Perfecting practice: a protocol for assessing simulation-based mastery learning and deliberate practice versus self-guided practice for bougie-assisted cricothyroidotomy performance

Qualification rate and associated factors regarding COVID-19 clinical skills training based on scenario simulation teaching to medical staffs in China: a hospital-based cross-sectional study

BACKGROUND

The coronavirus disease (COVID-19) pandemic has accentuated the need for effective clinical skills training in infectious diseases. This study aimed to explore the influencing factors of infectious disease clinical skills training based on scenario simulation teaching for medical staff in China.

METHODS

This hospital-based, cross-sectional study was conducted at the Third People's Hospital of Shenzhen between March and December 2022. Scenario simulation teaching was applied, and factors such as gender, educational level, professional background, and previous experience were examined to determine their impact on qualification outcomes.

RESULTS

The study included participants primarily between the ages of 20-40 years, with a higher proportion of women holding university degrees. Nurses and physicians were more likely to qualify, indicating the significance of professional backgrounds. Women showed a higher likelihood of qualifying than men and higher educational attainment correlated with better qualification rates. Prior experience with protective clothing in isolation wards was a significant determinant of successful qualification. Multivariate analysis underscored the influence of sex, education, and previous experience on training effectiveness.

CONCLUSION

Scenario simulation is an effective strategy for training clinical skills in treating infectious diseases. This study highlights the importance of considering sex, education, professional background, and prior experience when designing training programs to enhance the efficacy and relevance of infectious disease training.

Twelve tips for developing simulation-based mastery learning clinical skills checklists

Simulation-based mastery learning is a powerful educational paradigm that leads to high levels of performance through a combination of strict standards, deliberate practice, formative feedback, and rigorous assessment. Successful mastery learning curricula often require well-designed checklists that produce reliable data that contribute to valid decisions. The following twelve tips are intended to help educators create defensible and effective clinical skills checklists for use in mastery learning curricula. These tips focus on defining the scope of a checklist using established principles of curriculum development, crafting the checklist based on a literature review and expert input, revising and testing the checklist, and recruiting judges to set a minimum passing standard. While this article has a particular focus on mastery learning, with the exception of the tips related to standard setting, the general principles discussed apply to the development of any clinical skills checklist.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Are we talking about practice? A randomized study comparing simulation-based deliberate practice and mastery learning to self-guided practice

OBJECTIVES

Simulation-based technical skills training is now ubiquitous in medicine, particularly for high acuity, low occurrence (HALO) procedures. Mastery learning and deliberate practice (ML + DP) are potentially valuable educational methods, however, they are resource intensive. We sought to compare the effect of deliberate practice and mastery learning versus self-guided practice on skill performance of the rare, life-saving procedure, a bougie-assisted cricothyroidotomy (BAC).

METHODS

We conducted a multi-center, randomized study at five North American emergency medicine (EM) residency programs. We randomly assigned 176 EM residents to either the ML + DP or self-guided practice groups. Three blinded airway experts independently evaluated BAC skill performance by video review before (pre-test), after (post-test) and 6-12 months (retention) after the training session. The primary outcome was post-test skill performance using a global rating score (GRS). Secondary outcomes included performance time and skill performance at the retention test.

RESULTS

Immediately following training, GRS scores were significantly higher as mean performance improved from pre-test, (22, 95% CI = 21-23) to post-test (27, 95% CI = 26-28), (p < 0.001) for all participants. However, there was no difference between the groups on GRS scores (p = 0.2) at the post-test or at the retention test (p = 0.2). At the retention test, participants in the ML + DP group had faster performance times (66 s, 95% CI = 57-74) compared to the self-guided group (77 s, 95% CI = 67-86), (p < 0.01).

CONCLUSIONS

There was no significant difference in skill performance between groups. Residents who received deliberate practice and mastery learning demonstrated an improvement in skill performance time.

A Pharmacy Drug Knowledge Assessment Pilot: Who Will Fly Farthest and What Downs the Plane?

OBJECTIVE

To evaluate the effectiveness of a sequenced drug knowledge pilot in third professional year students in a capstone course.

METHODS

A three-phase drug knowledge pilot was conducted in spring 2022. Students completed a total of thirteen assessments, including nine low-stakes quizzes, three formative tests, and a final summative comprehensive exam. Results from the previous year's cohort (historical control) who only completed a summative comprehensive exam were compared to the pilot (test group) results to assess effectiveness. The faculty spent over 300 h developing content for the test group.

