Powerful medical education improves health care quality and return on investment.

INTRODUCTION: Powerful medical education (PME) involves the use of new technologies informed by the science of expertise that are embedded in laboratories and organizations that value evidence-based education and support innovation. This contrasts with traditional medical education that relies on a dated apprenticeship model that yields uneven results. PME involves an amalgam of features, conditions and assumptions, and contextual variables that comprise an approach to developing clinical competence grounded in education impact metrics including efficiency and cost-effectiveness. METHODS: This article is a narrative review based on SANRA criteria and informed by realist review principles. The review addresses the PME model with an emphasis on mastery learning and deliberate practice principles drawn from the new science of expertise. Pub Med, Scopus, and Web of Science search terms include medical education, the science of expertise, mastery learning, translational outcomes, cost effectiveness, and return on investment. Literature coverage is comprehensive with selective citations. RESULTS: PME is described as an integrated set of twelve features embedded in a group of seven conditions and assumptions and four context variables. PME is illustrated via case examples that demonstrate improved ventilator patient management learning outcomes compared to traditional clinical education and mastery learning of breaking bad news communication skills. Evidence also shows that PME of physicians and other health care providers can have translational, downstream effects on patient care practices, patient outcomes, and return on investment. Several translational health care quality improvements that derive from PME include reduced infections; better communication among physicians, patients, and families; exceptional birth outcomes; more effective patient education; and return on investment. CONCLUSIONS: The article concludes with challenges to hospitals, health systems, and medical education organizations that are responsible for producing physicians who are expected to deliver safe, effective, and cost-conscious health care.

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.

Clinical and demographic factors associated with pediatric difficult intravenous access in the operating room.

BACKGROUND: Pediatric intravenous catheter insertion can be difficult in the operating room due to the technical challenges of small diameter vessels and the need to rapidly gain intravenous access in anesthetized children. Few studies have examined factors associated with difficult vascular access in the operating room, especially accounting for the increased possibility to use ultrasound guidance. AIMS: The primary aim of the study was to identify factors associated with pediatric difficult vascular access in the operating room. Our primary hypothesis was that Black race, Hispanic ethnicity, and ultrasound use would be associated with pediatric difficult vascular access. METHODS: We performed a retrospective analysis of prospectively collected data from a cohort of pediatric patients who had intravenous catheters inserted in the operating room at an academic tertiary care children's hospital from March 2020 to February 2021. We measured associations among patients who were labeled as having difficult vascular access (>2 attempts at access) with demographic, clinical, and hospital factors. RESULTS: 12 728 intravenous catheter insertions were analyzed. Multivariable analysis showed significantly higher odds of difficult vascular access with Black non-Hispanic race (1.43, 95% CI: 1.06-1.93, p = .018), younger age (0.93, 95% CI: 0.89-0.98, p = .005), overweight (1.41, 95% CI: 1.04-1.90, p = .025) and obese body mass index (1.56, 95% 95% CI: 1.12-2.17, p = .008), and American Society of Anesthesiologists physical status III (1.54, 95% CI:1.11-2.13, p = .01). The attending anesthesiologist compared to all other practitioners (certified registered nurse anesthetist: (0.41, 95% CI: 0.31-0.56, p < .001, registered nurse: 0.25, 95% CI: 0.13-0.48, p < .001, trainee: 0.21, 95% CI: 0.17-0.28, p-value <.001 with attending as reference variable) and ultrasound use (2.61, 95% CI: 1.85-3.69, p < .001) were associated with successful intravenous catheter placement. CONCLUSIONS: Black non-Hispanic race/ethnicity, younger age, obese/overweight body mass index, American Society of Anesthesiologists physical status III, and ultrasound were all associated with pediatric difficult vascular access in the operating room.

Effect of Ventricular Assist Device Self-care Simulation-Based Mastery Learning on Driveline Exit Site Infections: A Pilot Study.

