Analyzing interprofessional teamwork in the operating room: An exploratory observational study using conventional and alternative approaches.

Intraoperative teamwork is vital for patient safety. Conventional tools for studying intraoperative teamwork typically rely on behaviorally anchored rating scales applied at the individual or team level, while others capture narrative information across several units of analysis. This prospective observational study characterizes teamwork using two conventional tools (Operating Theatre Team Non-Technical Skills Assessment Tool [NOTECHS]; Team Emergency Assessment Measure [TEAM]), and one alternative approach (modified-Systems Engineering Initiative for Patient Safety [SEIPS] model). We aimed to explore the advantages and disadvantages of each for providing feedback to improve teamwork practice. Fifty consecutive surgical cases at a Canadian academic hospital were recorded with the OR Black Box®, analyzed by trained raters, and summarized descriptively. Teamwork performance was consistently high within and across cases rated with NOTECHS and TEAMS. For cases analyzed with the modified-SEIPS tool, both optimal and suboptimal teamwork behaviors were identified, and team resilience was frequently observed. NOTECHS and TEAM provided summative assessments and overall pattern descriptions, while SEIPS facilitated a deeper understanding of teamwork processes. As healthcare organizations continue to prioritize teamwork improvement, SEIPS may provide valuable insights regarding teamwork behavior and the broader context influencing performance. This may ultimately enhance the development and effectiveness of multi-level teamwork interventions.

Online Patient Information for Hysterectomies: A Systematic Environmental Scan of Quality and Readability.

OBJECTIVE: Hysterectomy is a common gynaecological procedure, and therefore online information is highly valuable to patients. Our objective was to evaluate the quality, readability, and comprehensiveness of online patient information on hysterectomy. METHODS: The first 25 patient-directed websites on hysterectomy, identified using 5 online search engines (Google, Yahoo, AOL, Bing, Ask.com) as well as clinical professional societies, were assessed using validated tools for quality (DISCERN, JAMA benchmark), readability (Flesch-Kincaid Grade Level [FKGL], Gunning Fog, Simple Measure of Gobbledygook [SMOG], Flesch Reading Ease Score [FRES]), and completeness of information. RESULTS: We identified 50 websites for inclusion. Overall, websites were of good quality (median DISCERN score 53/80 [interquartile range {IQR} 47-61]; median JAMA score 3/4 [IQR 1-4]). Most websites described surgical risks (39, 78%), benefits (45, 90%), and types of hysterectomy (48, 96%). Content readability corresponded to grade 11 using FKGL (median 11.1 [IQR 10.2-13.0]) and SMOG (median 10.9 [IQR 10.2-12.4]), or 15 years education using Gunning Fog (median 14.7 [IQR 13.8-16.4]). Websites were assessed as difficult to read using FRES (median 45.6/100 [IQR 37.9-50.9]). No differences were observed in readability scores when we compared websites from clinical professional societies, government, health care, or academic organizations with other websites (P > 0.05). CONCLUSION: Online patient information on hysterectomy is of good quality and comprehensive. However, the content is above the American Medical Association's recommended grade 6 reading level. Website authors should consider readability to make their content more accessible to patients.

Cognitive aids with roles defined (CARD) for obstetrical crises: a multisite before-and-after cohort study.

PURPOSE: Patient outcome during an obstetrical emergency depends on prompt coordination of an interprofessional team. The cognitive aids with roles defined (CARD) is a cognitive aid that addresses the issue of teamwork in crisis management. This study evaluated the clinical impact of implementing the CARD cognitive aid during emergency Cesarean deliveries. METHODS: We conducted a prospective before-and-after cohort trial at the maternity units of two Canadian academic hospital campuses. Both sites received didactic online training regarding teamwork during crises, which involved training on using CARD for the "CARD" campus (intervention) and no mention of CARD at the "no CARD" campus (control). The primary outcome was the total time to delivery after the call for an emergency Cesarean delivery. Secondary outcomes included specific intervals of time within the time to delivery and clinical outcomes for both the babies and mothers. RESULTS: We analyzed data from 267 eligible emergency Cesarean deliveries that occurred between January 11 2014 and December 31 2017. The use of CARD did not significantly change the median [interquartile range] time to delivery of the baby during an emergency Cesarean delivery from the pre-intervention to the post-intervention time period (17 [12-28] vs 15 [13-20], respectively; median difference, 2; 95% confidence interval, -1 to 5; P = 0.36). The clinical outcomes for the baby or the mother and other secondary outcomes also did not change. CONCLUSIONS: The CARD cognitive aid did not significantly improve time-based or clinical maternal and neonatal outcomes of emergency Cesarean delivery at our academic maternity unit.

