Pediatric Residents' Procedural Competency Requirements: A National Needs Assessment of Program Directors and Chief Residents

BACKGROUND

There is increased learner competition for a shrinking pool of procedural training opportunities and indications in pediatrics. This study aimed to describe pediatric residency program directors' (PDs) and chief residents' (CRs) perspectives about whether procedural requirements for pediatric residents should be reformed and individualized.

METHODS

This was a survey-based, mixed methods study of PDs and CRs affiliated with the Association of Pediatric Program Directors (APPD). We used descriptive statistics to analyze demographics and perspectives, logistic regressions to examine individual and program factors, and thematic analysis for qualitative data.

RESULTS

Forty-seven percent (95/203) of PDs and 16% (64/392) of CRs responded, representing APPD membership across program setting, size, and region (average standard mean deviation 0.28). Ninety-one percent of PD respondents considered one or more of the current Accreditation Council for Graduate Medical Education (ACGME) required procedures nonessential; 74% favored individualizing procedural training. CR responses mirrored PD responses. Program size, setting, and access to procedural teams did not significantly associate with likelihood to favor individualization.

CONCLUSIONS

The majority of PD and CR respondents believe that current ACGME procedures should be reformed and individualized to future career goals. This change could allow maximization of limited time in residency in this era of decreased opportunity.

Incorporating a Three-Dimensional Printed Airway into a Pediatric Flexible Bronchoscopy Curriculum

Background

Although hands-on simulation plays a valuable role in procedural training, there are limited tools available to teach pediatric flexible bronchoscopy (PFB). Fellowship programs rely on patient encounters, with inherent risk, or high-cost virtual reality simulators that may not be widely available and create education inequalities.

Objective

Our objective was to study the educational value and transferability of a novel, low-cost, three-dimensional-printed pediatric airway model (3D-AM) for PFB training. Our central hypothesis was that the 3D-AM would have high educational value and would be easily transferrable to learners at different teaching hospitals.

Methods

The 3D-AM was designed to teach technical bronchoscopy skills, airway anatomy, airway pathology, and bronchoalveolar lavage (BAL). The curriculum was offered to incoming fellows in pediatric pulmonology, pediatric surgery, and pediatric critical care across three different teaching institutions. After course completion, each participant assessed the simulation model(s) with a 5-point Likert scale across six domains: physical attributes, realism of experience, ability to perform tasks, value, relevance, and global impression. The expert instructors assessed the learners' competency using a modified version of the Bronchoscopy Skills and Tasks Assessment Tool.

Results

A total of 14 incoming fellows participated in the course. The mean scores for the 3D-AM across all six domains and across the three institutions was between 4 and 5, suggesting that learners generally had a favorable impression and a similar experience across different institutions. All learners "agreed" or "strongly agreed" that the course was a valuable use of their time, helped teach technical skills and airway anatomy, and would be useful for extra training during fellowship. Most of the learners correctly identified anatomy, bronchomalacia, and performed a BAL. Wall trauma was observed in 36% of learners.

Conclusion

The utility, low cost, and transferability of this model may create opportunities for PFB training across different institutions despite resource limitations in the United States and abroad.

Impact of Didactic Instruction on the Utilization of Point-of-Care Ultrasound in Family Medicine Residents

Background and Objectives In 2014, the Council of Academic Family Medicine released recommendations for the education of family medicine residents in point-of-care ultrasound (POCUS) curricula for Family Medicine Residency programs. One barrier to resident education in POCUS is the lack of access to equipment. This pilot study evaluates whether introducing didactic education on POCUS within a Family Medicine Residency program, with limited access to equipment, correlated with increased utilization of ultrasound by residents. Methods Sixteen family medicine residents participated in the intervention, consisting of a four-hour didactic ultrasound session. Resident confidence in POCUS was evaluated utilizing a Likert scale. Resident utilization of POCUS in a clinical setting was also evaluated by review and analysis of resident procedure logs in the New Innovations database. Results The resident confidence in all skills increased immediately after the completion of the didactic teaching session. Residents demonstrated improved confidence in needle guidance immediately and six weeks after the session (p < 0.001). A review of resident activity two years after the intervention revealed a 9.6% increase in the proportion of resident ultrasounds performed compared to the academic year before the intervention. Conclusions Access to equipment is an ongoing barrier to Family Medicine Residency programs in providing education on POCUS. The results of this study indicate that introducing the basics of POCUS via a didactic teaching session not only increased resident confidence in basic ultrasound but also correlated with increased utilization of POCUS. This increased utilization occurred despite residents not having access to ultrasound in their home clinics.

The new normal: a review of the impact of COVID-19 on gastroenterology fellowship training

The COVID-19 pandemic had a significant impact on medical education and gastroenterology fellowship training. As a result of the pandemic, a trainee's physical safety, mental health and wellness, clinical and procedural training, and educational opportunities were all potentially altered. Changes necessitated at the start of the pandemic were different than those needed further along in the pandemic course. Fellowship programs were required to modify policies and adapt to changes rapidly to advocate for their trainees and ensure quality education. Much of COVID-19's initial impact on education - decreased endoscopic procedures and the loss of educational conferences - has largely returned to pre-pandemic form. However, other changes made during the pandemic have persisted and likely will continue in the future. This includes a virtual interview format for fellowship matches, a virtual option for many national conferences, and an expansion of simulation training. This article reviews the impact that COVID-19 had on medical education with a specific focus on gastroenterology fellowship. The paper highlights the initial impact of COVID-19, the lingering effects, and discusses the areas needed for further research to best understand the total impact COVID-19 had on our trainees' education.

