testing process, we found pediatric residents are relatively well equipped to identify ear pathology on VOQ.

Optical Identification of Middle Ear Infection

Ear infection is one of the most commonly occurring inflammation diseases in the world, especially for children. Almost every child encounters at least one episode of ear infection before he/she reaches the age of seven. The typical treatment currently followed by physicians is visual inspection and antibiotic prescription. In most cases, a lack of improper treatment results in severe bacterial infection. Therefore, it is necessary to design and explore advanced practices for effective diagnosis. In this review paper, we present the various types of ear infection and the related pathogens responsible for middle ear infection. We outline the conventional techniques along with clinical trials using those techniques to detect ear infections. Further, we highlight the need for emerging techniques to reduce ear infection complications. Finally, we emphasize the utility of Raman spectroscopy as a prospective non-invasive technique for the identification of middle ear infection.

3D printed myringotomy and tube simulation as an introduction to otolaryngology for medical students

OBJECTIVES

Surgical simulation models have been shown to improve surgical skill and confidence for surgical residents before real life procedures. Surgical simulators can be similarly applied in undergraduate medical education as a tool to introduce students to the field of otolaryngology.

METHODS

Ear models were created using 3D printing and high-performance silicone. Twenty medical students participated in a slide presentation and a myringotomy tube simulation station, each completing a pre- and post-survey using a 5-point Likert scale.

RESULTS

A previously validated 3D myringotomy simulator was used. Twenty medical student volunteers participated in the simulation including 14 first-year and 6 s-year medical students. None of the participating students reported observing myringotomy and placement of tympanostomy tubes before the session. Medical student participants rated their knowledge of the steps of the procedure and where to insert the tympanostomy tube at 2 (2 = disagree) or below with a mean of 1.35 SD = 0.47 and 1.2 SD = 0.41 respectively. At the completion of the educational session, the medical students rated their knowledge of the steps of the procedure as significantly improved at 4.45 SD = 0.6 (p = 0.00001).

DISCUSSION

We found that medical students with no prior exposure to ear anatomy or surgical training were able to use the simulator as an introduction to the specialty. There was a perceived improvement in their medical knowledge and basics of a procedural skill.

CONCLUSION

Medical schools can provide an inexpensive, safe, procedural practice tool using 3D printing as an introduction for students interested in surgical procedures.

A survey comparison of educational interventions for teaching pneumatic otoscopy to medical students

BACKGROUND

Though pneumatic otoscopy improves accurate diagnosis of ear disease, trainees lack proficiency. We evaluated the effect of three different training techniques on medical students' subsequent reported use of basic and pneumatic otoscopy in patient encounters.

METHODS

Pediatric clerkship students participated in an ear exam workshop with randomization to one of three educational interventions: task trainer (Life/form®, Fort Atkinson WI), instructional video, or peer practice. Each student received an insufflator bulb and logbook to record otoscopic exams and completed an 18-item anonymous survey at clerkship conclusion.

RESULTS

115 of 150 students (77%) completed the survey. There was no significant difference in number of basic or pneumatic otoscopic exams performed based on method of training. Most students (68-72%) felt more likely to perform pneumatic otoscopy after training. Though the majority of students performed basic otoscopy on patients when an ear exam was indicated, they used pneumatic otoscopy less than 10% of the time. Students reported significant barriers to otoscopy: time, access to equipment, cerumen impaction, patient hold, and anxiety. Student comments described a culture where insufflation was neither practiced nor valued by supervising physicians.

CONCLUSION

Training in pneumatic otoscopy can increase student comfort, but barriers exist to using the skill in clinical practice.

Effectiveness of discovery learning using a mobile otoscopy simulator on knowledge acquisition and retention in medical students: a randomized controlled trial

Background

Portable educational technologies, like simulators, afford students the opportunity to learn independently. A key question in education, is how to pair self-regulated learning (SRL) with direct instruction. A cloud-based portable otoscopy simulator was employed to compare two curricula involving SRL. Pre-clerkship medical students used a prototype smartphone application, a 3D ear attachment and an otoscope to complete either otoscopy curriculum.

Methods

Pre-clerkship medical students were recruited and randomized to two curriculum designs. The “Discovery then Instruction” group received the simulator one week before a traditional lecture, while the “Instruction then Discovery” group received it after the lecture. To assess participants’ ability to identify otoscopic pathology, we used a 100-item test at baseline, post-intervention and 2-week retention time points. Secondary outcomes included self-reported comfort, time spent using the device, and a survey on learning preferences.

