Why nutrition education is inadequate in the medical curriculum: a qualitative study of students' perspectives on barriers and strategies.

BACKGROUND: The provision of nutrition care by doctors is important in promoting healthy dietary habits, and such interventions can lead to reductions in disease morbidity, mortality, and medical costs. However, medical students and doctors report inadequate nutrition education and preparedness during their training at school. Previous studies investigating the inadequacy of nutrition education have not sufficiently evaluated the perspectives of students. In this study, students' perspectives on doctors' role in nutrition care, perceived barriers, and strategies to improve nutrition educational experiences are explored. METHODS: A total of 23 undergraduate clinical level medical students at the 5th to final year in the School of Medicine and Health Sciences of the University for Development Studies in Ghana were purposefully selected to participate in semi-structured individual interviews. Students expressed their opinions and experiences regarding the inadequacy of nutrition education in the curriculum. Each interview was audio-recorded and later transcribed verbatim. Using the constant comparison method, key themes were identified from the data and analysis was done simultaneously with data collection. RESULTS: Students opined that doctors have an important role to play in providing nutrition care to their patients. However, they felt their nutrition education was inadequate due to lack of priority for nutrition education, lack of faculty to provide nutrition education, poor application of nutrition science to clinical practice and poor collaboration with nutrition professionals. Students opined that their nutrition educational experiences will be improved if the following strategies were implemented: adoption of innovative teaching and learning strategies, early and comprehensive incorporation of nutrition as a theme throughout the curriculum, increasing awareness on the importance of nutrition education, reviewing and revision of the curriculum to incorporate nutrition, and involving nutrition/dietician specialists in medical education. CONCLUSION: Though students considered nutrition care as an important role for doctors they felt incapacitated by non-prioritisation of nutrition education, lack of faculty for teaching of nutrition education, poor application of nutrition science and poor collaboration with nutrition professionals. Incorporation of nutrition as a theme in medical education, improving collaboration, advocacy and creating enabling environments for nutrition education could address some of the barriers to nutrition education.

Realist synthesis of educational interventions to improve nutrition care competencies and delivery by doctors and other healthcare professionals.

OBJECTIVE: To determine what, how, for whom, why, and in what circumstances educational interventions improve the delivery of nutrition care by doctors and other healthcare professionals work. DESIGN: Realist synthesis following a published protocol and reported following Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. A multidisciplinary team searched MEDLINE, CINAHL, ERIC, EMBASE, PsyINFO, Sociological Abstracts, Web of Science, Google Scholar and Science Direct for published and unpublished (grey) literature. The team identified studies with varied designs; appraised their ability to answer the review question; identified relationships between contexts, mechanisms and outcomes (CMOs); and entered them into a spreadsheet configured for the purpose. The final synthesis identified commonalities across CMO configurations. RESULTS: Over half of the 46 studies from which we extracted data originated from the USA. Interventions that improved the delivery of nutrition care improved skills and attitudes rather than just knowledge; provided opportunities for superiors to model nutrition care; removed barriers to nutrition care in health systems; provided participants with local, practically relevant tools and messages; and incorporated non-traditional, innovative teaching strategies. Operating in contexts where student and qualified healthcare professionals provided nutrition care in developed and developing countries, these interventions yielded health outcomes by triggering a range of mechanisms, which included feeling competent, feeling confident and comfortable, having greater self-efficacy, being less inhibited by barriers in healthcare systems and feeling that nutrition care was accepted and recognised. CONCLUSIONS: These findings show how important it is to move education for nutrition care beyond the simple acquisition of knowledge. They show how educational interventions embedded within systems of healthcare can improve patients' health by helping health students and professionals to appreciate the importance of delivering nutrition care and feel competent to deliver it.

Program for laparoscopic urological skills assessment: setting certification standards for residents.