Ankle fracture internal fixation performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary, multicentre randomized controlled trial

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

Methods

We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs.

Results

Overall, 139 ankle fractures were fixed by 28 postgraduate year three to five trainee surgeons (mean age 29.4 years; 71% males) during ten months' follow-up. Under the intention-to-treat principle, a technically superior fixation was performed by the cadaveric-trained group compared to the standard-trained group, as measured on the first postoperative radiograph against predefined acceptability thresholds. The cadaveric-trained group used a lower intraoperative dose of radiation than the standard-trained group (mean difference 0.011 Gym2, 95% confidence interval 0.003 to 0.019; p = 0.009). There was no difference in procedure time.

Conclusion

Trainees randomized to cadaveric training performed better ankle fracture fixations and irradiated patients less during surgery compared to standard-trained trainees. This effect, which was previously unknown, is likely to be a consequence of the intervention. Further study is required.

How Good is Good Enough?: Current-Day Pediatric Residency Program Directors' Challenges in Assessing and Achieving Resident Procedural Competency

OBJECTIVE

Significant gaps exist in the pediatric resident (PR) procedural experience. Graduating PRs are not achieving competency in the 13 ACGME recommended procedures. It is unclear why PR are not able to achieve competency, or how existing gaps may be addressed.

METHODS

We performed in-depth one-on-one semistructured interviews with 12 pediatric residency program directors (PPDs). The interviews were audio-recorded, and transcribed verbatim. Coding of the data using conventional content analysis led to generation of categories, which were validated through consensus development.

RESULTS

We identified 4 main categories, including (1) programs struggle to ensure adequate training in procedural skills for PRs, with various barriers reported; (2) programs develop individualized strategies to address challenges in procedural skills training, and multiple options are necessary; (3) PPDs face challenges defining procedural competency and standardizing expectations; and (4) expectations for PR procedural training may require modification based upon current practice environments. Solutions include simulation, procedural boot camps, and procedural/subspecialty electives.

CONCLUSIONS

Numerous methods to combat challenges in PR procedural training have been identified by participating PPDs, including simulation, tailoring electives, and developing institutional guidelines. However, accreditation bodies may need to update procedural expectations based on individual resident career goals and realities of current day practice.

An Assessment of Upper-Extremity Surgical Technique Videos and Their Relationship With Procedural Learning Theory

PURPOSE

Our purpose was to ascertain how well award-winning and highly viewed upper-extremity surgical videos meet the needs of users and adhere to procedural learning theory. We hypothesized that upper-extremity videos hosted on academic society websites meet user needs better than upper-extremity videos hosted on a commercial website.

METHODS

Twenty-five upper-extremity videos were evaluated by 3 reviewers. A standardized scoring sheet was used to assess each video's content, production quality, and adequacy. Video lengths were compared. The inclusion frequencies of specific content categories, the adequacy of content, and meeting certain production standards, all of which assess consistency with procedural learning theory, were reported, stratified by video host. Associations between the video host and video content, production quality, and adequacy were assessed.

RESULTS

The median lengths of academically hosted and commercially hosted videos were similar. Regardless of the video host, no video contained information in all content categories. Sixty percent of the scored categories were present in less than 75% of evaluated videos. Academically hosted videos contained scored content more frequently than commercially hosted videos in 68.4% of categories. There were significant associations between academic hosts and inclusion of a case presentation, surgical indications, outcomes literature, a preoperative examination, follow-up visit intervals, and alternative surgical techniques. Overall, academically hosted videos had a higher percentage of adequate content categories compared with commercially hosted videos.

CONCLUSIONS

Videos on academic websites more consistently meet users' content needs and production expectations, as informed by procedural learning theory, while having higher rates of adequate content compared with videos on commercial websites.

CLINICAL RELEVANCE

While academically hosted videos appear to more consistently adhere to the tenets of procedural learning theory, opportunity exists for video creators to more consistently apply procedural learning theory, allowing for the creation of even more educationally beneficial online surgical videos.

Train Strategies for Haptic and 3D Simulators to Improve the Learning Process in Dentistry Students

Dental training faces the growing shortage of extracted teeth and the ethical precepts of Bionot learning on patients and reducing the environmental damage that preclinical trainings generate. Haptic and 3D simulators reproduce pathologies and provide a greater magnification of the processes, reducing water expenditure and pollution, but their curricular integration is complex. Two resources of complementary use (informative written manual and video tutorial) were designed to facilitate the theoretical and technical domain (know how the simulator works and make it work), as well as the advanced management of the simulator (operate the simulator autonomously, without setbacks). After 5 years of using these resources, an evaluative study was conducted with 175 students and 32 teachers. The aim was to assess the student’s perception of knowledge/learning, its statistical relationship with the didactic resources used and compare these results with the teachers’ perception of their students’ knowledge/learning. Spearman’s Rho coefficient and Kolmogorov-Smirnov test were performed. Both students and teachers considered that the technical domain (make the simulator work) was the domain that prevailed the most. There was a tendency for students not to value much the necessity of a specific preparation prior to using the simulator. This tendency resulted in a low level of study of both the written manual and the video tutorial. In conclusion, both students and teachers considered that the best strategy of knowledge/learning was the direct exchange with the simulator.