BACKGROUND: Ventricular assist device simulation-based mastery learning (SBML) results in better patient and caregiver self-care skills compared with usual training. OBJECTIVE: The aim of this study was to evaluate the effect of SBML on driveline exit site infections. METHODS: We compared the probability of remaining infection free at 3 and 12 months between patients randomized to SBML or usual training. RESULTS: The SBML-training group had no infections at 3 months and 2 infections at 12 months, yielding a Kaplan-Meier estimate of the probability of remaining infection free of 0.857 (95% confidence interval [CI], 0.692-1.00) at 12 months. The usual-training group had 6 infections at 3 months with no additional infections by 12 months. Kaplan-Meier estimates of remaining infection free at 3 and 12 months were 0.878 (95% CI, 0.758-1.00) and 0.748 (95% CI, 0.591-0.946), respectively. Time-to-infection distributions for SBML versus usual training showed a difference in 12-month infection rates of 0.109 (P = .07). CONCLUSIONS: Ventricular assist device self-care SBML resulted in fewer 12-month infections.

Development and evaluation of a simulation-based mastery learning maintenance of certification course.

BACKGROUND/OBJECTIVES: To develop and evaluate a post-acute care simulation-based mastery learning (SBML) continuing medical education (CME)/maintenance of certification (MOC) procedure course. DESIGN: Pretest-posttest study of the SBML intervention. SETTING: A 2-day post-acute care procedures course. PARTICIPANTS: Sixteen practicing clinicians (5 physicians,11 advanced practice providers). Participants engaged in a skills pretest on knee aspiration/injection, gastrostomy tube removal/replacement, tracheostomy tube exchange, and basic suturing using a checklist created for each procedure. Participants received a didactic on each procedure followed by deliberate practice with feedback. Using the same checklists, participants completed a skills posttest and were required to meet a minimum passing standard (MPS) to obtain CME/MOC credit. MEASUREMENTS: The MPS for each skills checklist was determined by a multidisciplinary panel of 11 experts. Participants completed surveys on procedure self-confidence and a course evaluation. RESULTS: There was statistically significant improvement between pre- and posttests for all four procedures (p < .001). All participants were able to meet or exceed the MPS for each skill during the 2-day course. Participants' self-confidence regarding each procedure improved significantly (p < .001). CONCLUSION: An SBML training course granting CME/MOC credit for post-acute care providers significantly improves performance of knee aspiration/injection, gastrostomy tube removal/replacement, tracheostomy tube exchange, and basic suturing.

Improving cardiology fellow education of right heart catheterization using a simulation based curriculum.

BACKGROUND: Medical procedures are traditionally taught informally at patients' bedside through observation and practice using the adage "see one, do one, teach one." This lack of formalized training can cause trainees to be unprepared to perform procedures independently. Simulation based education (SBE) increases competence, reduces complications, and decreases costs. We developed, implemented, and evaluated the efficacy of a right heart catheterization (RHC) SBE curriculum. METHODS: The RHC curriculum consisted of a pretest, video didactics, deliberate practice, and a posttest. Pre-and posttest skills examinations consisted of a dichotomous 43-item checklist on RHC skills and a 14-item hemodynamic waveform quiz. We enrolled two groups of fellows: 6 first-year, novice cardiology fellows at Northwestern University in their first month of training, and 11 second- and third-year fellows who had completed traditional required, level I training in RHC. We trained the first-year fellows at the beginning of the 2018-2019 year using the SBE curriculum and compared them to the traditionally-trained cardiology fellows who did not complete SBE. RESULTS: The SBE-trained fellows significantly improved RHC skills, hemodynamic knowledge, and confidence from pre- to posttesting. SBE-trained fellows performed similarly to traditionally-trained fellows on simulated RHC skills checklists (88.4% correct vs. 89.2%, p = .84), hemodynamic quizzes (94.0% correct vs. 86.4%, p = .12), and confidence (79.4 vs. 85.9 out of 100, p = .15) despite less clinical experience. CONCLUSIONS: A SBE curriculum for RHC allowed novice cardiology fellows to achieve level I skills and knowledge at the beginning of fellowship and can train cardiology fellows before patient contact.

Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses.