AIM: There is growing pressure from the government and the public to define proficiency standards for surgical skills. Aim of this study was to estimate the reliability of the Program for Laparoscopic Urological Skills (PLUS) assessment and to set a certification standard for second-year urological residents. METHODS: Fifty participants were assessed on performance time and performance quality to investigate the reliability of the PLUS assessment. Generalisability coefficient of 0.8, on a scale of 0 to 1.0, was considered to indicate good reliability for assessment purposes. Pass/fail standards were based on laparoscopic experience: Novices, intermediates, and experts (>100 procedures). The pass/fail standards were investigated for the PLUS performances of 33 second-year urological residents. RESULTS: Fifteen novices, twenty-three intermediates and twelve experts were included. An inter-trial reliability of >0.80 was reached with two trials for each task. Inter-rater reliability of the quality measurements was 0.79 for two judges. Pass/fail scores were determined for the novice/intermediate boundary and the intermediate/expert boundary. Pass rates for second-year residents were 63.64% and 9.09%, respectively. CONCLUSION: The PLUS assessment is reliable for setting a certification standard for second-year urological residents that serves as a starting point for residents to proceed to the next level of laparoscopic competency.

Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review.

Learning from error is not just an individual endeavour. Organisations also learn from error. Hospitals provide many learning opportunities, which can be formal or informal. Informal learning from error in hospitals has not been researched in much depth so this narrative review focuses on five learning opportunities: morbidity and mortality conferences, incident reporting systems, patient claims and complaints, chart review and prospective risk analysis. For each of them we describe: (1) what can be learnt, categorised according to the seven CanMEDS competencies; (2) how it is possible to learn from them, analysed against a model of informal and incidental learning; and (3) how this learning can be enhanced. All CanMEDS competencies could be enhanced, but there was a particular focus on the roles of medical expert and manager. Informal learning occurred mostly through reflection and action and was often linked to the learning of others. Most important to enhance informal learning from these learning opportunities was the realisation of a climate of collaboration and trust. Possible new directions for future research on informal learning from error in hospitals might focus on ways to measure informal learning and the balance between formal and informal learning. Finally, 12 recommendations about how hospitals could enhance informal learning within their organisation are given.

Program for laparoscopic urologic skills: a newly developed and validated educational program.

OBJECTIVE: To develop and evaluate a program for laparoscopic urologic skills (PLUS) to determine the face, content, and construct validation to achieve uniformity and standardization in training residents in urology. METHODS: The PLUS consists of 5 basic laparoscopic tasks. Three tasks were abstracted from the Fundamentals of Laparoscopic Surgery program, and 2 additional tasks were developed under continuous evaluation by expert urologists. Fifty participants were recruited from different hospitals and performed the final PLUS training. They all completed a questionnaire after performance. Three outcome parameters were measured: performance quality, time, and dropped objects. The relationship between laparoscopic experience and the outcome parameters was investigated. RESULTS: Of the 50 participants, 13 were students, 20 were residents, and 17 were urologists. Double-log linear regression analysis for all 5 tasks showed a significant effect (effect size range 0.53-0.82; P < .0005) for laparoscopic experience on performance time. Substantial correlations were found between experience and quality ratings (log-linear regression effect size 0.37; P = .012) and the number of dropped objects (Spearman correlation effect size 0.49; P < .01). The usefulness of the PLUS model as a training tool for basic laparoscopic skills was rated 4.55 on a scale from 1 (not useful) to 5 (useful) (standard deviation 0.58; range 3-5). CONCLUSION: The results of the present study indicated the face, content, and construct validity for the PLUS. The training is considered appropriate for use as a primary training tool for an entry test or as part of a step-wise training program in which basic and procedural laparoscopic skills are integrated.

A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.

BACKGROUND: Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. METHODS: The aim of this paper was to provide a more comprehensive overview of medical error in hospitals using a combination of different information sources. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. The main outcome measures were distribution of incidents over the thirteen categories of the ICPS classifier "Incident type", described as odds ratios (OR) and proportional similarity indices (PSI). RESULTS: A total of 1012 incidents resulted in 1282 classified items. Large differences between data from IRS and patient complaints (PSI = 0.32) and from IRS and retrospective chart review (PSI = 0.31) were mainly attributable to behaviour (OR = 6.08), clinical administration (OR = 5.14), clinical process (OR = 6.73) and resources (OR = 2.06). CONCLUSIONS: IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.