Old Dog, New Trick: Efficacy of Self-Directed Procedural Training for Attending Critical Care Physicians

BACKGROUND

In teaching hospitals, the majority of central venous lines (CVL) are placed by trainees, resulting in little opportunity for attending critical care physicians to maintain this procedural skill. Additionally, not all attending critical care physicians have been trained in the most up-to-date method of dynamic ultrasound (US) guided CVL placement. Furthermore, there is no standardized method to assess procedural competency of attending critical care physicians or to train them in the evolving practice of CVL placement. Despite these limitations, attending critical care physicians are ultimately responsible for supervision of CVL placement by trainees.

OBJECTIVE

To assess the utility of an instructional video to impact attending critical care physicians' competency and confidence in dynamic US guided CVL placement.

METHODS

A pre-post intervention study was conducted at an academic medical center. Attending critical care physicians were first asked to obtain CVL access on a gelatin model using US guidance. They then participated in the intervention, which consisted of watching a short instructional video demonstrating a method of dynamic US guided CVL placement. They were then asked to obtain access again, this time using the described method. All CVL placements were video recorded to assess competency in dynamic US guided CVL placement as well as the time required to obtain CVL access. Two blinded and independent reviewers evaluated each video with discrepancies resolved by a third reviewer. Participants were also surveyed pre and post intervention to assess their confidence in performing and supervising CVL placement.

RESULTS

A total of 21 attending critical care physicians were included. Pre-intervention, four used dynamic US guidance compared to 16 post-intervention (P < .001). Confidence in both CVL placement and supervision improved post-intervention (P = .03 each). Time required to obtain CVL access did not differ significantly pre and post intervention. The majority (20/21) believed there should be required competency testing for CVL placement.

CONCLUSIONS

Pre-intervention dynamic US guided CVL competency was poor in this sample of attending critical care physicians but improved significantly with an instructional video intervention. This study suggests there is a role for procedural competency testing among attending critical care physicians, and that significant improvement is achievable with relatively minimal instruction.

A Point-of-Care Ultrasound Rotation for Medical Education Fellows in Emergency Medicine

A Medical Education (MedEd) fellowship provides emergency medicine (EM) residency graduates the structured and rigorous training to develop skills as educators. Although not accredited by the Accreditation Council for Graduate Medical Education (ACGME), MedEd fellowships have established minimum curriculum standards [1]. Our institution’s MedEd fellowship curriculum incorporates an innovative opportunity for fellows: two 3-week rotations in Point-of-Care Ultrasound (POCUS). Here we describe the rationale for using this POCUS rotation to reinforce key MedEd concepts that benefit the MedEd fellows, the POCUS trainees, and the Ultrasound section. Ultimately, we believe this addition in training helps further develop MedEd fellows’ teaching skills, with specific attention to kinesthetic and visual-spatial content.

Pretraining of basic skills on a virtual reality vitreoretinal simulator: A waste of time

PURPOSE

To investigate whether pretraining of basic skills in virtual vitreoretinal surgery affected the performance curve when proceeding to procedure-specific modules.

METHODS

This study was a prospective, randomized, controlled, two-centre study. Medical students were randomized into two groups: Group 1 pretrained basic psycho-motor skills (Navigation Training level 2 and Bimanual Training level 3) until they reached their performance curve plateau. Hereafter, both groups trained on the procedure-specific modules (Posterior Hyaloid level 3 and ILM Peeling level 3) until they reached their performance curve plateau. Plateau was defined as three consecutive sessions with the same score with an acceptable variation. The primary outcome was time used to reach performance curve plateau in the procedure-specific modules.

RESULTS

A total of 68 medical students were included, and equally randomized into two groups. The participants in Group 1 used a median time of 88 minutes to reach plateau in the basic skills modules but did not differ from Group 2 in time to reach plateau on the procedure-specific modules (183 min versus 210 min, p = 0.40) or in the amplitude of plateau. Group 1 and 2 differed significantly in the starting score of ILM peeling level 3 (0 (0-0) versus 3.5 (0-75), p = 0.03).

CONCLUSION

We were not able to show positive skill transfer from basic skills training to the procedure-specific modules in time, starting score or amplitude of plateau. Thus, we recommend that aspiring vitreoretinal surgeons proceed directly to simulation-based training of procedures instead of spending valuable training time on basic skills training.

Comparison of Two Simulated Procedural Assessment Formats in Attending Emergency Physicians

Background

Emergency physicians must be proficient at inserting central venous catheters and performing lumbar punctures to provide life-saving therapies to critically ill patients. An assessment of procedural skill is rarely performed after an emergency physician has completed residency. Current board certification exams for emergency medicine focus only on verbal descriptions of procedures to assess skill. We compared two methods of procedural skill assessment, simulated task trainer and verbal description, to assess the range of skill in central venous catheter insertion and lumbar punctures of emergency attending physicians at a large, urban, academic tertiary care institution.