RESULTS

The pilot group had a mean score of 80.9% on the final competency exam, which was one percent lower than the control group who had a less rigorous intervention. A sub-analysis was conducted that removed the students who failed (<73%) the final competency exam, and no significant difference in the exam score was found. One practice drug exam was found to be moderately correlated and significant (r = 0.62) with the final knowledge exam performance in the control. The number of attempts on the low-stakes assessments had a low correlation with the final exam score in the test group compared to the control (r = 0.24).

CONCLUSION

The results of this study suggest a need to further investigate the best practices for knowledge-based drug characteristic assessments.

Reduction in ionizing radiation exposure during minimally invasive anterior plate osteosynthesis of distal radius fracture: Naive versus deliberate practice

This study aimed to decrease surgeon exposure to ionizing radiation through a new learning technique, "deliberate practice", which consists in improving performance by setting goals with feedback. The hypothesis was that exposure to ionizing radiation during distal radius fracture surgery using the minimally invasive plate osteosynthesis (MIPO) technique decreased faster with "deliberate" practice than with "naïve" practice. Radiographic dosimetry was measured in the first 30 fractures operated on by MIPO by 6 surgeons. The first 3 surgeons operated "naively" (Group 1) and the next 3 according to the "deliberate" procedure (Group 2). Group 2 received weekly feedback (number of exposed hands, number of fluoroscopic views, exposure duration, and X-ray dose). An expert, using fluoroscopic images and surgical videos, provided suggestions for improvement. Mean number of exposed hands was 23.66 in Group 1 and 1.9 in Group 2. Mean number of fluoroscopic views was 78.31 and 35.0, respectively. Mean X-ray exposure time was 74.34 and 32.89 s, respectively. Mean dosimetry was 1.40 mGy (and 0.59 mGy, respectively. The hypothesis was thus confirmed: dosimetry decreased faster in Group 2 than in Group 1. Teaching this deliberate practice should be generalized, to decrease the growth phase and increase the plateau phase of the learning curve.

Building a doctor, one skill at a time: Rethinking clinical training through a new skills-based feedback modality

The Accreditation Council for Graduate Medical Education milestones and entrustable professional activities (EPAs) are important assessment approaches but may lack specificity for learners seeking improvement through daily feedback. As in other professions, clinicians grow best when they engage in deliberate practice of well-defined skills in familiar contexts. This growth is augmented by specific, actionable coaching from supervisors. This article proposes a new feedback modality called microskills, which are derived from the psychology, negotiation, and business literature, and are unique in their ability to elicit targeted feedback for trainee development. These microskills are grounded in both clinical and situational contexts, thereby mirroring learners' cognitive schemas and allowing for more natural skill selection and adoption. When taken as a whole, microskills are granular actions that map to larger milestones, competencies, and EPAs. This article outlines the theoretical justification for this new skills-based feedback modality, the methodology behind the creation of clinical microskills, and provides a worked example of microskills for a pediatric resident on a hospital medicine rotation. Ultimately, microskills have the potential to complement milestones and EPAs and inform feedback that is specific, actionable, and relevant to medical learners.

Novel cricothyrotomy assessment tool for attending physicians: A multicenter study of an error avoidance checklist

BACKGROUND

This study used existing literature and expert feedback to develop and pilot a novel error-avoidance checklist tool for cricothyrotomy in attending physicians. Prior literature has not focused on expert cricothyrotomy performance. While published checklists teach a specific procedural method, ideal for novice learners, this may hinder expert learners.

OBJECTIVES

We endeavored to create a succinct error-avoidance checklist for cricothyrotomy. We hypothesized that such a checklist would prove feasible and acceptable to attending physicians.

METHODS

This is a multicenter prospective checklist creation, evaluation, and feasibility study. Multiple experts pursued an iterative process to reach consensus on a 7-item error-avoidance checklist. The checklist was trialed for feasibility in pilot sessions at two sites by 45 attending emergency physicians who used the checklist for peer performance assessment and provided feedback.

RESULTS

During the pilot implementation, 94% of respondents completed the procedure within the allotted 120 s. Greater than 85% of respondents agreed that four of the five procedural errors on the checklist were very or somewhat critical to avoid, including cutting >2 cm from midline, creating a false passage, failing to continuously maintain an object in the trachea, and injuring oneself during the procedure. Only 66% of participants felt severing the cricoid cartilage was critical. Successful breath administration and time under 120 s were critical for 100% and 95% of participants, respectively. The checklist was rated "easy" or "very easy" to use by 93% of participants, and 95% found this checklist reasonable for evaluating attending physicians.