BACKGROUND: Difficult intravenous access (DIVA) is a common problem in Emergency Departments (EDs), yet the prevalence and clinical impact of this condition is poorly understood. Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is a successful modality for obtaining intravenous (IV) access in patients with DIVA. OBJECTIVES: We aimed to describe the prevalence of DIVA, explore how DIVA affects delivery of care, and determine if nurse insertion of USGPIV improves care delays among patients with DIVA. METHODS: We retrospectively queried the electronic medical record for all ED patients who had a peripheral IV (PIV) inserted at a tertiary academic medical center from 2015 to 2017. We categorized patients as having DIVA if they required ≥3 PIV attempts or an USGPIV. We compared metrics for care delivery including time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED length of stay (LOS) between patients with and without DIVA. We also compared these metrics in patients with DIVA with a physician-inserted USGPIV versus those with a nurse-inserted USGPIV. RESULTS: A total of 147,260 patients were evaluated during the study period. Of these, 13,192 (8.9%) met criteria for DIVA. Patients with DIVA encountered statistically significant delays in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients without DIVA (all p < 0.001). Patients with nurse-inserted USGPIVs also had statistically significant improvements in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients with physician-inserted USGPIVs (all p < 0.001). CONCLUSION: DIVA affects many ED patients and leads to delays in PIV access-related care. Nurse insertion of USGPIVs improves care in patients with DIVA.

Use of a simulation-based mastery learning curriculum for neurology residents to improve the identification and management of status epilepticus.

BACKGROUND: Appropriate and timely treatment of status epilepticus (SE) decreases morbidity and mortality. Therefore, skill-based training in the identification and management of SE is crucial for clinicians. OBJECTIVE: The objective of the study was to develop and evaluate the impact of a simulation-based mastery learning (SBML) curriculum to train neurology residents on the identification and management of SE. METHODS: We used pretest-posttest design with a retention test on SE skills for this study. Neurology residents in the second postgraduate year (PGY-2) were eligible to participate in the SE SBML curriculum. Learners completed a baseline-simulated SE skills assessment (pretest) using a 26-item dichotomous skills checklist. Next, they participated in a didactic session about the identification and management of SE, followed by deliberate skills practice. Subsequently, participants completed another skills assessment (posttest) using the same 26-item checklist. All participants were required to meet or exceed a minimum passing standard (MPS) determined by a panel of 14 SE experts using the Mastery Angoff standard setting method. After meeting the MPS at posttest, participants were reassessed during an unannounced in situ simulation session on the medical wards. We compared pretest with posttest simulated SE skills performance and posttest with reassessment in situ performance. RESULTS: The MPS was set at 88% (23/26) checklist items correct. Sixteen neurology residents participated in the intervention. Participant performance improved from a median of 44.23% (Interquartile range (IQR): 34.62-55.77) at pretest to 94.23% (IQR: 92.13-100) at the posttest after SBML (p < .001). There was no significant difference in scores between the posttest and in situ test up to 8 months later (94.23%; IQR: 92.31-100 vs. 92.31%; IQR: 88.46-96.15; p = .13). CONCLUSIONS: Our SBML curriculum significantly improved residents' SE identification and management skills that were largely retained during an unannounced simulated encounter in the hospital setting.

Use of a simulation-based mastery learning curriculum to improve ultrasound-guided vascular access skills of pediatric anesthesiologists.

BACKGROUND: Pediatric vascular access is inherently challenging due to the small caliber of children's vessels. Ultrasound-guided intravenous catheter insertion has been shown to increase success rates and decrease time to cannulation in patients with difficult intravenous access. Although proficiency in ultrasound-guided intravenous catheter insertion is a critical skill in pediatric anesthesia, there are no published competency-based training curricula. AIMS: The objective of this study was to evaluate the performance of pediatric anesthesiologists who participated in a novel ultrasound-guided intravenous catheter insertion simulation-based mastery learning curriculum. METHODS: Pediatric anesthesia attendings, fellows, and rotating residents participated in the ultrasound-guided intravenous catheter insertion simulation-based mastery learning curriculum from August 2019 to February 2020. The 2-hour curriculum consisted of participants first undergoing a simulated skills pretest followed by watching a video on ultrasound-guided intravenous catheter insertion and deliberate practice on a simulator. Subsequently, all participants took a post-test and were required to meet or exceed a minimum passing standard. Those who were unable to meet the minimum passing standard participated in further practice until they could be retested and met this standard. We compared pre to post-test ultrasound-guided intravenous catheter insertion skills and self-confidence before and after participation in the curriculum. RESULTS: Twenty-six pediatric anesthesia attendings, 12 fellows, and 38 residents participated in the curriculum. At pretest, 16/76 (21%) participants were able to meet or exceed the minimum passing standard. The median score on the pretest was 21/25 skills checklist items correct and improved to 24/25 at post-test (95% CI 3.0-4.0, P < .01). Self-confidence significantly improved after the course from an average of 3.2 before the course to a postcourse score of 3.9 (95% CI 0.5-0.9, P < .01; 1 = Not all confident, 5 = Very confident). CONCLUSIONS: Simulation-based mastery learning significantly improved anesthesiologists' ultrasound-guided intravenous catheter insertion performance in a simulated setting.