Methodology

This is a prospective cohort study of simulated internal jugular central venous catheter insertion and lumbar puncture skill by emergency attending physicians on a task trainer versus verbal description. A total of 17 attending emergency medicine physicians consented to participate in the study during a yearly procedural skills session. For each subject, two expert raters used previously published checklists to assess procedural skill and give a global rating score.

Results

More checklist items were performed correctly on the task trainer than on verbal assessment for central line (task trainer = 78.4% ± 8.32% and verbal = 68.26% ± 8.9%) and lumbar puncture (task trainer = 85.57% ± 7.6% and verbal = 73.53%4 ± 10.34%) procedures, both with significant differences (p < 0.001). Of the participants, 82% strongly preferred the task trainer format to the verbal description assessment format.

Conclusions

The higher scores on the simulated format compared to the current verbal format imply that a shift towards simulated procedural assessment techniques may benefit examinees. More work is needed to determine if objective checklist scores for practicing attending emergency physicians correlate with subjective expert assessments of their procedural skills.

The role of dry-lab and cadaveric simulation for cystoscopy and intravesical Botulinum toxin injections

Background

The aim of this study is to assess validity of the ETXY Multifunctional trainer (ProDelphus, Olinda, Pernambuco, Brazil), a bench-top dry-lab model for simulation of cystoscopy and intravesical injections of Botulinum Toxin A (BTX-A) injections, in terms of educational value, feasibility and acceptability as well as evaluating the use of fresh frozen cadavers for intravesical BTX-A injections.

Methods

Prospective study with novice trainees and urologists (n=58) trained by experts (n=14) in a 30-min hands-on training session in intravesical administration of BTX-A over 6 training sessions throughout one year. Outcome measures were demonstrated through distribution and analysis of evaluation surveys on a 5-point Likert scale.

Results

There were 56 participants (96.6%) believed that the model has a role in training for the procedure. Participants also reported the training being an important confidence-booster for performing BTX-A injections (mean: 4.05/5) and useful for teaching procedural steps (mean: 3.89). Experts highly rated the realism of the simulator especially in simulation of needle penetration (mean: 3.98) and delivery (mean 4.03). Fresh frozen cadavers had a mean realism rating of 4.54 and participants affirmed that they should be routinely used for training and assessment (mean: 3.92).

Conclusions

This study demonstrated face and content validity in addition to establishing the feasibility and acceptability of the ETXY Multifunctional model in the training of intravesical BTX-A administration. Additionally, the simulator demonstrated educational value and fresh frozen cadavers were shown to be the preferred simulation modality for this procedure. Further evaluation in randomised controlled studies is needed to demonstrate higher evidence quality.

Rapid Cycle Deliberate Practice (RCDP) as a Method to Improve Airway Management Skills - A Randomized Controlled Simulation Study

Background: Paediatric intubations are a relatively rare but critical procedure that requires adequate practice to achieve skillful performance. Simulation is a method to teach intubation skills in a safe environment. Rapid Cycle Deliberate Practice (RCDP), as a method of simulation debriefing, has been shown to improve pediatric resident resuscitation skills. It has not been demonstrated if RCDP can be effectively used in procedural skills training. The objective of this study was to determine if RCDP with feedback in real-time, as well as an opportunity to repeat the action, is superior to a simulation where no feedback is provided during the simulation and is instead provided after the simulation.

Materials and Methods: This was a randomized controlled single-blinded study. All participants were videotaped during a simulated pre-assessment intubation, then received either the intervention (RCDP) or the control teaching (feedback after the simulation), followed by a post-assessment intubation. These videos were scored by two independent raters on an intubation checklist. The primary outcome was the change in score. The secondary outcome was intubation success.

Results: Thirty-five students met the inclusion criteria. The RCDP group achieved a significantly higher score improvement in the preparation and post-procedure care categories. The overall score change in the RCDP group was significantly higher than in the control group, with a mean difference of -11.86 (CI -15.57 to -8.15, p<0.00001), but there was no significant improvement in intubation success.

Conclusion: Our study suggests that RCDP is an effective method to teach the procedural skill of intubation with an emphasis on procedural choreography. RCDP could be an appropriate method for debriefing learners in procedural skills training in this population.

Prospective Cohort Study of Haptic Virtual Reality Laparoscopic Appendicectomy Learning Curve Trajectory

Background: Simulation training is strongly advocated by 24/7 risk-rich professions because swift learning curve inflection point attainment delivers earlier competence; the left-shift effect. The aim of this study was to determine the value of haptic laparoscopic virtual reality simulation, by iterative benchmark exercise (n = 8), before simulated laparoscopic appendicectomy (SLA); the hypothesis was that favorable benchmark learning curve trajectories would be associated with improved SLA competence when compared with consultant expert performance. Methods: A 28-trainee cohort completed 1349 Laparoscopic Haptic Virtual Reality Skills (LHVRS) tasks, during which 19 ergonomic variables were assessed by virtual interface, including force feedback (Surgicalscience.com), before 153 SLAs. Primary outcome measure was SLA composite competence score related to six consultant trainer experts. Results: Of the eight LHVRS tasks, the three with the steepest learning curve trajectories correlated with better median overall SLA competence scores, namely tissue grasping/lifting (rho = 0.362, P = .049), fine dissection (rho = 0.388, P = .028), and camera navigation (rho = 0.518, P = .007); fine dissection was the only haptic laparoscopic virtual reality simulation task that predicted a SLA score within a Youden index defined, 70% of the consultant expert level (area under curve [AUC] = 0.803, P = .028). A significant SLA learning curve emerged, with a learning curve trajectory inflection point at the fourth SLA attempt (first SLA 30.5% versus fourth SLA score 76.0%, gradient 76°, P = .010). Conclusion: Learning curve trajectory can be measured, influenced, and accelerated significantly; a pronounced left-shift effect, with translational potential for enhanced shorter training time and improved patient safety.