Results

Thirty-four students completed the study. Analysis of knowledge acquisition and retention showed improvement in scores of both groups and no significant effects of group (F_1,31 = 0.53, p = 0.47). An analysis of participants’ self-reported comfort showed a significant group x test interaction (F_1,36 = 4.61, p = 0.04), where only the discovery then instruction group’s comfort improved significantly. Overall device usage was low, as the discovery then instruction group spent 21.47 ± 26.28 min, while the instruction then discovery group spent 13.84 ± 18.71 min. The discovery first group’s time spent with the simulator correlated moderately with their post-test score (r = 0.42, p = 0.07). After the intervention, most participants in both groups (63–68%) stated that they would prefer the instruction then discovery sequence.

Conclusions

Both curricular sequences led to improved knowledge scores with no statistically significant knowledge differences. When given minimal guidance, students engaged in discovery learning minimally. There is value in SRL in simulation education, and we plan to further improve our curricular design by considering learner behaviours identified in this study.

Exploring Validation and Verification: How they Different and What They Mean to Healthcare Simulation

STATEMENT

The healthcare simulation (HCS) community recognizes the importance of quality management because many novel simulation devices and techniques include some sort of description of how they tested and assured their simulation's quality. Verification and validation play a key role in quality management; however, literature published on HCS has many different interpretations of what these terms mean and how to accomplish them. The varied use of these terms leads to varied interpretations of how verification process is different from validation process. We set out to explore the concepts of verification and validation in this article by reviewing current psychometric science description of the concepts and exploring how other communities relevant to HCS, such as medical device manufacturing, aviation simulation, and the fields of software and engineering, which are building blocks of technology-enhanced HCS, use the terms, with the focus of trying to clarify the process of verification. We also review current literature available on verification, as compared with validation in HCS and, finally, offer a working definition and concept for each of these terms with hopes to facilitate improved communication within, and with colleagues outside, the HCS community.

Teaching Pediatric Otoscopy Skills to Pediatric and Emergency Medicine Residents: A Cross-Institutional Study

OBJECTIVE

To evaluate a pediatric otoscopy curriculum with the use of outcome measures that included assessment of skills with real patients.

METHODS

Thirty-three residents in an intervention group from 2 institutions received the curriculum. In the previous year, 21 residents in a nonintervention group did not receive the curriculum. Both groups were evaluated at the beginning and end of their internship years with the use of the same outcome assessments: 1) a written test, 2) an objective standardized clinical examination (OSCE), and 3) direct observation of skills in real patients with the use of a checklist with established validity.

RESULTS

The intervention group had a significant increase in percentage reaching minimum passing levels between the beginning and end of the internship year for the written test (12% vs 97%; P < .001), OSCE (0% vs 78%; P < .001), and direct observation (0% vs 75%; P < .001); significant mean percentage gains for the written test (21%; P < .001), OSCE (28%; P < .001), and direct observation (52%; P = .008); and significantly higher (P < .001) mean percentage gains than the nonintervention group on the written test, OSCE, and direct observation. The nonintervention group did not have a significant increase (P = .99) in percentage reaching minimum passing levels, no significant mean percentage gains in the written test (2.7%; P = .30) and direct observation (6.7%; P = .61), and significant regression in OSCE (-5.2%; P = .03).

CONCLUSIONS

A pediatric otoscopy curriculum with multimodal outcome assessments was successfully implemented across different specialties at multiple institutions and found to yield gains, including in skills with real patients.

Smartphone Otoscopy Sans Attachment: A Paradigm Shift in Diagnosing Ear Pathologies

Objective

To study the validity of smartphone otoscopy.

Setting

Ear, nose, and throat (ENT) outpatient clinic of a tertiary care hospital in eastern India.

Study Design

Experimental study design to compare the efficacy of smartphone otoscopy with otoendoscopes.

Subjects and Methods

One hundred tympanic membranes (TMs) of 50 patients were examined and photographed by third-year senior residents (6 years of ENT training) using a zero-degree otoendoscope. The same 100 ears were then examined using a smartphone. Assistive light of the phone was used to illuminate the ear canal. The camera of the phone was focused to visualize and photograph the TM.

Results

Compared with the gold-standard otoendoscopes, smartphones could correctly diagnose 75% of the cases. Sensitivity and specificity of smartphone otoscopy were 87.8% and 80%, respectively. Positive predictive value was 90.6%, whereas negative predictive value was 75%. Smartphone otoscopy could correctly diagnose 88.57% of normal TMs, 86.36% of retracted TMs, and 82.85% of perforated TMs.

