The multiple process model of goal-directed aiming/reaching: insights on limb control from various special populations.

Several years ago, our research group forwarded a model of goal-directed reaching and aiming that describes the processes involved in the optimization of speed, accuracy, and energy expenditure Elliott et al. (Psychol Bull 136:1023-1044, 2010). One of the main features of the model is the distinction between early impulse control, which is based on a comparison of expected to perceived sensory consequences, and late limb-target control that involves a spatial comparison of limb and target position. Our model also emphasizes the importance of strategic behaviors that limit the opportunity for worst-case or inefficient outcomes. In the 2010 paper, we included a section on how our model can be used to understand atypical aiming/reaching movements in a number of special populations. In light of a recent empirical and theoretical update of our model Elliott et al. (Neurosci Biobehav Rev 72:95-110, 2017), here we consider contemporary motor control work involving typical aging, Down syndrome, autism spectrum disorder, and tetraplegia with tendon-transfer surgery. We outline how atypical limb control can be viewed within the context of the multiple-process model of goal-directed reaching and aiming, and discuss the underlying perceptual-motor impairment that results in the adaptive solution developed by the specific group.

Early Impulse Control: Treatment of Potential Errors within Pre-Programming and Control.

Early aiming adjustments following an online perturbation are made possible by impulse control. This process may unfold even earlier when perturbations impose a greater risk of a costly overshoot error. Participants executed upward and downward aims to mediate the cost of potential errors-downward overshoots require more energy to correct against gravity. On 33% of the trials, texture elements on the aiming surface were shifted following onset to appear congruent or incongruent with the aiming direction, and consequently generate a misperception of the limb moving slower or faster, respectively. Thus, the risk of potential errors could be influenced by the online perturbation (e.g., increased perceived likelihood of overshooting following the incongruent background). Findings indicated greater undershooting for down compared to up, which reflects the principle of movement optimisation. There was also more undershooting for an incongruent compared to congruent background, which is consistent with early online adjustments counter-acting the misperceived limb velocity. However, there were no interactions throughout the movement trajectory. We suggest that while the initial pre-programme considers the cost of potential errors (target direction), early impulse control fails to discriminate the likelihood of these errors occurring following an online perturbation (moving background).

A multiple-trainee, multiple-level, multiple-competency (multi-TLC) simulation-based approach to training obstetrical emergencies.

Competency-based education requires that programs increase the breadth of direct observation and assessment to improve resident training. To achieve these goals, the authors developed and executed a multiple-trainee, multiple-level, multiple-competency (Multi-TLC) obstetrical emergencies simulation curriculum. Depending upon their training level (PGY1-PGY5), obstetrics and gynaecology residents participated in various roles (i.e., first responder, second responder, confederates, and evaluators) within four simulation scenarios designed to provide opportunities for education, direct observation, and assessment across a number of competencies (i.e., medical expert, communicator, collaborator, leader, advocate, and scholar). The curriculum was carried out over 8 h spread evenly across 2 days (i.e., 4 h/day) and involved periods of pre-briefing, live simulation, and debriefing. An evaluation of the Multi-TLC was operationalised via a context-input-process-product model. This report presents the outcomes of that evaluation derived from quasi-experimental comparisons of the new and previous curricula across four priorities for simulation-based education identified by the Department of Obstetrics and Gynecology at McMaster University (Hamilton, ON, Canada): increasing learning opportunities, maintaining or improving resident learning, maintaining or reducing program costs, and improving resident satisfaction. The evaluation revealed that the Multi-TLC curriculum permitted a greater breadth of direct observation and assessment across competencies, maintained the previous learning objectives while also addressing additional ones, and was done so in a way that reduced the overall financial and human resource costs associated with the department's obstetrical emergency simulation curriculum. A Multi-TLC organisation of simulation curricula can facilitate efficient application of competency-based education principles.

A Call to Investigate the Relationship Between Education and Health Outcomes Using Big Data.

There exists an assumption that improving medical education will improve patient care. While seemingly logical, this premise has rarely been investigated. In this Invited Commentary, the authors propose the use of big data to test this assumption. The authors present a few example research studies linking education and patient care outcomes and argue that using big data may more easily facilitate the process needed to investigate this assumption. The authors also propose that collaboration is needed to link educational and health care data. They then introduce a grassroots initiative, inclusive of universities in one Canadian province and national licensing organizations that are working together to collect, organize, link, and analyze big data to study the relationship between pedagogical approaches to medical training and patient care outcomes. While the authors acknowledge the possible challenges and issues associated with harnessing big data, they believe that the benefits supersede these. There is a need for medical education research to go beyond the outcomes of training to study practice and clinical outcomes as well. Without a coordinated effort to harness big data, policy makers, regulators, medical educators, and researchers are left with sometimes costly guesses and assumptions about what works and what does not. As the social, time, and financial investments in medical education continue to increase, it is imperative to understand the relationship between education and health outcomes.

The Application of Observational Practice and Educational Networking in Simulation-Based and Distributed Medical Education Contexts.