Graduating Pediatric Resident Reports on Procedural Training and Preparation

OBJECTIVE

To determine pediatric resident training and preparation for 14 Accreditation Council for Graduate Medical Education (ACGME)-required procedures.

METHODS

We included a national, random sample of 1000 graduating pediatric residents in 2015. For each of the ACGME-required procedures, residents were asked if they received training, successfully completed the procedure at least once, were comfortable performing the procedure unsupervised, and desired more training. To examine relationships among these 4 measures of training, we conducted logistic regression models and receiver operating characteristics curves. We used chi-square to examine whether desiring more training varied according to program size or career goal.

RESULTS

Response rate was 55% (550 of 1000). More than half of the residents received training in each procedure (56.4%-99.3% across procedures) and had successfully completed them at least once (59.8%-99.6%). However, 91.3% desired more training in at least 1 procedure, and 30.0% would like more training in more than half of the procedures (≥8). Relationships were found between the 4 training measures, with some relationships stronger than others. Residents with primary care goals were more likely than those with subspecialty or hospital practice goals to desire more training in abscess incision and drainage and temporary splinting of fractures (P < .05). Residents in large programs were more likely than those in smaller programs to desire more training in bladder catheterization, peripheral intravenous catheter placement, and venipuncture (P < .05).

CONCLUSIONS

Although pediatric residents are overall well prepared to perform ACGME-required procedures, exceptions exist. Considering the role of program size and resident career goal might help when optimizing and individualizing resident procedural training and preparation.

When Old Habits Train a New Generation: Findings From a National Survey of Internal Medicine Program Directors on Procedural Training

Resident physicians routinely perform bedside procedures that pose substantial risk to patients. However, no standard programmatic approach to supervision and procedural competency assessment among residents currently exists. The authors performed a national survey of internal medicine (IM) program directors to examine procedural assessment and supervision practices of IM residency programs. Procedures chosen were those commonly performed by medicine residents at the bedside. Of the 368 IM programs, 226 (61%) completed the survey. Programs reported the predominant method of training as 171 (74%) apprenticeship and 106 (46%) as module based. The majority of programs used direct observation to attest to competence, with 55% to 62% relying on credentialed residents. Most programs also relied on a minimum number of procedures to determine competence (64%-88%), 72% of which reported 5 procedures (a lapsed historical standard). This national survey demonstrates that procedural assessment practices for IM residents are insufficiently robust and may put patients at undue risk.

Development of Reliable and Validated Tools to Evaluate Technical Resuscitation Skills in a Pediatric Simulation Setting: Resuscitation and Emergency Simulation Checklist for Assessment in Pediatrics

OBJECTIVES

To develop a reliable and validated tool to evaluate technical resuscitation skills in a pediatric simulation setting.

STUDY DESIGN

Four Resuscitation and Emergency Simulation Checklist for Assessment in Pediatrics (RESCAPE) evaluation tools were created, following international guidelines: intraosseous needle insertion, bag mask ventilation, endotracheal intubation, and cardiac massage. We applied a modified Delphi methodology evaluation to binary rating items. Reliability was assessed comparing the ratings of 2 observers (1 in real time and 1 after a video-recorded review). The tools were assessed for content, construct, and criterion validity, and for sensitivity to change.

RESULTS

Inter-rater reliability, evaluated with Cohen kappa coefficients, was perfect or near-perfect (>0.8) for 92.5% of items and each Cronbach alpha coefficient was ≥0.91. Principal component analyses showed that all 4 tools were unidimensional. Significant increases in median scores with increasing levels of medical expertise were demonstrated for RESCAPE-intraosseous needle insertion (P = .0002), RESCAPE-bag mask ventilation (P = .0002), RESCAPE-endotracheal intubation (P = .0001), and RESCAPE-cardiac massage (P = .0037). Significantly increased median scores over time were also demonstrated during a simulation-based educational program.

CONCLUSIONS

RESCAPE tools are reliable and validated tools for the evaluation of technical resuscitation skills in pediatric settings during simulation-based educational programs. They might also be used for medical practice performance evaluations.