Conclusion

This modality of "smart otoscopy" has no added cost and can be used by most doctors after minimal training. It is an excellent teaching tool and can be used universally even in resource-limited settings.

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

OBJECTIVE

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

DESIGN

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

SETTING

Clinical Teaching Centre, Queen's University.

PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

A Method for Functional Task Alignment Analysis of an Arthrocentesis Simulator

INTRODUCTION

During simulation-based education, simulators are subjected to procedures composed of a variety of tasks and processes. Simulators should functionally represent a patient in response to the physical action of these tasks. The aim of this work was to describe a method for determining whether a simulator does or does not have sufficient functional task alignment (FTA) to be used in a simulation.

METHODS

Potential performance checklist items were gathered from published arthrocentesis guidelines and aggregated into a performance checklist using Lawshe's method. An expert panel used this performance checklist and an FTA analysis questionnaire to evaluate a simulator's ability to respond to the physical actions required by the performance checklist.

RESULTS

Thirteen items, from a pool of 39, were included on the performance checklist. Experts had mixed reviews of the simulator's FTA and its suitability for use in simulation. Unexpectedly, some positive FTA was found for several tasks where the simulator lacked functionality.

CONCLUSIONS

By developing a detailed list of specific tasks required to complete a clinical procedure, and surveying experts on the simulator's response to those actions, educators can gain insight into the simulator's clinical accuracy and suitability. Unexpected of positive FTA ratings of function deficits suggest that further revision of the survey method is required.

Improving learning and confidence through small group, structured otoscopy teaching: a prospective interventional study

Background

Otologic diseases are common and associated with significant health care costs. While accurate diagnosis relies on physical exam, existing studies have highlighted a lack of comfort among trainees with regards to otoscopy. As such, dedicated otoscopy teaching time was incorporated into the undergraduate medical curriculum in the form of a small group teaching session. In this study, we aimed to examine the effect of a small-group, structured teaching session on medical students’ confidence with and learning of otoscopic examination.

Methods

Using a prospective study design, an otolaryngologist delivered an one-hour, small group workshop to medical learners. The workshop included introduction and demonstration of otoscopy and pneumatic otoscopy followed by practice with peer feedback. A survey exploring students’ confidence with otoscopy and recall of anatomical landmarks was distributed before(T1), immediately after(T2), and 1 month following the session(T3).

Results

One hundred and twenty five learners participated from February 2016 to February 2017. Forty nine participants with complete data over T1-T3 demonstrated significant improvement over time in confidence (Wilk’s lambda = .09, F(2,48) = 253.31 p < .001, η² = .91) and learning (Wilk’s lambda = 0.34, F(2,47) = 24.87 p < .001, η² = .66).

Conclusions

A small-group, structured teaching session had positive effects on students’ confidence with otoscopy and identification of otologic landmarks. Dedicated otoscopy teaching sessions may be a beneficial addition to the undergraduate medical curriculum.

Clinical translation of handheld optical coherence tomography: practical considerations and recent advancements

Since the inception of optical coherence tomography (OCT), advancements in imaging system design and handheld probes have allowed for numerous advancements in disease diagnostics and characterization of the structural and optical properties of tissue. OCT system developers continue to reduce form factor and cost, while improving imaging performance (speed, resolution, etc.) and flexibility for applicability in a broad range of fields, and nearly every clinical specialty. An extensive array of components to construct customized systems has also become available, with a range of commercial entities that produce high-quality products, from single components to full systems, for clinical and research use. Many advancements in the development of these miniaturized and portable systems can be linked back to a specific challenge in academic research, or a clinical need in medicine or surgery. Handheld OCT systems are discussed and explored for various applications. Handheld systems are discussed in terms of their relative level of portability and form factor, with mention of the supporting technologies and surrounding ecosystem that bolstered their development. Additional insight from our efforts to implement systems in several clinical environments is provided. The trend toward well-designed, efficient, and compact handheld systems paves the way for more widespread adoption of OCT into point-of-care or point-of-procedure applications in both clinical and commercial settings.