Reducing errors in health care: cost-effectiveness of multidisciplinary team training in obstetric emergencies (TOSTI study); a randomised controlled trial.

BACKGROUND: There are many avoidable deaths in hospitals because the care team is not well attuned. Training in emergency situations is generally followed on an individual basis. In practice, however, hospital patients are treated by a team composed of various disciplines. To prevent communication errors, it is important to focus the training on the team as a whole, rather than on the individual. Team training appears to be important in contributing toward preventing these errors. Obstetrics lends itself to multidisciplinary team training. It is a field in which nurses, midwives, obstetricians and paediatricians work together and where decisions must be made and actions must be carried out under extreme time pressure.It is attractive to belief that multidisciplinary team training will reduce the number of errors in obstetrics. The other side of the medal is that many hospitals are buying expensive patient simulators without proper evaluation of the training method. In the Netherlands many hospitals have 1,000 or less annual deliveries. In our small country it might therefore be more cost-effective to train obstetric teams in medical simulation centres with well trained personnel, high fidelity patient simulators, and well defined training programmes. METHODS/DESIGN: The aim of the present study is to evaluate the cost-effectiveness of multidisciplinary team training in a medical simulation centre in the Netherlands to reduce the number of medical errors in obstetric emergency situations. We plan a multicentre randomised study with the centre as unit of analysis. Obstetric departments will be randomly assigned to receive multidisciplinary team training in a medical simulation centre or to a control arm without any team training.The composite measure of poor perinatal and maternal outcome in the non training group was thought to be 15%, on the basis of data obtained from the National Dutch Perinatal Registry and the guidelines of the Dutch Society of Obstetrics and Gynaecology (NVOG). We anticipated that multidisciplinary team training would reduce this risk to 5%. A sample size of 24 centres with a cluster size of each at least 200 deliveries, each 12 centres per group, was needed for 80% power and a 5% type 1 error probability (two-sided). We assumed an Intraclass Correlation Coefficient (ICC) value of maximum 0.08.The analysis will be performed according to the intention-to-treat principle and stratified for teaching or non-teaching hospitals.Primary outcome is the number of obstetric complications throughout the first year period after the intervention. If multidisciplinary team training appears to be effective a cost-effective analysis will be performed. DISCUSSION: If multidisciplinary team training appears to be cost-effective, this training should be implemented in extra training for gynaecologists. TRIAL REGISTRATION: The protocol is registered in the clinical trial register number NTR1859.

Analysis of pitfalls encountered by residents in transurethral procedures in master-apprentice type of training.

BACKGROUND AND PURPOSE: Today's simulators are frequently limited in their possibilities to train all aspects of endourological procedures. It is therefore indicated to first make an inventory of training needs before (re)developing simulators. This study examined pitfalls encountered by residents in real-time transurethral procedures. MATERIALS AND METHODS: First, difficulties that residents encounter in transurethral procedures (transurethral resection of the bladder tumor [TURBT], transurethral resection of the prostate [TURP], ureterorenoscopy [URS]) were identified by asking urologists and residents to complete an open questionnaire. Based on their answers a list of pitfalls was designed and tested in 28 pilot observations. Then, two raters (interrater agreement 0.72, 0.70, and 0.75 for TURBT, TURP, and URS, respectively) categorized all observed procedure-related interactions between residents and supervisors in 80 procedures as (1) (type of ) pitfall or (2) no pitfall. RESULTS: Pitfalls most frequently encountered were as follows: (1) planning/anticipation on new situations (median 27.3%, 29.3%, and 31.8% of total pitfalls in TURBT, TURP, and URS, respectively); (2) handling of instruments (11.5%, 10.6%, and 20.0% for TURBT, TURP, and URS); (3) irrigation management for TURBT (7.7%), depth of resection for TURP (8.9%), and use of X-ray for URS (13.3%). CONCLUSION: Designers of endourological simulators should include possibilities to train planning/anticipation on new situations, handling of instruments in all transurethral procedures, and irrigation management in TURBT, depth of resection in TURP, and timing usage of X-ray in URS.