RéSUMé: OBJECTIF: Les devenirs des patientes pendant les urgences obstétricales dépendent de la coordination rapide d'une équipe interprofessionnelle. Le système CARD (Cognitive Aids with Roles Defined) est un outil de soutien cognitif qui est centré sur le travail d'équipe dans la gestion de crise. Cette étude a évalué l'impact clinique de la mise en œuvre d'un système CARD pendant les accouchements par césarienne d'urgence. MéTHODE: Nous avons réalisé une étude de cohorte prospective avant / après dans les services de maternité de deux campus hospitaliers universitaires canadiens. Les deux sites ont eu accès à une formation didactique en ligne portant sur le travail d'équipe pendant les crises; dans le campus « CARD ¼ (groupe intervention), une formation sur l'utilisation du système CARD a été incluse, alors qu'aucune mention du système n'a été faite dans le campus « sans CARD ¼ (groupe témoin). Le critère d'évaluation principal était le délai total jusqu'à l'accouchement après l'appel pour un accouchement par césarienne d'urgence. Les critères secondaires comprenaient les intervalles spécifiques de temps jusqu'à l'accouchement et les pronostics cliniques des bébés et de leurs mères. RéSULTATS: Nous avons analysé les données de 267 accouchements par césarienne d'urgence éligibles survenus entre le 11 janvier 2014 et le 31 décembre 2017. L'utilisation du système CARD n'a pas modifié de manière significative le délai médian [écart interquartile] jusqu'à l'accouchement du bébé pendant un accouchement par césarienne d'urgence tel que mesuré entre le moment pré-intervention et le moment post-intervention (17 [12­28] vs 15 [13­20], respectivement; différence médiane, 2; intervalle de confiance 95 %, −1 à 5; P = 0,36). Les pronostics cliniques des bébés et des mères et les autres critères d'évaluation secondaires n'ont pas non plus été modifiés. CONCLUSION: Le système CARD n'a pas amélioré de façon significative les pronostics maternels et néonatals fondés sur le temps ou la clinique en cas d'accouchement par césarienne d'urgence dans notre service de maternité universitaire.

Health Care Team Training and Simulation-Based Education in Obstetrics During the COVID-19 Pandemic.

Health care team training and simulation-based education are important for preparing obstetrical services to meet the challenges of the COVID-19 pandemic. Priorities for training are identified in two key areas. First, the impact of infection prevention and control protocols on processes of care (e.g., appropriate and correct use of personal protective equipment, patient transport, preparation for emergency cesarean delivery with the potential for emergency intubation, management of simultaneous obstetric emergencies, delivery in alternate locations in the hospital, potential for increased decision-to-delivery intervals, and communication with patients). And second, the effects of COVID-19 pathophysiology on obstetrical patients (e.g., testing and diagnosis, best use of modified obstetric early warning systems, approach to maternal respiratory compromise, collaboration with critical care teams, and potential need for cardiopulmonary resuscitation). However, such training is more challenging during the COVID-19 pandemic because of the requirements for social distancing. This article outlines strategies (spatial, temporal, video-recording, video-conferencing, and virtual) to effectively engage in health care team training and simulation-based education while maintaining social distancing during the COVID-19 pandemic.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes.

STUDY OBJECTIVE: Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications. DESIGN: Retrospective, multicenter, cohort study (Canadian Task Force classification II-2). SETTING: Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites. PATIENTS: Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012. INTERVENTION: ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS: Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality. CONCLUSION: Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Developing a Canadian Curriculum for Simulation-Based Education in Obstetrics and Gynaecology: A Delphi Study.

OBJECTIVE: As obstetrics and gynaecology (Ob/Gyn) residency training programs move towards a competence-based approach to training and assessment, the development of a national standardized simulation curriculum is essential. The primary goal of this study was to define the fundamental content for the Canadian Obstetrics and Gynecology Simulation curriculum. METHODS: A modified Delphi technique was used to achieve consensus in three rounds by surveying residency program directors or their local simulation educator delegates in 16 accredited Canadian Ob/Gyn residency programs. A consensus rate of 80% was agreed upon. Survey results were collected over 11 months in 2016. RESULTS: Response rates for the Delphi were 50% for the first round, 81% for the second round, and 94% for the third round. The first survey resulted in 84 suggested topics. These were organized into four categories: obstetrics high acuity low frequency events, obstetrics common events, gynaecology high acuity low frequency events, and gynaecology common events. Using the modified Delphi method, consensus was reached on 6 scenarios. CONCLUSION: This study identified the content for a national simulation-based curriculum for Ob/Gyn residency training programs and is the first step in the development of this curriculum.

Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety.

BACKGROUND: Answering telephone calls and pagers is common distraction in the operating room. We sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance. METHODS: We conducted a randomized crossover study of obstetrics and gynecology residents. After studying a patient sign-out list, subjects performed a virtual salpingectomy. They were randomized to a distraction phase followed by quiet phase or vice versa. In the distraction phase, a pager beeped and subjects were asked questions based on the sign-out list. Accuracy of responses and the number of unsafe responses were recorded. In the quiet phase, trainees performed the task uninterrupted. Measures of surgical performance were successful task completion, time to task completion and operative blood loss. RESULTS: The mean score for correct responses to clinical questions during the distracted phase was 80 % (SD ±14 %). Nineteen residents (63 %) made at least 1 unsafe clinical decision while operating on the simulator (range 0-3). Subjects were more likely to successfully complete the surgical task in the allotted time under the quiet compared to distraction condition (OR 11.3, p = 0.03). There was no difference between the conditions in paired analysis for mean time (seconds) to task completion [426 (SD 133) vs. 440 (SD 186), p = 0.61] and mean operative blood loss (mL) [73.14 (SD 106) vs. 112.70 (SD 358), p = 0.47]. CONCLUSIONS: Distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents' ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.

Critical Appraisal Skills Among Canadian Obstetrics and Gynaecology Residents: How Do They Fare?

OBJECTIVES: Evidence-based medicine has become the standard of care in clinical practice. In this study, our objectives were to (1) determine the type of epidemiology and/or biostatistical training being given in Canadian obstetrics and gynaecology post-graduate programs, (2) determine obstetrics and gynaecology residents' level of confidence with critical appraisal, and (3) assess knowledge of fundamental biostatistical and epidemiological principles among Canadian obstetrics and gynaecology trainees. METHODS: During a national standardized in-training examination, all Canadian obstetrics and gynaecology residents were invited to complete an anonymous cross-sectional survey to determine their levels of confidence with critical appraisal. Fifteen critical appraisal questions were integrated into the standardized examination to assess critical appraisal skills objectively. Primary outcomes were the residents' level of confidence interpreting biostatistical results and applying research findings to clinical practice, their desire for more biostatistics/epidemiological training in residency, and their performance on knowledge questions. RESULTS: A total of 301 of 355 residents completed the survey (response rate=84.8%). Most (76.7%) had little/no confidence interpreting research statistics. Confidence was significantly higher in those with increased seniority (OR=1.93), in those who had taken a previous epidemiology/statistics course (OR=2.65), and in those who had prior publications (OR=1.82). Many (68%) had little/no confidence applying research findings to clinical practice. Confidence increased significantly with increasing training year (P<0.001) and with formal epidemiology training during residency (OR=2.01). The mean score of the 355 residents on the knowledge assessment questions was 69.8%. Increasing seniority was associated with improved overall test performance (P=0.02). Poorer performance topics included analytical study method (9.9%), study design (36.9%), and sample size (42.0%). Most (84.4%) wanted more epidemiology teaching. CONCLUSION: Canadian obstetrics and gynaecology residents may have the biostatistical and epidemiological knowledge to interpret results published in the literature, but lack confidence applying these skills in clinical settings. Most residents want additional training in these areas, and residency programs should include training in formal curriculums to improve their confidence and prepare them for a lifelong practice of evidence-based medicine.