CONCLUSIONS

We present the multicenter development and implementation of a novel error-avoidance checklist tool for use in expert cricothyrotomy performance. Attending emergency medicine (EM) physicians rated our tool easy to use and agreed that most of the proposed errors were critical. Participants overwhelmingly agreed this tool would be reasonable for evaluation of cricothyrotomy performance among attending EM physicians.

Otoskills training during covid-19 pandemic: a before-after study

BACKGROUND

The ongoing COVID-19 pandemic has disrupted the surgical training of residents. There is a real concern that trainees will not be able to meet their training requirements. Low-fidelity surgical simulation appears to be an alternative for surgical training. The educational benefits of repeating ossiculoplasty simulations under a microscope have never been evaluated. With this study we aimed to evaluate the differences in performance scores and on a global rating scale before and after training on an ossiculoplasty simulator.

METHODS

In this quasi-experimental, prospective, single-centre, before-after study with blinded rater evaluation, residents performed five microscopic ossiculoplasty tasks with a difficulty gradient (sliding beads onto rods, the insertion of a partial prosthesis, the insertion of a total prosthesis, and the insertion of a stapedotomy piston under microscopic or endoscopic surgery) before and after training on the same simulator. Performance scores were defined for each task, and total performance scores (score/min) were calculated. All data were collected prospectively.

RESULTS

Six out of seven intermediate residents and 8/9 novices strongly agreed that the simulator was an effective training device and should be included in the ENT residency program. The mean effect of training was a significant increase in the total performance score (+ 0.52 points/min, [95 % CI, 0.40-0.64], p < 0.001), without a significant difference between novice and intermediate residents.

CONCLUSIONS

This preliminary study shows that techniques for middle-ear surgery can be acquired using a simulator, avoiding any risk for patients, even under lockdown measures.

Review of a Role 2 in Afghanistan: Understanding the Data on Medical and Surgical Volumes in a Deployed Setting

INTRODUCTION

The U.S. forward military surgical assets have deployed throughout the Iraq and Afghanistan theaters of operations to maintain surgical support for injured service members in compliance with the "golden hour" as specified in the Gates Memorandum. The support of evacuation times of less than 60 minutes to a surgical capability has resulted in smaller surgical teams being deployed to an increased number of locations. Over the last 5 years, the combat trauma patient encounters have decreased. Although some Role 2 medical treatment facilities (MTFs) maintain a medical mission, most of them are set up to provide trauma care. The largest and busiest Role 2 MTF is located near Kabul and serves the NATO population. The aims of this review are to examine the epidemiological data of the largest Role 2 MTF in theater, to examine damage control surgical capability optimization in a facility with a largely medical mission, and to analyze what this may mean in the context of surgical skill atrophy.

METHODS

As part of a performance improvement project, a retrospective review of prospectively collected data at the Hamid Karzai NATO Role 2 MTF was conducted. Four years of clinical and epidemiological data were reviewed. Independent source verification of the records was conducted by validating records via comparison to the ancillary services' records. When available, data on other MTFs in Afghanistan were used for comparison. Descriptive statistics were used to analyze demographics, evacuations, surgeries, and admissions.

RESULTS

Over the studied period, 0.7% of patients were seen for battle injuries. The average number of patients seen was 636 per month with 184 per month in 2016 and a steady increase to 805 per month in 2019. The operative volume was a mean of 2.8 surgeries per month with a median of 2 surgeries per month (orthopedic and general surgery combined). Other Role 2 facilities were on average seeing even fewer operative patients, although there were some treating more operative patients. From available data, no other Role 2 MTFs were treating close to as many total patients (all types combined). The two Role 3 facilities evaluated saw significantly more operative patients at an average of 53 surgeries per month.

CONCLUSION

The ratio of operative cases per surgeon is substantially higher at these Role 3 facilities, when compared to Role 2 facilities, although still significantly lower than would be expected at an U.S. Level 1 trauma center. This is consistent with other larger epidemiological studies on forward MTF workload. The vast majority of patient care is related to treatment of disease and preventative medicine. Only 0.7% of the large volume of patient visits evaluated were for battle injuries. There is a scarcity of both surgical and trauma patients, with a more pronounced reduction at Role 2 compared to Role 3 facilities. This is especially evident here with a facility that has such a large patient population but low trauma or surgical patient volume. Sustaining trauma and surgical skills for both surgeons and trauma teams with a paucity of trauma patients is a significant concern.