A simulator for teaching transrectal ultrasound procedures: how useful and realistic is it?

INTRODUCTION: : We describe a new simulator for teaching transrectal ultrasound (TRUS) and present the results of a preliminary evaluation of the simulator's realism and usefulness for training. METHODS: : A simulator for abdominal ultrasound was adjusted by the developer to enable simulation of TRUS by providing an opening for inserting a dummy rectal probe. To enable TRUS simulation, data from ultrasound prostate imaging of eight real patients obtained with our regular ultrasound machine were transferred to the simulator by connecting the computer of the simulator to the ultrasound machine. These data were used to create images in the TRUS simulator. Residents and urologists used the simulator to perform TRUS in one of the eight patient cases and judged the simulator's realism and usefulness. RESULTS: : We were able to construct an initial urological module for the TRUS simulator. The images shown on the monitor of the simulator are quite realistic. The simulator can be used without difficulty to collect data, to create cases, and to perform TRUS. The absence of an option for prostate biopsy and the lack of tissue resistance were mentioned as two important shortcomings. Forty-seven participants rated the simulator's overall realism and usefulness for training purposes as 3.8 (standard deviation: 0.7) and 4.0 (standard deviation: 0.8) on a five-point Likert scale, respectively. CONCLUSIONS: : The simulator we describe can be used as a training tool for TRUS. It enables training with different patient cases and minimizes the burden to patients. Simulation of prostate biopsies should be added to increase the model's usefulness.

Transfer of cysto-urethroscopy skills from a virtual-reality simulator to the operating room: a randomized controlled trial.

OBJECTIVE: To assess whether real-time cysto-urethroscopy (CUS) performance improves by simulator-based training (criterion or predictive validity), addressing the research question 'Does practical skills training on the URO Mentor (UM, Simbionix USA Corp., Cleveland, OH, USA) virtual-reality simulator improve the performance of flexible CUS in patients'. SUBJECTS AND METHODS: Participants (71 interns from Catharina Hospital Eindhoven, CHE, and 29 from University Medical Centre Groningen, UMCG) were randomized to carry out CUS in a patient after training on the UM (UM-trained, 50) or without training on UM (control, 50). The assessment of real-time performance consisted of scoring on a Global Rating Scale (GRS) by supervisors unaware of training status. Data were analysed using stepwise multiple linear regression. The effect size (ES) indication for correlations was used to interpret the magnitude of a standard regression coefficient (beta); an ES of 0.10, 0.30 and 0.50 were considered small, moderate and large, respectively. The study was approved by the Medical Review Ethics Committees of the participating hospitals. RESULTS: Overall, the group that received training performed significantly better than the controls (P < or = 0.003, beta range 0.30-0.47). There was no effect of training for participants with a specific preference for a surgical speciality in two of five GRS scores. Participants from CHE obtained higher GRS 3 scores than those from UMCG. Significantly more UMCG trainees indicated having had stress than those from CHE (P < 0.001). CONCLUSIONS: The results showed that interns who had trained on UM outperformed controls for a CUS procedure in a patient. Training for CUS on the UM is to be recommended for learning to respect tissue, procedural knowledge, flow of procedure and forward planning. Use of the UM to train interns with a specific interest in a surgical speciality in handling instruments, and time and motion, seems to be of limited value.

Acquisition of flexible cystoscopy skills on a virtual reality simulator by experts and novices.