Use of Simulation in Canadian Neonatal-Perinatal Medicine Training Programs

Introduction Simulation is used for the delivery of education and on occasion assessment. Before such a tool is used routinely in neonatal training programs across Canada, a need assessment is required to determine its current usage by accredited training programs. Our aim was to characterize the type of simulation modalities used and the perceived simulation-based training needs in Canadian neonatal-perinatal medicine (NPM) training programs. Methods A 22-item and 13-item online descriptive survey was sent to all NPM program directors and fellows in Canada, respectively. The survey was modeled on a previously validated tool by Johnston, et al. and responses were collected over 30 days. Results In total, eight (63%) program directors and 24 (28%) fellows completed the survey, with all respondents indicating that simulation is being used. Both lab-based and in situ simulations are occurring, with a range of simulation modalities employed to primarily teach resuscitation, procedural and communication skills. Fellows indicated that simulation should also be used to also teach other important topics, including disease-specific management, crisis resource management, and prevention of medical error. Five (63%) programs have faculty with formal simulation training and four (50%) programs have at least one faculty involved in simulation research. Conclusion Simulation is widely used in Canadian NPM training programs, with program directors and fellows identifying this as an important tool. Simulation can be used to teach a range of skills, but programs need to align their curriculum with both training objectives and learner needs. There is an opportunity for faculty development and increased simulation research.

Evaluation of Procedural Simulation as a Training and Assessment Tool in General Surgery-Simulating a Laparoscopic Appendectomy

BACKGROUND

Laparoscopic appendectomy is a commonly performed surgical procedure, but few training models have been described for it. We examined a virtual reality module for practising a laparoscopic appendectomy.

METHODS

A prospective cohort study with the following 3 groups of surgeons (n = 45): novices (0 procedures), intermediates (10-50 procedures), and experienced (>100 procedures). After being introduced to the simulator and 1 familiarization attempt on the procedural module, the participants practiced the module 20 times. Movements, task time, and procedure-specific parameters were compared over time.

RESULTS

The time and movement parameters were significantly different during the first attempt, and more experienced surgeons used fewer movements and less time than novices (p < 0.01), although only 2 parameters were significantly different between novices and intermediates. All 3 groups improved significantly over 20 attempts (p < 0.0001). The intraclass correlation coefficient varied between 0.55 and 0.68 and did not differ significantly between the 3 groups (p > 0.05). When comparing novices with experienced surgeons, novices had a higher risk of burn damage to cecum (odds ratio [OR] = 3.0 [95% CI: 1.3; 7.0] p = 0.03), pressure damage to appendix (OR = 3.1 [95% CI: 2.0; 4.9] p < 0.0001), and grasping of the appendix (OR = 2.9 [95% CI: 1.8; 4.7] p < 0.0001). The risk of causing a perforation was not significantly different among the different experience levels (OR = 1.9 [95% CI: 0.9; 3.8] p = 0.14). Only 3 out of 5 error parameters differed significantly when comparing novices and experienced surgeons. Similarly, when comparing intermediates and novices, it was only 2 of the parameters that differed.

DISCUSSION

The simulator module for practising laparoscopic appendectomy may be useful as a training tool, but further development is required before it can be used for assessment purposes. Procedural simulation may demonstrate more variation for movement parameters, and future research should focus on developing better procedure-specific parameters.

Using Learner-Centered, Simulation-Based Training to Improve Medical Students' Procedural Skills

PURPOSE

To evaluate the effectiveness of a learner-centered, simulation-based training developed to help medical students improve their procedural skills in intubation, arterial line placement, lumbar puncture, and central line insertion.

METHOD

The study participants were second and third year medical students. Anesthesiology residents provided the training and evaluated students' procedural skills. Two residents were present at each station to train the medical students who rotated through all 4 stations. Pre/posttraining assessment of confidence, knowledge, and procedural skills was done using a survey, a multiple-choice test, and procedural checklists, respectively.

RESULTS

In total, 24 students were trained in six 4-hour sessions. Students reported feeling significantly more confident, after training, in performing all 4 procedures on a real patient (P < .001). Paired-samples t tests indicated statistically significant improvement in knowledge scores for intubation, t(23) = -2.92, P < .001, and arterial line placement, t(23) = -2.75, P < .001. Procedural performance scores for intubation (t(23) = -17.29, P < .001), arterial line placement (t(23) = -19.75, P < .001), lumbar puncture (t(23) = -16.27, P < .001), and central line placement (t(23) = -17.25, P < .001) showed significant improvement. Intraclass correlation coefficients indicated high reliability in checklist scores for all procedures.

CONCLUSIONS

The simulation sessions allowed each medical student to receive individual attention from 2 residents for each procedure. Students' written comments indicated that this training modality was well received. Results showed that medical students improved their self-confidence, knowledge, and skills in the aforementioned procedures.

Versatile, Reusable, and Inexpensive Ultrasound Phantom Procedural Trainers

We have constructed simple and inexpensive models for ultrasound-guided procedural training using synthetic ballistic gelatin. These models are durable, leak resistant, and able to be shaped to fit a variety of simulation scenarios to teach procedures. They provide realistic tactile and sonographic training for our learners in a safe, idealized setting.

Development and assessment of a pediatric emergency medicine simulation and skills rotation: meeting the demands of a large pediatric clerkship

OBJECTIVE

To implement a curriculum using simulation and skills training to augment a Pediatric Emergency Medicine (PEM) rotation within a pediatric clerkship.

BACKGROUND

PEM faculty are often challenged with a high learner to teacher ratio in a chaotic clinical setting. This challenge was heightened when our pediatric clerkship's traditional 1-week PEM rotation (consisting of 4 students completing four 8-hour ED shifts/week) expanded to 8 students every 2 weeks. We sought to meet this challenge by integrating simulation-based education into the rotation.