Patient, Caregiver, and Clinician Perceptions of Ventricular Assist Device Self-care Education Inform the Development of a Simulation-based Mastery Learning Curriculum.

BACKGROUND: Patients who undergo ventricular assist device (VAD) implantation and their caregivers must rapidly learn a significant amount of self-care skills and knowledge. OBJECTIVE: The aim of this study was to explore patient, caregiver, VAD coordinator, and physician perspectives and perceptions of existing VAD self-care training to inform development of a simulation-based mastery learning (SBML) curriculum to teach patients and caregivers VAD self-care skills and knowledge. METHODS: We conducted semistructured, in-person interviews with patients with a VAD, their caregivers, VAD coordinators, and physicians (cardiac surgeons, an infectious disease physician, and advanced heart failure cardiologists). We used a 2-cycle team-based iterative inductive approach to coding and analysis. RESULTS: We interviewed 16 patients, 12 caregivers, 7 VAD coordinators, and 11 physicians. Seven major themes were derived from the interviews including (1) identification of critical curricular content, (2) need for standardization and assessment, (3) training modalities, (4) benefits of repetition, (5) piercing it all together, (6) need for refresher training, and (7) provision of training before implant. CONCLUSIONS: Findings from this study suggest that SBML is a natural fit for the high-risk tasks needed to save VAD self-care. The 7 unique training-related themes derived from the qualitative data informed the design and development of a VAD SBML self-care curriculum.

Attending Physician Adherence to a 29-Component Central Venous Catheter Bundle Checklist During Simulated Procedures.

OBJECTIVES: Central venous catheter insertions may lead to preventable adverse events. Attending physicians' central venous catheter insertion skills are not assessed routinely. We aimed to compare attending physicians' simulated central venous catheterinsertion performance to published competency standards. DESIGN: Prospective cohort study of attending physicians' simulated internal jugular and subclavian central venous catheter insertion skills versus a historical comparison group of residents who participated in simulation training. SETTING: Fifty-eight Veterans Affairs Medical Centers from February 2014 to December 2014 during a 2-day simulation-based education curriculum and two academic medical centers in Chicago. SUBJECTS: A total of 108 experienced attending physicians and 143 internal medicine and emergency medicine residents. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Using a previously published central venous catheter insertion skills checklist, we compared Veterans Affairs Medical Centers attending physicians' simulated central venous catheter insertion performance to the same simulated performance by internal medicine and emergency medicine residents from two academic centers. Attending physician performance was compared to residents' baseline and posttest (after simulation training) performance. Minimum passing scores were set previously by an expert panel. Attending physicians performed higher on the internal jugular (median, 75.86% items correct; interquartile range, 68.97-86.21) and subclavian (median, 83.00%; interquartile range, 59.00-86.21) assessments compared to residents' internal jugular (median, 37.04% items correct; interquartile range, 22.22-68.97) and subclavian (median, 33.33%; interquartile range, 0.00-70.37; both p < 0.001) baseline assessments. Overall simulated performance was poor because only 12 of 67 attending physicians (17.9%) met or exceeded the minimum passing score for internal jugular central venous catheter insertion and only 11 of 47 (23.4%) met or exceeded the minimum passing score for subclavian central venous catheter insertion. Resident posttest performance after simulation training was significantly higher than attending physician performance (internal jugular: median, 96%; interquartile range, 93.10-100.00; subclavian: median, 100%; interquartile range, 96.00-100.00; both p < 0.001). CONCLUSIONS: This study demonstrates highly variable simulated central venous catheter insertion performance among a national cohort of experienced attending physicians. Hospitals, healthcare systems, and governing bodies should recognize that even experienced physicians require periodic clinical skill assessment and retraining.

Complications of thoracentesis: incidence, risk factors, and strategies for prevention.

PURPOSE OF REVIEW: Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema. RECENT FINDINGS: Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study. SUMMARY: Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.

Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals.

BACKGROUND: Physicians increasingly refer thoracentesis procedures to interventional radiology (IR) rather than performing them at the bedside. Factors associated with thoracentesis procedures at university hospitals were studied to determine clinical outcomes by provider specialty. METHODS: An administrative database review was performed of patients who underwent an inpatient thoracentesis procedure in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through September 2013. The incidence of iatrogenic pneumothorax, mean total hospital costs, and mean length of stay (LOS) were compared by clinical specialty. RESULTS: There were 113,860 admissions with 132,472 thoracentesis procedures performed on 99,509 patients at 234 UHC hospitals. IR performed 43,783 (33%) thoracentesis procedures; medicine, 22,243 (17%); and pulmonary, 26,887 (20%). The incidence of iatrogenic pneumothorax was 2.8% for IR, 2.9% for medicine, and 3.1% for pulmonary. Medicine and pulmonary had equivalent risk of iatrogenic pneumothorax compared to IR after controlling for clinical covariates. Admissions with medicine and pulmonary procedures were associated with significantly lower costs compared to IR admissions (p < 0.001) after controlling for clinical covariates. Admissions with IR procedures had a mean LOS of 14.1 days; medicine, 13.2 days; and pulmonary, 15.9 days. Admissions with medicine and pulmonary procedures were associated with fewer hospital days when compared to IR in the controlled model (p < 0.001). CONCLUSION: Admissions with medicine and pulmonary bedside thoracentesis procedures are as safe and less costly than IR procedures. Shifting IR thoracentesis procedures to the bedside might be a potential way to reduce hospital costs while still ensuring high-quality patient care, provided that portable ultrasound is used.

Thoracentesis outcomes: a 12-year experience.

BACKGROUND: Despite a lack of evidence in the literature, several assumptions exist about the safety of thoracentesis in clinical guidelines and practice patterns. We aimed to evaluate specific demographic and clinical factors that have been commonly associated with complications such as iatrogenic pneumothorax, re-expansion pulmonary oedema (REPE) and bleeding. METHODS: We performed a cohort study of inpatients who underwent thoracenteses at Cedars-Sinai Medical Center (CSMC) from August 2001 to October 2013. Data were collected prospectively including information on volume of fluid removed, procedure side, whether the patient was on positive pressure ventilation, number of needle passes and supine positioning. Iatrogenic pneumothorax, REPE and bleeding were tracked for 24 h after the procedure or until a clinical question was reconciled. Demographic and clinical characteristics were obtained through query of electronic medical records. RESULTS: CSMC performed 9320 inpatient thoracenteses on 4618 patients during the study period. There were 57 (0.61%) iatrogenic pneumothoraces, 10 (0.01%) incidents of REPE and 17 (0.18%) bleeding episodes. Iatrogenic pneumothorax was significantly associated with removal of >1500 mL fluid (p<0.0001), unilateral procedures (p=0.001) and more than one needle pass through the skin (p=0.001). For every 1 mL of fluid removed there was a 0.18% increased risk of REPE (95% CI 0.09% to 0.26%). There were no significant associations between bleeding and demographic or clinical variables including International Normalised Ratio, partial thromboplastin time and platelet counts. CONCLUSIONS: Our series of thoracenteses had a very low complication rate. Current clinical guidelines and practice patterns may not reflect evidence-based best practices.

Simulation-Based Mastery Learning Improves Central Line Maintenance Skills of ICU Nurses.

OBJECTIVE: This study evaluated the impact of a simulation-based mastery learning (SBML) curriculum on central line maintenance and care among a group of ICU nurses. METHODS: The intervention included 5 tasks: (a) medication administration, (b) injection cap (needleless connector) changes, (c) tubing changes, (d) blood drawing, and (e) dressing changes. All participants underwent a pretest, engaged in deliberate practice with directed feedback, and completed a posttest. We compared pretest and posttest scores and assessed correlations between demographics, self-confidence, and pretest performance. RESULTS: The number of nurses passing each task at pretest varied from 24 of 49 (49%) for dressing changes to 44 of 49 (90%) for tubing changes. At pretest, scores ranged from a median of 0.0% to 73.1%. At posttest, all scores rose to a median of 100.0%. Total years in nursing and ICU nursing had significant, negative correlations with medication administration pretest performance (r = -0.42, P = .003; r = -0.42, P = .003, respectively). CONCLUSION: ICU nurses displayed large variability in their ability to perform central line maintenance tasks. After SBML, there was significant improvement, and all nurses reached a predetermined level of competency.