Objectifs : La médecine factuelle est devenue la norme de diligence en pratique clinique. Dans le cadre de cette étude, nous avions pour objectifs (1) de déterminer le type de formation en épidémiologie et/ou en biostatistique qui est offert par les programmes canadiens d'études supérieures en obstétrique-gynécologie, (2) de déterminer le degré d'aisance des résidents en obstétrique-gynécologie envers l'évaluation critique et (3) d'évaluer les connaissances que détiennent les stagiaires canadiens en obstétrique-gynécologie en ce qui concerne les principes fondamentaux de la biostatistique et de l'épidémiologie. Méthodes : Dans le cadre d'un examen intermédiaire standardisé national, nous avons convié tous les résidents canadiens en obstétrique-gynécologie à remplir un questionnaire transversal anonyme visant à déterminer leurs degrés d'aisance envers l'évaluation critique. Quinze questions d'évaluation critique ont été intégrées à l'examen standardisé pour évaluer, de façon objective, les compétences relevant de l'évaluation critique. Les critères d'évaluation principaux ont été le degré d'aisance des résidents envers l'interprétation de résultats biostatistiques et l'application des résultats de la recherche à la pratique clinique, leur souhait d'obtenir plus de formation en biostatistique / épidémiologie pendant leur résidence et leur rendement quant aux questions sur les connaissances. Résultats : Au total, 301 des 355 résidents ont rempli le questionnaire (taux de réponse = 84,8 %). La plupart d'entre eux (76,7 %) étaient peu à l'aise / n'étaient pas à l'aise en ce qui concerne l'interprétation de résultats statistiques de recherche. Le degré d'aisance était considérablement accru chez les résidents plus expérimentés (RC = 1,93), chez ceux qui avaient déjà suivi un cours en épidémiologie / statistique (RC = 2,65) et chez ceux qui étaient déjà parvenus à faire publier un article (RC 1= ,82). Bon nombre de ces résidents (68 %) étaient peu à l'aise / n'étaient pas à l'aise en ce qui concerne l'application des résultats de la recherche à la pratique clinique. Le degré d'aisance connaissait une hausse considérable au fil des années de formation (P < 0,001) et en présence d'une formation officielle en épidémiologie au cours de la résidence (RC.= 2,01). Le score moyen des 355 résidents quant aux questions sur l'évaluation des connaissances a été de 69,8 %. Le niveau d'expérience était associé à une amélioration du rendement global pendant le test (P = 0,02). Parmi les rubriques ayant donné lieu au rendement le plus faible, on trouvait la méthode d'étude analytique (9,9 %), le devis d'étude (36,9 %) et la taille d'échantillon (42,0 %). La plupart des résidents (84,4 %) souhaitaient obtenir plus de formation en épidémiologie. Conclusion : Bien que les résidents canadiens en obstétrique-gynécologie détiennent les connaissances requises en biostatistique et en épidémiologie pour interpréter les résultats publiés dans la littérature, ils manquent d'aisance quant à l'application de ces connaissances en milieu clinique. La plupart des résidents souhaitent obtenir plus de formation dans ces domaines; les programmes de résidence devraient donc inclure une telle formation aux curriculums officiels, et ce, en vue d'accroître la confiance des résidents et de les préparer à pratiquer une médecine factuelle tout au long de leur carrière.

Experiencing Health Advocacy During Cervical Cancer Awareness Week: A National Initiative for Obstetrics and Gynaecology Residents.

OBJECTIVE: The Royal College of Physicians and Surgeons of Canada requires that residents demonstrate competence in health advocacy (HA). We sought to develop and implement a national educational module for obstetrics and gynaecology residents to address the role of HA. This pilot program was centred on cervical cancer prevention, which lends itself to applying the principles of advocacy. METHODS: An educational module was developed and disseminated to all obstetrics and gynaecology residency programs in Canada. The module describes options for HA involving cervical dysplasia screening, such as an outreach clinic or a forum for public/student education, which were to be implemented during Cervical Cancer Awareness Week. The measures of success were the number of programs implementing the curriculum, number of residents who participated, diversity of projects implemented, individuals (patients or learners) reached by the program, and the overall experience of the trainees. RESULTS: Three programs implemented the curriculum in 2011, one in 2012, and seven in 2013. After three years, the module has involved seven of 16 medical schools, over 100 residents, and thousands of women either directly or indirectly. Additionally, attributes of HA experienced by the residents were identified: teamwork, leadership, increased systems knowledge, increased social capital within the community, creativity, innovation, and adaptability. CONCLUSION: We have demonstrated that an educational module can be implemented nationally, helping our residents fulfill their HA requirements. Other specialties could use this module in building HA into their own programs.