Noninvasive in vivo optical coherence tomography tracking of chronic otitis media in pediatric subjects after surgical intervention

In an institutional review board-approved study, 25 pediatric subjects diagnosed with chronic or recurrent otitis media were observed over a period of six months with optical coherence tomography (OCT). Subjects were followed throughout their treatment at the initial patient evaluation and preoperative consultation, surgery (intraoperative imaging), and postoperative follow-up, followed by an additional six months of records-based observation. At each time point, the tympanic membrane (at the light reflex region) and directly adjacent middle-ear cavity were observed in vivo with a handheld OCT probe and portable system. Imaging results were compared with clinical outcomes to correlate the clearance of symptoms in relation to changes in the image-based features of infection. OCT images of most all participants showed the presence of additional infection-related biofilm structures during their initial consultation visit and similarly for subjects imaged intraoperatively before myringotomy. Subjects with successful treatment (no recurrence of infectious symptoms) had no additional structures visible in OCT images during the postoperative visit. OCT image findings suggest surgical intervention consisting of myringotomy and tympanostomy tube placement provides a means to clear the middle ear of infection-related components, including middle-ear fluid and biofilms. Furthermore, OCT was demonstrated as a rapid diagnostic tool to prospectively monitor patients in both outpatient and surgical settings.

Otologic Skills Training

This article presents a summary of the current simulation training for otologic skills. There is a wide variety of educational approaches, assessment tools, and simulators in use, including simple low-cost task trainers to complex computer-based virtual reality systems. A systematic approach to otologic skills training using adult learning theory concepts, such as repeated and distributed practice, self-directed learning, and mastery learning, is necessary for these educational interventions to be effective. Future directions include development of measures of performance to assess efficacy of simulation training interventions and, for complex procedures, improvement in fidelity based on educational goals.

Teaching the pediatric ear exam and diagnosis of Acute Otitis Media: a teaching and assessment model in three groups

BACKGROUND

The serious consequences of inaccurate diagnosis of acute otitis media have led to a call for greater education to develop proficient pediatric otoscopy skills. Despite the clinical and educational needs, peer-reviewed standardized curricula with validated assessment instruments remain limited. This study evaluated a pediatric otoscopy curriculum incorporated into the Pediatric medical student clerkship with use of outcome measures that included assessment of skills with real patients. The objective was to determine whether students who received the intervention would demonstrate significant gains in pediatric otoscopy skills when compared with students with only routine immersion learning exposure.

METHODS

During their Pediatric clerkship, an intervention group (IG) of 100 medical students received routine instruction and a curriculum intervention. A non-intervention group (NIG) of 30 students received only routine instruction. Outcome measures included written tests and assessment of skills with real patients. A retention group (RG) consisted of 79 students in the IG who completed a written test at the end of medical school. Paired t-tests were used to compare differences in pre-intervention, post-intervention, and retention scores for the IG, NIG, and RG, while analysis of covariance tests were used to compare differences in scores between the IG and NIG.

RESULTS

Pre-intervention scores were similar for the IG and NIG for the written test (mean/SD of 12.9/2.9 for IG and 12.9/1.8 for NIG, p = 0.78) and skills checklist (mean/SD of 11.1/4.4 for IG and 10.9/4.0 for NIG, p = 0.88). The IG had significantly higher post-intervention scores than the NIG for the written test (mean/SD of 22.6/1.7 for IG and 13.9/2.5 for NIG, p < 0.001) and skills checklist (mean/SD of 19.2/3.4 for IG and 11.0/3.8 for NIG, p < 0.001). The IG also had significantly higher gain in scores than the NIG for the written test (mean/SD +9.6/2.8 for IG and +1.0/2.3 for NIG, p < 0.001) and skills checklist (mean/SD of +8.1/4.8 for IG and +0.1/4.5 for NIG, p < 0.001). For the RG, there was a significant decrease (p < 0.001) from the post-intervention scores to retention scores (mean/SD of -7.4/2.7) but a significant increase (p < 0.001) from the pre-intervention score to retention score (mean + 2.6/3.3).

CONCLUSIONS

Medical students who received a formal curriculum intervention demonstrated significant gains in pediatric otoscopy skills when compared with students with only routine immersion learning exposure. However, learning gains diminished over time, emphasizing the need for continued practice opportunities to reinforce students' skills. Our study provides a formal curriculum to meet identified educational gaps in the important topic of pediatric otoscopy and offers a model for teaching of other clinical skills using rigorous outcome measures including assessment of skills in real patients.