Simulation of Adult Surgical Cricothyrotomy for Anesthesiology and Emergency Medicine Residents: Adapted for COVID-19

INTRODUCTION

In a CICO (cannot intubate, cannot oxygenate) situation, anesthesiologists and acute care physicians must be able to perform an emergency surgical cricothyrotomy (front-of-neck airway procedure). CICOs are high-acuity situations with rare opportunities for safe practice. In COVID-19 airway management guidelines, bougie-assisted surgical cricothyrotomy is the recommended emergency strategy for CICO situations.

METHODS

We designed a 4-hour procedural simulation workshop on surgical cricothyrotomy to train 16 medical residents. We provided prerequisite readings, a lecture, and a videotaped demonstration. Two clinical scenarios introduced deliberate practice on partial-task neck simulators and fresh human cadavers. We segmented an evidence-based procedure and asked participants to verbalize the five steps of the procedure on multiple occasions.

RESULTS

Thirty-two residents who participated in the workshops were surveyed, with a 97% response rate (16 of 16 from anesthesiology, 15 of 16 from emergency medicine). Participants commented positively on the workshop's authenticity, its structure, the quality of the feedback provided, and its perceived impact on improving skills in surgical cricothyrotomy. We analyzed narrative comments related to three domains: preparation for the procedure, performing the procedure, and maintaining the skills. Participants highlighted the importance of performing the procedure many times and mentioned the representativeness of fresh cadavers.

DISCUSSION

We developed a surgical cricothyrotomy simulation workshop for anesthesiology and emergency medicine residents. Residents in the two specialities uniformly appreciated its format and content. We identified common pitfalls when executing the procedure and provided practical tips and material to facilitate implementation, in particular to face the COVID-19 pandemic.

Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation

Reflective practice is essential for the ongoing maturation of clinicians and requires regular self-evaluation in association with ongoing mentoring and feedback. Currently, most resident physicians do not have access to educational experiences that fulfill these needs. We present a novel model for structured one-on-one longitudinal coaching using the principles of deliberate practice to improve diagnostic skills. This is an easily implementable educational model that can be replicated in residencies across the country to improve clinical reasoning. Skills learned through this program have the potential not only to bolster the academic approach to patients but to also directly improve the clinical assessment and care of patients under the trainee's care.

A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit

Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.

Comparison of different feedback modalities for the training of procedural skills in Oral and maxillofacial surgery: a blinded, randomized and controlled study

BACKGROUND

The feedback given to students plays an important role in their efficiency related to learning practical skills. In the present study, diverse feedback modalities have been investigated. Our hypothesis is that individualized and unsupervised video feedback can produce a similar learning experience as performing practical skills in an oral and maxillofacial surgery setting with conventional direct expert feedback (control group).

METHODS

This prospective, randomized, controlled, and blinded study compared direct expert feedback (DEF), individualized video feedback (IVF) and unsupervised video feedback (UVF). The participants were fourth-year dental students from University Goethe in Frankfurt. The students were assigned to one of the three feedback methods (n = 20 per group) using simple randomization. All participants watched an instruction video for an interdental ('Ernst') ligature and periphery venous catheterization. Next, the students were video recorded performing the tasks by themselves (pre-test). Following this, every student received feedback using one of the above-mentioned feedback modalities. The participants then performed the same task again while being video recorded (post-test) to measure the acquired competence. Six weeks later, the students participated in an objective structured clinical examination (OSCE) to evaluate their long-term knowledge retention. All examiners were blinded regarding the students' instructional approach and their affiliation in terms of the learning group.

RESULTS

For the interdental ligature, we found significant improvements in performance in each feedback modality group between the pre-test and post-test (p < 0.001). UVF had the strongest effect on performance time. The comparison between each group in the post-test showed no significant differences between the three groups.

CONCLUSION

This study showed that IVF and UVF can be considered an alternative or adjunct to conventional methods (i.e. DEF) when learning procedural skills in oral and maxillofacial surgery. However, DEF showed to be the most effective method of feedback and therefore preferable in teaching.