Objectif : Le Collège royal des médecins et chirurgiens du Canada exige que les résidents fassent preuve de compétence dans le rôle de promoteur de la santé (PS ou promotion de la santé). Nous avons cherché à élaborer et à mettre en œuvre, à l'intention des résidents en obstétrique-gynécologie, un module pédagogique national traitant de ce rôle de PS. Ce programme pilote était centré sur la prévention du cancer du col utérin, soit un sujet se prêtant bien à l'application des principes de la promotion de la santé. Méthodes : Un module pédagogique a été élaboré et transmis à tous les programmes de résidence en obstétrique-gynécologie au Canada. Ce module décrit les options de PS mettant en jeu le dépistage de la dysplasie cervicale (telles qu'une clinique visant l'élargissement de la population desservie ou un forum d'éducation visant le public / la population étudiante) qui devaient être mises en œuvre au cours de la Semaine de sensibilisation au cancer du col de l'utérus. La réussite a été mesurée en fonction du nombre de programmes mettant en œuvre le curriculum, du nombre de résidents y ayant participé, de la diversité des projets mis en œuvre, de la nature des personnes (patientes ou apprenants) atteintes par le programme et de l'expérience globale des stagiaires. Résultats : Trois programmes ont mis en œuvre le curriculum en 2011, un programme l'a fait en 2012 et sept l'ont fait en 2013. Après trois ans, le module s'est attiré la participation directe ou indirecte de sept des 16 facultés de médecine, de plus de 100 résidents et de milliers de femmes. De plus, les attributs de la PS vécus par les résidents ont été identifiés : travail d'équipe, leadership, connaissances accrues au sujet des systèmes, capital social accru au sein de la communauté, créativité, innovation et adaptabilité. Conclusion : Nous avons démontré qu'un module pédagogique, visant à aider nos résidents à répondre à leurs exigences en matière de PS, peut être mis en œuvre à l'échelle nationale. D'autres spécialités pourraient utiliser ce module pour incorporer la PS dans leurs programmes respectifs.

Transesophageal echocardiography simulation is an effective tool in teaching psychomotor skills to novice echocardiographers.

BACKGROUND: Performance of transesophageal echocardiography (TEE) requires the psychomotor ability to obtain interpretable echocardiographic images. The purpose of this study was to determine the effectiveness of a simulation-based curriculum in which a TEE simulator is used to teach the psychomotor skills to novice echocardiographers and to compare instructor-guided with self-directed online delivery of the curriculum. METHODS: After institutional review board approval, subjects inexperienced in TEE completed an online review of TEE material prior to a baseline pre-test of TEE psychomotor skills using the simulator. Subjects were randomized to two groups. The first group received an instructor-guided lesson of TEE psychomotor skills with the simulator. The second group received a self-directed slide presentation of TEE psychomotor skills with the simulator. Both lessons delivered identical information. Following their respective training sessions, all subjects performed a post-test of their TEE psychomotor skills using the simulator. Two assessors rated the TEE performances using a validated scoring system for acquisition of images. RESULTS: Pre-test TEE simulator scores were similar between the two instruction groups (9.0 vs 5.0; P = 0.28). The scores in both groups improved significantly following training, regardless of the method of instruction (P < 0.0001). The improvement in scores (post-test scores minus pre-test scores) did not differ significantly between instruction groups (12.5 vs 14.5; P = 0.55). There was strong inter-rater reliability between assessors (α = 0.98; 95% confidence interval [CI]: 0.97 to 0.99). CONCLUSIONS: High-fidelity TEE simulators are an effective training adjunct for the acquisition of basic TEE psychomotor skills. There was no difference in improvement between the different modalities of instruction. Further research will examine the need for a faculty resource for a curriculum in which a simulator is used as an adjunct.

Impact of a COVID-19 code blue protocol on resuscitation care and CPR quality during in-hospital cardiac arrest.

OBJECTIVE: We sought to evaluate the impact of a COVID-19 Code Blue policy on in-hospital cardiac arrest (IHCA) processes of care, cardiopulmonary resuscitation (CPR) quality metrics, and survival to hospital discharge. METHODS: We completed a health record review of consecutive IHCA for which resuscitation was attempted. We report Utstein outcomes and CPR quality metrics 33 months before (July,2017-March,2020) and after (April,2020-December,2022) the implementation of a COVID-19 Code Blue policy requiring all team members to don personal protective equipment including gown, gloves, mask, and eye protection for all IHCA. RESULTS: There were 800 IHCA with the following characteristics (Before n = 396; After n = 404): mean age 66, 62.9% male, 81.3% witnessed, 31.3% in the emergency department, 25.6% cardiac cause, and initial shockable rhythm in 16.7%. Among all 404 patients screened for COVID-19, 25 of 288 available test results before IHCA occurred were positive. Comparing the before and after periods: there were relevant time delays (min:sec) in start of chest compressions (0:17vs.0:37;p = 0.005), team arrival (0:43vs.1:21;p = 0.002), 1st rhythm analysis (1:15vs.3:16;p < 0.0001), 1st epinephrine (3:44vs.4:34;p = 0.02), and airway insertion (8:38vs. 10:18;p = 0.02). Resuscitation duration was similar (18:28vs.19:35;p = 0.34). Exception of peri-shock pause which appeared longer (0:06vs.0:14;p = 0.07), chest compression fraction, rate and depth were identical and good. Factors independently associated with survival were age (adjOR 0.98;p < 0.001), male sex (adjOR 1.51;p = 0.048), witnessed (adjOR 2.35;p = 0.02), shockable rhythm (adjOR 3.31;p < 0.0001), hospital location (p = 0.0002), and COVID-19 period (adjOR 0.68;p = 0.052). CONCLUSIONS: The COVID-19 Code Blue policy was associated with delayed processes of care but similarly good CPR quality. The COVID-19 period appeared associated with decreased survival.