OBJECTIVE: To assess the construct validity of the URO Mentor (Simbionix Corp., Cleveland, OH, USA) virtual reality training model for several variables of skills training in cysto-urethroscopy, addressing two research questions: (i) Does training on the URO Mentor significantly improve novices' performance in terms of time, trauma, areas inspected and Global Rating Scale (GRS) score?; (ii) is discrimination between different levels of expertise possible using the URO Mentor? METHODS: Thirty experts and 50 novices performed seven tasks on the URO Mentor during one training session. The first, fourth and seventh tasks were 'test tasks' to evaluate participants' performance. The simulator recorded procedure time and trauma; a supervisor scored which areas were inspected and gave scores on the GRS. A two-way analysis of variance with repeated-measures test was used to analyse experts' and novices' performances, with P < 0.05 considered to indicate statistical significance. Effect sizes (ES) were calculated to quantify the practical significance of the results; ES of 0.10, 0.30, and 0.50 were considered small, medium and large, respectively. RESULTS: Novices' performances showed a significant improvement with large ES in time (linear trend of learning curve P < 0.001, ES 0.66) and mean GRS score (linear trend P < 0.001, ES 0.84, quadratic trend P = 0.018, ES 0.24). There was a medium improvement for trauma (linear trend P < 0.001, ES 0.40) and a small improvement in areas inspected (linear trend P = 0.032, ES 0.21). That the 95% confidence intervals of the measures on the first task of experts and novices did not coincide indicates that differentiation between experts and novices on the four variables measured can be achieved using the URO Mentor. CONCLUSIONS: Training on the URO Mentor appears to result in a medium to large improvement of novices' performances for time, trauma, areas inspected and GRS scores. Moreover, discrimination between different levels of expertise is possible using this simulator.

Combined student ratings and self-assessment provide useful feedback for clinical teachers.

Many evaluation instruments have been developed to provide feedback to physicians on their clinical teaching but written feedback alone is not always effective. We explored whether feedback effectiveness improved when teachers' self-assessment was added to written feedback based on student ratings. 37 physicians (10 residents, 27 attending physicians) from different specialties (Internal Medicine, Surgery, Obstetrics/Gynecology, Pediatrics, Neurology, Dermatology, Ophthalmology, ENT, and Psychiatry) were invited to fill out a self-assessment questionnaire on their teaching skills. Students completed an almost identical questionnaire to evaluate the same teachers based on their experiences during clerkships. After receiving written feedback incorporating their self-assessment and the student ratings, the teachers indicated their perceptions of the self-assessment exercise and the written feedback in a questionnaire (five-point Likert scale items) and next, in more detail, in semi-structured interviews with a purposive sample of 12 of the participating teachers. 25 physicians participated (67%). The results showed that self-assessment and student feedback were both perceived as useful (3.7, SD 1.0) but the latter was considered more effective. The physicians we interviewed considered the combination of self-assessment with student ratings more effective than either self-assessment or written feedback alone. Notably, discrepancies between student ratings and self-assessment were deemed a strong incentive for change. We conclude that self-assessment can be a useful tool to stimulate improvement of clinical teaching when it is combined with written feedback based on student ratings. Future research among larger groups is needed to confirm our findings and examine whether these combined tools actually lead to improved teaching.

The virtual reality endourologic simulator is realistic and useful for educational purposes.

PURPOSE: To examine the educational value of URO Mentor, a virtual reality simulator for endourologic procedures, by establishing its face and content validity. MATERIALS AND METHODS: Eighty-nine urologists and residents in urology performed a urethrocystoscopy task (bladder inspection, biopsy, and coagulation) or a ureterorenoscopy task (manipulation of a distal ureter stone) using the URO Mentor. They completed an evaluation questionnaire about these tasks. Questionnaire bias related to task performance on URO Mentor was analyzed as well (Hawthorne effect). RESULTS: The overall rating of the URO Mentor was 7.3 on a 10-point scale (1 = poor, 10 = excellent). Regression analysis showed that ratings were not related to previous experience or task performance using the URO Mentor. Of all subjects, 25% rated the realism of URO Mentor as >or=3.5 on a five-point scale, and 82% rated its usefulness as an educational tool as >or=3.5 on a five-point scale. More than 73% of all participants said they would purchase a URO Mentor if financial means were available; participants who needed more time to complete the task were less positive in their answers to this question. CONCLUSIONS: URO Mentor appears to be a realistic and useful training model for endourologic procedures.

How useful and realistic is the uro trainer for training transurethral prostate and bladder tumor resection procedures?