Temporary hemodialysis catheters: recent advances.

The insertion of non-tunneled temporary hemodialysis catheters (NTHCs) is a core procedure of nephrology practice. While urgent dialysis may be life-saving, mechanical and infectious complications related to the insertion of NTHCs can be fatal. In recent years, various techniques that reduce mechanical and infectious complications related to NTHCs have been described. Evidence now suggests that ultrasound guidance should be used for internal jugular and femoral vein NTHC insertions. The implementation of evidence-based infection-control 'bundles' for central venous catheter insertions has significantly reduced the incidence of bloodstream infections in the intensive care unit setting with important implications for how nephrologists should insert NTHCs. In addition, the Cathedia Study has provided the first high-level evidence about the optimal site of NTHC insertion, as it relates to the risk of infection and catheter dysfunction. Incorporating these evidence-based techniques into a simulation-based program for training nephrologists in NTHC insertion has been shown to be an effective way to improve the procedural skills of nephrology trainees. Nonetheless, there are some data suggesting nephrologists have been slow to adopt evidence-based practices surrounding NTHC insertion. This mini review focuses on techniques that reduce the complications of NTHCs and are relevant to the practice and training of nephrologists.

A critical review of simulation-based mastery learning with translational outcomes.

OBJECTIVES: This article has two objectives. Firstly, we critically review simulation-based mastery learning (SBML) research in medical education, evaluate its implementation and immediate results, and document measured downstream translational outcomes in terms of improved patient care practices, better patient outcomes and collateral effects. Secondly, we briefly address implementation science and its importance in the dissemination of innovations in medical education and health care. METHODS: This is a qualitative synthesis of SBML with translational (T) science research reports spanning a period of 7 years (2006-2013). We use the 'critical review' approach proposed by Norman and Eva to synthesise findings from 23 medical education studies that employ the mastery learning model and measure downstream translational outcomes. RESULTS: Research in SBML in medical education has addressed a range of interpersonal and technical skills. Measured outcomes have been achieved in educational laboratories (T1), and as improved patient care practices (T2), patient outcomes (T3) and collateral effects (T4). CONCLUSIONS: Simulation-based mastery learning in medical education can produce downstream results. Such results derive from integrated education and health services research programmes that are thematic, sustained and cumulative. The new discipline of implementation science holds promise to explain why medical education innovations are adopted slowly and how to accelerate innovation dissemination.

Effect of Polypectomy Simulation-Based Mastery Learning on Skill Retention Among Practicing Endoscopists.

PURPOSE: Practicing endoscopists frequently perform and teach screening colonoscopies and polypectomies, but there is no standardized method to train and assess physicians who perform polypectomy procedures. The authors created a polypectomy simulation-based mastery learning (SBML) curriculum and hypothesized that completion of the curriculum would lead to immediate improvement in polypectomy skills and skill retention at 6 and 12 months after training. METHOD: The authors performed a pretest-posttest cohort study with endoscopists who completed SBML and were randomized to follow-up at 6 or 12 months from May 2021 to August 2022. Participants underwent SBML training, including a pretest, a video lecture, deliberate practice, and a posttest. All learners were required to meet or exceed a minimum passing standard on a 17-item skills checklist before completing training and were randomized to follow-up at 6 or 12 months. The authors compared simulated polypectomy skills performance on the checklist from pretest to posttest and posttest to 6- or 12-month follow-up test. RESULTS: Twenty-four of 30 eligible participants (80.0%) completed the SBML intervention, and 20 of 24 (83.3%) completed follow-up testing. The minimum passing standard was set at 93% of checklist items correct. The pretest passing rate was 4 of 24 participants (16.7%) compared with 24 of 24 participants (100%) at posttest ( P < .001). There were no significant differences in passing rates from posttest to combined 6- and 12-month posttest in which 18 of 20 participants (90.0%) passed. CONCLUSIONS: Before training and despite years of clinical experience, practicing endoscopists demonstrated poor performance of polypectomy skills. SBML was an effective method for practicing endoscopists to acquire and maintain polypectomy skills during a 6- to 12-month period.