METHODS

Clerkship students from March to June 2012 completed our traditional rotation. Students between July and October 2012 completed the new PEM-SIM curriculum with 19 hours ED shifts/week and 16 hours/week of simulation/skills training. Pre/post-tests evaluated 1) medical management/procedural comfort (five-point Likert scale); and 2) PEM knowledge (15 multiple-choice questions).

RESULTS

One hundred and nine students completed the study (48 traditional, 61 PEM-SIM). Improvement in comfort was significantly higher for the PEM-SIM group than the traditional group for 6 of 8 (75%) medical management items (p<0.05) and 3 of 7 (43%) procedures, including fracture splinting, lumbar puncture, and abscess incision/drainage (p<0.05). PEM-SIM students had significantly more improvement in mean knowledge compared to the traditional group (p<0.001).

CONCLUSIONS

We have successfully integrated 16 hours/week of faculty-facilitated simulation-based education into a PEM rotation within our clerkship. This curriculum is beneficial in clinical settings with high learner to teacher ratios and when patient care experiences alone are insufficient for all students to meet rotation objectives.

A novel cadaveric simulation program in urology

OBJECTIVE

To evaluate the urology human cadaver training program developed by the British Association of Urological Surgeons.

DESIGN

This prospective, observational comparative study recruited urology residents, with different levels of experience, in 2 sessions of a 3-day modular cadaveric operative urology training. Participants performed various procedures on fresh-frozen cadaveric specimens, as per module, supervised by certified urological surgeons. At the conclusion of each module, all residents and faculty were invited to complete an evaluation survey.

SETTING

The training days were hosted by the British Association of Urological Surgeons at the University of Manchester Surgical Skills and Simulation Centre.

PARTICIPANTS

A total of 81 urology residents were recruited, with a maximum of 14 participants attending each module, over 2 sessions. We allocated 2 participants to each cadaver with access to all necessary equipment and guidance.

RESULTS

A total of 102 evaluation surveys were received from the trainees and faculty; a response rate of 94%. All procedures scored a mean of 3 on 5 for face validity, which is higher than the acceptability range. Regarding content validity, participants and faculty rated all aspects ≥3 on 5. Respondents held a positive view of the cadaver sessions and believed them to be useful for learning anatomy and steps of an operation (mean = 4.54) and as a confidence booster for performing a procedure (mean = 4.33). Furthermore, it was thought that the training program significantly improved skills (mean = 4.11), gave transferrable skills for the operating room (mean = 4.21), and was feasible to be incorporated into training programs (mean = 4.29). Human cadaveric simulation was rated as the best mode of simulation-based training for all the procedures in the curriculum.

CONCLUSIONS

This study on cadaveric simulation training demonstrated face and content validities. It also showed feasibility, acceptability, a high value for educational influence and cost-effectiveness for cadaveric simulation. A simulation-based training pathway has been proposed for effective procedural training in urology.

Thinking it through: mental rehearsal and performance on 2 types of laparoscopic cholecystectomy simulators

OBJECTIVE

Simulation-based training (SBT) in laparoscopic cholecystectomy (LCCY) provides an opportunity for junior residents to learn the procedure in a safe, nonthreatening environment. Mental rehearsal (MR) has the potential of augmenting skill acquisition. This project investigated the correlation between MR of LCCY with performance on 2 different types of simulators: a procedural task (PT) training model and virtual reality (VR) machine.

DESIGN

Prospective, quasi-experimental design with purposeful sampling. Postgraduate years (PGYs) 1 through 3 general surgical residents underwent standardized, distributed SBT in LCCY on either a PT trainer or a VR machine with group-based MR undertaken before 2 SBT sessions. Participants completed a pre-MR and post-MR session mental imagery questionnaire (MIQ) containing 8-items using a 7-point Likert-type scale. Data related to VR objective measures and PT video-based performances were also collected. Total scale mean scores were calculated for the first MR session and the second MR session and were compared using the t test. Pearson correlation analysis of MIQ scores with performance scores was determined.

SETTING

Louisiana State University Health New Orleans Health Sciences Center in New Orleans, Louisiana. This health sciences center is a tertiary care, academic state institution located in the Southeastern United States.

PARTICIPANTS

A total of 21 PGYs 1 through 3 general surgery residents participated. They were purposefully divided into the PT and VR training groups to allow for even PGY distribution. Of the 21 participants, 19 completed both training sessions (n = 10 for PT [PGY1 = 4, PGY2 = 4, PGY3 = 2] and n = 9 for VR [PGY1 = 4, PGY2 = 3, PGY3 = 2]).

RESULTS

After the Bonferroni adjustment, significant gains in the MIQ items related to confidence, visual imagery, and knowledge of the procedure were found. VR performance data demonstrated some statistically significant improvements. A significant negative correlation was present between the two-handed clip-and-cut VR task and MIQ gains.

CONCLUSIONS

Group MR in LCCY before SBT on a VR machine is related to improved performance time for the VR two-handed clip-and-cut task. MR may be a useful adjunct to SBT LCCY. Future work will look at the translation of these skills to clinical practice.