Standardized Checklist for Otoscopy Performance Evaluation: A Validation Study of a Tool to Assess Pediatric Otoscopy Skills

INTRODUCTION

Acute otitis media (AOM) is the most frequently diagnosed pediatric illness in the United States and the most common indication for antibiotic prescription. Skill in pediatric otoscopy is essential to correctly identify children with AOM. However, studies have found diagnostic inconsistency and significant overdiagnosis among practitioners. Given the potential public and individual health consequences, there has been a call for improved education regarding the diagnostic certainty of AOM. Yet educational efforts continue to be limited, particularly in regard to competency assessment. The lack of a validated tool to assess otoscopy skill attainment objectively diminishes the instructor's ability to provide useful feedback and direction to the learner.

METHODS

We have undertaken an educational intervention with the goal of developing a validated Standardized Checklist for Otoscopy Performance Evaluation (SCOPE), building on key principles of the general pediatric ear exam. The SCOPE was developed with the input of process and content experts with attention to specific domains of validity.

RESULTS

Our analysis provides important validity evidence for the SCOPE assessment tool. The instrument was piloted and successfully implemented with medical students and varying levels of residents in pediatrics and emergency medicine over a 5-year period in varied settings: urgent care, large and small pediatric clinics, and the emergency departments at two institutions. It has been used for both instruction and assessment purposes.

DISCUSSION

Because the SCOPE can be used in teaching demonstration purposes, in formative and summative assessment settings, and across the continuum of learners, this instrument offers the potential for more educational efforts in the field of assessment in direct patient care. We anticipate that the SCOPE will foster an environment of efficient yet high-yield review and discussion of otoscopy and diagnostic competency.

Face and content validity of a novel, web-based otoscopy simulator for medical education

Background

Despite the fact that otoscopy is a widely used and taught diagnostic tool during medical training, errors in diagnosis are common. Physical otoscopy simulators have high fidelity, but they can be expensive and only a limited number of students can use them at a given time.

Objectives

1) To develop a purely web-based otoscopy simulator that can easily be distributed to students over the internet. 2) To assess face and content validity of the simulator by surveying experts in otoscopy.

Methods

An otoscopy simulator, OtoTrain™, was developed at Western University using web-based programming and Unity 3D. Eleven experts from academic institutions in North America were recruited to test the simulator and respond to an online questionnaire. A 7-point Likert scale was used to answer questions related to face validity (realism of the simulator), content validity (expert evaluation of subject matter and test items), and applicability to medical training.

Results

The mean responses for the face validity, content validity, and applicability to medical training portions of the questionnaire were all ≤3, falling between the “Agree”, “Mostly Agree”, and “Strongly Agree” categories. The responses suggest good face and content validity of the simulator. Open-ended questions revealed that the primary drawbacks of the simulator were the lack of a haptic arm for force feedback, a need for increased focus on pneumatic otoscopy, and few rare disorders shown on otoscopy.

Conclusion

OtoTrain™ is a novel, web-based otoscopy simulator that can be easily distributed and used by students on a variety of platforms. Initial face and content validity was encouraging, and a skills transference study is planned following further modifications and improvements to the simulator.

Noninvasive depth-resolved optical measurements of the tympanic membrane and middle ear for differentiating otitis media

OBJECTIVE/HYPOTHESIS

In this study, optical coherence tomography (OCT) is used to noninvasively and quantitatively determine tympanic membrane (TM) thickness and the presence and thickness of any middle-ear biofilm located behind the TM. These new metrics offer the potential to differentiate normal, acute, and chronic otitis media (OM) infections in pediatric subjects.

STUDY DESIGN

Case series with comparison group.

METHODS

The TM thickness of 34 pediatric subjects was acquired using a custom-built, handheld OCT system following a traditional otoscopic ear exam.

RESULTS

Overall thickness (TM and any associated biofilm) was shown to be statistically different for normal, acute, and chronic infection groups (normal-acute and normal-chronic: P value < 0.001; acute-chronic: P value = 0.0016). Almost all observed scans from the chronic group had an accompanying biofilm structure. When the thickness of the TM and biofilm were considered separately in chronic OM, the chronic TM thickness correlated with the normal group (P value = 0.68) yet was still distinct from the acute OM group (P value < 0.001), indicating that the TM in chronic OM returns to relatively normal thickness levels.

CONCLUSION

Identifying these physical changes in vivo provides new metrics for noninvasively and quantitatively differentiating normal, acute, and chronic OM. This new diagnostic information has the potential to assist physicians to more effectively and efficiently screen, manage, and refer patients based on quantitative data.

LEVEL OF EVIDENCE

4.