Educational and Patient Care Impacts of In Situ Simulation in Healthcare: A Systematic Review.

ABSTRACT: This systematic review was performed to assess the effectiveness of in situ simulation education. We searched databases including MEDLINE and Embase for studies comparing in situ simulation with other educational approaches. Two reviewers screened articles and extracted information. Sixty-two articles met inclusion criteria, of which 24 were synthesized quantitatively using random effects meta-analysis. When compared with current educational practices alone, the addition of in situ simulation to these practices was associated with small improvements in clinical outcomes, including mortality [odds ratio, 0.66; 95% confidence interval (CI), 0.55 to 0.78], care metrics (standardized mean difference, -0.34; 95% CI, -0.45 to -0.21), and nontechnical skills (standardized mean difference, -0.52; 95% CI, -0.99 to -0.05). Comparisons between in situ and traditional simulation showed mixed learner preference and knowledge improvement between groups, while technical skills showed improvement attributable to in situ simulation. In summary, available evidence suggests that adding in situ simulation to current educational practices may improve patient mortality and morbidity.

Too much small talk? Medical students' pelvic examination skills falter with pleasant patients.

CONTEXT: The competent performance of a female pelvic examination requires both technical proficiency and superlative communication skills. However, the ideal medium with which to assess these skills remains to be elucidated. Part-task trainers (PTTs) offer an effective and affordable means of testing technical skills, but may not allow students to demonstrate their communication skills. Hybrids involving standardised patients (SPs) (SP-PTT) offer a more realistic assessment of communication, but students may feel awkward when examining the female genitalia. OBJECTIVE: The objective of this study was to compare the use of PTTs with that of SP-PTT hybrids in the assessment of technical and communication skills in the female pelvic examination. METHODS: A total of 145 medical students were randomised to one of three conditions during their summative objective structured clinical examination (OSCE) at the completion of clerkship. Students performed the female pelvic examination on: (i) a PTT alone ('plastic' condition); (ii) an SP-PTT hybrid with an SP who did not engage in any superfluous conversation ('perfunctory' condition), or (iii) an SP-PTT hybrid with an SP who was trained to offer small talk and banter, which was judged to better reflect the typical doctor-patient interaction ('pleasant' condition). RESULTS: Communication skills did not differ significantly among the three groups (p = 0.354). There was a significant difference among groups in technical skills scores (p = 0.0018). Students in the 'plastic' condition performed best, followed by those in the 'perfunctory' and 'pleasant' conditions, respectively. CONCLUSIONS: Medical students demonstrate equivalent communication skills whether they work with a PTT or an SP-PTT hybrid, but their technical skills suffer in the presence of an SP. Working with the PTT alone does not appear to disadvantage students in terms of communication skills, but may offer better conditions for performing technical aspects of the procedure. Whether the 'plastic patient' is the most meaningful and valid means of predicting overall competence in the clinical setting is still a matter for debate.

Managing expectations of surgical training: a national perspective on gynaecologic endoscopy practice.