Procedural specificity in laparoscopic simulator training: protocol for a randomised educational superiority trial

BACKGROUND

The use of structured curricula for minimally invasive surgery training is becoming increasingly popular. However, many laparoscopic training programs still use basic skills and isolated task training, despite increasing evidence to support the use of training models with higher functional resemblance, such as whole procedural modules. In contrast to basic skills training, procedural training involves several cognitive skills such as elements of planning, movement integration, and how to avoid adverse events. The objective of this trial is to investigate the specificity of procedural practice in laparoscopic simulator training.

METHODS/DESIGN

A randomised single-centre educational superiority trial. Participants are 96 surgical novices (medical students) without prior laparoscopic experience. Participants start by practicing a series of basic skills tasks to a predefined proficiency level on a virtual reality laparoscopy simulator. Upon reaching proficiency, the participants are randomised to either the intervention group, which practices two procedures (an appendectomy followed by a salpingectomy) or to the control group, practicing only one procedure (a salpingectomy) on the simulator. 1:1 central randomisation is used and participants are stratified by sex and time to complete the basic skills. Data collection is done at a surgical skills centre.The primary outcome is the number of repetitions required to reach a predefined proficiency level on the salpingectomy module. The secondary outcome is the total training time to proficiency. The improvement in motor skills and effect on cognitive load are also explored.

DISCUSSION

The results of this trial might provide new knowledge on how the technical part of surgical training curricula should be comprised in the future. To examine the specificity of practice in procedural simulator training is of great importance in order to develop more comprehensive surgical curricula.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02069951.

A broadly applicable surgical teaching method: evaluation of a stepwise introduction to cataract surgery

OBJECTIVE

Although cataract surgery is one of the most commonly performed surgeries in the country, it is a microsurgical procedure that is difficult to learn and to teach. This study aims to assess the effectiveness of a new method for introducing postgraduate year (PGY)-3 ophthalmology residents to cataract surgery.

SETTING

Hospital-based ophthalmology residency program.

DESIGN

Retrospective cohort study.

PARTICIPANTS

PGY-3 and PGY-4 residents of the Harvard Medical School Ophthalmology Residency from graduating years 2010 to 2012.

RESULTS

In July 2009, a new method of teaching PGY-3 ophthalmology residents cataract surgery was introduced, which was termed "the stepwise introduction to cataract surgery." This curriculum aimed to train residents to perform steps of cataract surgery by deliberately practicing each of the steps of surgery under a structured curriculum with faculty feedback. Assessment methods included surveys administered to the PGY-4 residents who graduated before the implementation of these measures (n = 7), the residents who participated in the first and second years of the new curriculum (n = 16), faculty who teach PGY-4 residents cataract surgery (n = 8), and review of resident Accreditation Council for Graduate Medical Education surgical logs. Resident survey response rate was 100%. Residents who participated in the new curriculum performed more of each step of cataract surgery in the operating room, spent more time practicing each step of cataract surgery on a cataract surgery simulator during the PGY-3 year, and performed more primary cataract surgeries during the PGY-3 year than those who did not. Faculty survey response rate was 63%. Faculty noted an increase in resident preparedness following implementation of the new curriculum. There was no statistical difference between the precurriculum and postcurriculum groups in the percentage turnover of cataracts for the first 2 cataract surgery rotations of the PGY-4 year of training.

CONCLUSIONS

The introduction of cataract surgery to PGY-3 residents in an organized, stepwise manner improved resident preparedness for the PGY-4 year of residency. This surgical teaching method can be easily applied to other surgical specialties.

A human cadaver fascial compartment pressure measurement model

BACKGROUND

Fresh human cadavers provide an effective model for procedural training. Currently, there are no realistic models to teach fascial compartment pressure measurement.

OBJECTIVES

We created a human cadaver fascial compartment pressure measurement model and studied its feasibility with a pre-post design.

METHODS

Three faculty members, following instructions from a common procedure textbook, used a standard handheld intra-compartment pressure monitor (Stryker(®), Kalamazoo, MI) to measure baseline pressures ("unembalmed") in the anterior, lateral, deep posterior, and superficial posterior compartments of the lower legs of a fresh human cadaver. The right femoral artery was then identified by superficial dissection, cannulated distally towards the lower leg, and connected to a standard embalming machine. After a 5-min infusion, the same three faculty members re-measured pressures ("embalmed") of the same compartments on the cannulated right leg. Unembalmed and embalmed readings for each compartment, and baseline readings for each leg, were compared using a two-sided paired t-test.

RESULTS

The mean baseline compartment pressures did not differ between the right and left legs. Using the embalming machine, compartment pressure readings increased significantly over baseline for three of four fascial compartments; all in mm Hg (±SD): anterior from 40 (±9) to 143 (±44) (p = 0.08); lateral from 22 (±2.5) to 160 (±4.3) (p < 0.01); deep posterior from 34 (±7.9) to 161 (±15) (p < 0.01); superficial posterior from 33 (±0) to 140 (±13) (p < 0.01).

CONCLUSION

We created a novel and measurable fascial compartment pressure measurement model in a fresh human cadaver using a standard embalming machine. Set-up is minimal and the model can be incorporated into teaching curricula.