PURPOSE: We evaluated the face and content validity (novice and expert opinions of realism and usefulness) of the Uro Trainer (Karl Storz GmbH, Tuttlingen, Germany), a simulator for transurethral resection procedures, to ascertain whether it is justifiable to continue the validation process by performing prospective experimental studies. MATERIALS AND METHODS: Between 2006 and 2008, 104 urologists and urology residents performed a transurethral bladder tumor resection and/or transurethral prostate resection procedure on the Uro Trainer, and rated simulator usefulness and realism on a 10-point scale (1-not at all useful/realistic/poor, 10-very useful/realistic/excellent). Participants were classified as experts (more than 50 procedures performed) or novices (50 or fewer procedures performed). Because the literature offered no guidelines for interpreting our data, we used criteria from other studies to interpret the results. RESULTS: A total of 161 questionnaires were analyzed from 97 (21% experts, 79% novices) and 64 (30% experts, 70% novices) participants who performed transurethral prostate resection and transurethral bladder tumor resection procedures, respectively. Mean usefulness, realism and overall scores varied from 5.6 to 8.2 (SD 1.4-2.5). Measured by validity criteria from other studies, Uro Trainer face and content validity was unsatisfactory, with ratings on only 3%, 5% and 8% of the parameters interpreted as positive, moderately acceptable and good, respectively. CONCLUSIONS: Measured against criteria from other validation studies, Uro Trainer face and content validity appears to be unsatisfactory. Modification of the simulator seems advisable before further experimental validation studies are initiated. The lack of general guidelines for establishing face and content validity suggests a need for consensus about appropriate methods for evaluating the validity of simulators.

Update on training models in endourology: a qualitative systematic review of the literature between January 1980 and April 2008.

CONTEXT: Interest in the use of simulators in urological skills training is on the increase. To ensure effective implementation of training models, an overview of the nature and validity of the available models is of the essence. OBJECTIVE: To obtain an overview of training models and their validity by performing a qualitative systematic review of the literature. EVIDENCE ACQUISITION: Studies were identified through searches of PubMed, the Cochrane Library, and Web of Science between January 1980 and April 2008 using two search strategies: "urology and (training or simulat or model)" and combinations of these terms with "prostate," "kidney," "bladder," or "ureter." Studies were included if they (1) described one or more training models, and/or (2) examined the validity of training models. Studies in undergraduate education and of training models for physical examination were excluded. Validation studies were scored according to Kirkpatrick and Oxford Centre for Evidence-Based Medicine (OCEBM) levels of evidence. EVIDENCE SYNTHESIS: Forty-five articles (out of the initial list of 4753 retrieved articles, 0.9%) were included, describing 30 types of training models and 54 validation studies. The largest number of models has been described for ureterorenoscopy (nine types). Only three randomised controlled trials (RCTs), receiving a 1b OCEBM level of evidence score, were found. Studies investigating the impact of simulator training on performance in patients (criterion B validity) were scarce. The number of participants in experimental studies ranged from 7 to 136. CONCLUSIONS: Due to growing interest in training models in urology, it is increasingly urgent to determine which of these models are most valuable for postgraduate training. Because the validation studies published so far are few in number, have low evidence levels, and are composed of only a few RCTs, it is important that more randomised controlled validation studies including larger numbers of participants are performed.

How to introduce incognito standardized patients into outpatient clinics of specialists in rheumatology.

To know what is going on in physicians' surgery hours, assessment of practice performance is important with regard to quality assessment activities. The incognito standardized patient (SP) method is a powerful method to assess this. However, until now no reports have been published about specialists' performance using this method. In this study, 27 rheumatologists in 16 hospitals were each visited by eight incognito SPs to study the feasibility of sending incognito SPs to specialists working in different hospitals, of follow-up consultations and of simulating additional investigations. SPs recorded performance on case-specific checklists. The different steps needed for these visits are described in detail. A total of 136 first and 32 follow-up visits took place. SPs remained undetected in 98% of the visits. It is concluded that this SP method is a feasible one, however, only to be used for very specific purposes. Use of incognito SPs for larger scale projects is not recommended.