OBJECTIVE: To determine if the opinion of obstetrics and gynaecology postgraduate trainees differs from practising gynaecologists with respect to the expected endoscopic surgical skill set of a general gynaecologist upon graduation from residency. METHODS: An electronic survey was designed, validated, and pre-tested. It was sent to 775 Canadian obstetrics and gynaecology residents, fellows, and practising physicians through the Society of Obstetricians and Gynaecologists of Canada's electronic mailing list. Survey respondents were asked their opinion on the level of training (no extra post-residency training vs. fellowship) required to perform various endoscopic procedures. RESULTS: We received 301 responses (39% response rate). Obstetrics and gynaecology trainees and practising physicians agreed on the training and skill level necessary to perform many endoscopic procedures. However, there were significant differences of opinion among trainees and practising physicians regarding advanced endoscopic procedures such as laparoscopic hysterectomy, cystotomy and enterotomy repair, and appendectomy. More trainees felt that a general gynaecologist without additional post-residency surgical training should be competent to perform such procedures, while practising physicians felt fellowship training was necessary. CONCLUSION: Our survey highlights the different expectations of learners versus those in practice with regard to skills required to perform certain endoscopic procedures, particularly laparoscopic hysterectomy. Trainees who responded believed that after graduation from residency any obstetrician-gynaecologist should be able to perform more advanced endoscopic procedures, but practising physicians did not agree. This discordance between learners and practising colleagues highlights an important educational challenge in obstetrics and gynaecology surgical training. Greater clarification of what is expected of our training programs would be beneficial for both residents and training programs.

Objectif : Déterminer si l'opinion des stagiaires postdoctoraux en obstétrique-gynécologie diffère de celle des gynécologues praticiens en ce qui a trait à l'ensemble de compétences en chirurgie endoscopique dont devrait disposer un gynécologue généraliste à la fin de sa résidence. Méthodes : Un sondage électronique a été conçu, validé et prétesté. Nous l'avons fait parvenir, par l'intermédiaire de la liste de diffusion électronique de la Société des obstétriciens et gynécologues du Canada, à 775 résidents, boursiers et praticiens canadiens du domaine de l'obstétrique-gynécologie. Nous avons demandé aux répondants de nous fournir leur opinion quant au niveau de formation requis (aucune formation post-résidence supplémentaire vs fellowship) pour l'exécution de diverses interventions endoscopiques. Résultats : Nous avons reçu 301 réponses (taux de réponse de 39 %). Les stagiaires en obstétrique-gynécologie et les gynécologues prati­ciens étaient du même avis quant au niveau de formation et aux compétences nécessaires pour l'exécution de nombreuses interventions endoscopiques. Toutefois, nous avons constaté des différences d'opinion considérables entre les stagiaires et les praticiens en ce qui concerne les interventions endoscopiques avancées (comme l'hystérectomie laparoscopique, la réparation de cystostomie et d'entérostomie, et l'appendicectomie). Un plus grand nombre de stagiaires étaient d'avis qu'un gynécologue généraliste devrait, sans formation chirurgicale post-résidence supplémentaire, disposer de la compétence requise pour mener de telles interventions, tandis que les praticiens estimaient qu'une formation de type fellowship s'avérait nécessaire. Conclusion : Notre sondage souligne les différences en matière d'attentes, entre les stagiaires et les praticiens, en ce qui concerne les compétences requises pour mener certaines interventions endoscopiques (particulièrement l'hystérectomie laparoscopique). Les stagiaires ayant répondu au sondage estimaient que, à la fin du programme de résidence, tout obstétricien-gynécologue devrait être en mesure de mener des interventions endoscopiques plus avancées, mais les praticiens ne partageaient pas cet avis. Cet écart entre les stagiaires et les praticiens souligne l'existence d'un important défi pédagogique en ce qui concerne la formation chirurgicale en obstétrique-gynécologie. Une meilleure clarification des attentes envers nos programmes de formation s'avérerait bénéfique tant pour les résidents que pour les programmes de formation.

Assessing residents' disclosure of adverse events: traditional objective structured clinical examinations versus mixed reality.

OBJECTIVE: The skill of disclosing adverse events is difficult to assess. Assessment of this competency in medical trainees is commonly achieved via the objective structured clinical examination (OSCE) using a standardized patient (SP). We hypothesized that the addition of a simulated clinical adverse event prior to the SP encounter could increase trainees' engagement and empathy, thereby improving performance. The objective of this study was to explore whether experiencing a simulated adverse event prior to an SP encounter alters resident performance on a disclosure OSCE. METHODS: Sixteen obstetrics and gynaecology residents participated in this mixed methods study. Prior to disclosing the complication in an SP encounter, residents were randomized either to receive a written description of an adverse event, or to experience a mannequin simulation of an adverse event. Mean OSCE scores from blinded examiners were compared in each group. Focus group discussions elicited residents' reflections on the experience of disclosing the adverse event. RESULTS: The mean score was 16.6/23 ± 2.9 (range 10 to 20) for the traditional OSCE group and 16.9/23 ± 1.7 (range 15 to 20) for the simulation group. Analysis of the focus group data revealed several themes, such as the type of context the residents desired, the emotional involvement they felt, and their insights about their experience of the simulation scenario or with the SP. CONCLUSION: The assessment of adverse event disclosure was not enhanced by the addition of a simulated experience. Study participants reported that the simulation did not provide the contextual information required to elicit empathy and a sense of being emotionally invested in the adverse event.

Emotions in simulation-based education: friends or foes of learning?

In simulation-based education, there is growing interest in the effects of emotions on learning from simulation sessions. The perception that emotions have an important impact on performance and learning is supported by the literature. Emotions are pervasive: at any given moment, individuals are in one emotional state or another. Emotions are also powerful: they guide ongoing cognitive processes in order to direct attention, memory and judgment towards addressing the stimulus that triggers the emotion. This occurs in a predictable way. The purpose of this paper is to present a narrative overview of the research on emotions, cognitive processes and learning, in order to inform the simulation community of the potential role of emotions during simulation-based education.

Facing hierarchy: a qualitative study of residents' experiences in an obstetrical simulation scenario.

BACKGROUND: Residents in surgical specialties face a steep hierarchy when managing medical crises. Hierarchy can negatively impact patient safety when team members are reluctant to speak up. Yet, simulation has scarcely been previously utilized to qualitatively explore the way residents in surgical specialities navigate this challenge. The study aimed to explore the experiences of residents in one surgical specialty, obstetrics and gynecology (Ob/Gyn), when challenging hierarchy, with the goal of informing future interventions to optimize resident learning and patient safety. METHODS: Eight 3rd- and 4th-year Ob/Gyn residents participated in a simulation scenario in which their supervising physician made an erroneous medical decision that jeopardized the wellbeing of the labouring mother and her foetus. Residents participated in 30-45 min semi-structured interviews that explored their approach to managing this scenario. Transcribed interviews were analysed using qualitative thematic inquiry by three research team members, finalizing the identified themes once consensus was reached. RESULTS: Study results show that the simulated scenario did create an experience of hierarchy that challenged residents. In response, residents adopted three distinct communication strategies while confronting hierarchy: (1) messaging - a mere reporting of existing clinical information; (2) interpretive - a deliberate construction of clinical facts aimed at swaying supervising physician's clinical decision; and (3) advocative - a readiness to confront the staff physician's clinical decision. Furthermore, residents utilized coping mechanisms to mitigate challenges related to confronting hierarchy, namely deflecting responsibility, diminishing urgency, and drafting allies. Both these communication strategies and coping mechanisms shaped their practice when challenging hierarchy to preserve patient safety. CONCLUSIONS: Understanding the complex processes in which residents engage when confronting hierarchy can serve to inform the development and study of curricular innovations. Informed by these processes, we must move beyond solely teaching residents to speak up and consider a broader curriculum that targets not only residents but also faculty physicians and the learning environment within the organization.

Assessing residents' communication skills: disclosure of an adverse event to a standardized patient.

INTRODUCTION: Disclosing adverse events to patients after a poor outcome is an essential task involving both communication skills and professionalism, but one that is difficult to teach and assess during clinical rotations. Beyond ensuring clinical competency, these skills are essential in minimizing medico-legal risk. An objective structured clinical examination (OSCE) station with a standardized patient allows an opportunity to evaluate these skills. Our objective was to assess residents' communication skills involving the disclosure of a poor outcome to a standardized patient using a standardized patient encounter, and to compare their performance before and after formal teaching on disclosure. METHODS: Fourteen obstetrics and gynaecology residents (PGY-2 to PGY-5) were evaluated in a two-station OSCE. In the first station, they obtained a history and counselled an obstetrical patient, and in the second station they met with the same patient to discuss an adverse outcome that had occurred. The residents were evaluated using guidelines for the disclosure of adverse events developed by the Canadian Patient Safety Institute and published by the Canadian Medical Protective Association. The residents then participated in a workshop on disclosure and were retested. RESULTS: The mean score in the pre-workshop disclosure OSCE was 59.1% (12.4/21, SD 2.7), while the mean score in the post-workshop OSCE was 80.1% (16.9/21, SD 2.1). Using the paired Student t test, the scores differed significantly with P < 0.01. CONCLUSION: Residents' performance in disclosure improves after formal teaching and the OSCE is an effective technique for testing communication skills.