INTRODUCTION: Research has revealed that individuals can improve technical skill performance by viewing demonstrations modeled by either expert or novice performers. These findings support the development of video-based observational practice communities that augment simulation-based skill education and connect geographically distributed learners. This study explores the experimental replicability of the observational learning effect when demonstrations are sampled from a community of distributed learners and serves as a context for understanding learner experiences within this type of training protocol. METHODS: Participants from 3 distributed medical campuses engaged in a simulation-based learning study of the elliptical excision in which they completed a video-recorded performance before being assigned to 1 of 3 groups for a 2-week observational practice intervention. One group observed expert demonstrations, another observed novice demonstrations, and the third observed a combination of both. Participants returned for posttesting immediately and 1 month after the intervention. Participants also engaged in interviews regarding their perceptions of the usability and relevance of video-based observational practice to clinical education. RESULTS: Checklist (P < 0.0001) and global rating (P < 0.0001) measures indicate that participants, regardless of group assignment, improved after the intervention and after a 1-month retention period. Analyses revealed no significant differences between groups. Qualitative analyses indicate that participants perceived the observational practice platform to be usable, relevant, and potentially improved with enhanced feedback delivery. CONCLUSIONS: Video-based observational practice involving expert and/or novice demonstrations enhances simulation-based skill learning in a group of geographically distributed trainees. These findings support the use of Internet-mediated observational learning communities in distributed and simulation-based medical education contexts.

Admission factors associated with international medical graduate certification success: a collaborative retrospective review of postgraduate medical education programs in Ontario.

BACKGROUND: The failure rate on certification examinations of The College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) is significantly higher for international medical graduates than for Canadian medical school graduates. The purpose of the current study was to generate evidence that supports or refutes the validity of hypotheses proposed to explain the lower success rates. METHODS: We conducted retrospective analyses of admissions and certification data to determine the factors associated with success of international medical graduate residents on the certification examinations. International medical graduates who entered an Ontario residency program between 2005 and 2012 and had written a certification examination by the time of the analysis (2015) were included in the study. Data available at the time of admission for each resident, including demographic characteristics, previous experiences and previous professional experiences, were collected from each of the 6 Ontario medical schools and matched with certification examination results provided by The CFPC and the RCPSC. We developed logistic regression models to determine the association of each factor with success on the examinations. RESULTS: Data for 900 residents were analyzed. The models revealed resident age to be strongly associated with performance across all examinations. Fluency in English, female sex and the Human Development Index value associated with the country of medical school training had differential associations across the examinations. INTERPRETATION: The findings should contribute to an improved understanding of certification success by international medical graduates, help residency programs identify at-risk residents and underpin the development of specific educational and remedial interventions. In considering the results, it should be kept in mind that some variables are not amenable to changes in selection criteria.

An examination of Eyal & Hurst's (2008) framework for promoting retention in resource-poor settings through locally-relevant training: A case study for the University of Guyana Surgical Training Program.

BACKGROUND: Eyal and Hurst proposed that locally relevant medical education can offset the prevalence of physician "brain drain" in resource-poor regions of the world, and presented a framework of the ethical and pragmatic benefits and concerns posed by these initiatives. The present study explored the framework's utility through a case study of the University of Guyana Diploma in Surgery (UGDS) program. METHODS: The framework's utility was evaluated using a case study design that included review and analysis of documents and semi-structured interviews with graduates, trainees, faculty members, and policy makers associated with the UGDS program. Data were analyzed from constructivist and interpretivist perspectives, and compared against the benefits and concerns described by Eyal and Hurst. RESULTS: The framework is a useful template for capturing the breadth of experience of locally relevant training in the Guyanese setting. However, the results suggest that delineating the framework factors as either beneficial or concerning may constrict its applicability. The case study design also provided specific insights about the UGDS program, which indicate that the Program has promoted the retention of graduates and a sustainable culture of postgraduate medical education in Guyana. CONCLUSION: It is suggested that the framework be modified so as to represent the benefits and concerns of locally relevant training along a continuum of advantage. These approaches may help us understand retention within a resource-poor country, but also within particularly remote areas and public health care systems generally.

The art of medicine: arts-based training in observation and mindfulness for fostering the empathic response in medical residents.

Empathy is an essential attribute for medical professionals. Yet, evidence indicates that medical learners' empathy levels decline dramatically during medical school. Training in evidence-based observation and mindfulness has the potential to bolster the acquisition and demonstration of empathic behaviours for medical learners. In this prospective cohort study, we explore the impact of a course in arts-based visual literacy and mindfulness practice (Art of Seeing) on the empathic response of medical residents engaged in obstetrics and gynaecology and family medicine training. Following this multifaceted arts-based programme that integrates the facilitated viewing of art and dance, art-making, and mindfulness-based practices into a practitioner-patient context, 15 resident trainees completed the previously validated Interpersonal Reactivity Index, Compassion, and Mindfulness Scales. Fourteen participants also participated in semistructured interviews that probed their perceived impacts of the programme on their empathic clinical practice. The results indicated that programme participants improved in the Mindfulness Scale domains related to self-confidence and communication relative to a group of control participants following the arts-based programme. However, the majority of the psychometric measures did not reveal differences between groups over the duration of the programme. Importantly, thematic qualitative analysis of the interview data revealed that the programme had a positive impact on the participants' perceived empathy towards colleagues and patients and on the perception of personal and professional well-being. The study concludes that a multifaceted arts-based curriculum focusing on evidence-based observation and mindfulness is a useful tool in bolstering the empathic response, improving communication, and fostering professional well-being among medical residents.

The effect of modeled absolute timing variability and relative timing variability on observational learning.

There is much evidence to suggest that skill learning is enhanced by skill observation. Recent research on this phenomenon indicates a benefit of observing variable/erred demonstrations. In this study, we explore whether it is variability within the relative organization or absolute parameterization of a movement that facilitates skill learning through observation. To do so, participants were randomly allocated into groups that observed a model with no variability, absolute timing variability, relative timing variability, or variability in both absolute and relative timing. All participants performed a four-segment movement pattern with specific absolute and relative timing goals prior to and following the observational intervention, as well as in a 24h retention test and transfers tests that featured new relative and absolute timing goals. Absolute timing error indicated that all groups initially acquired the absolute timing, maintained their performance at 24h retention, and exhibited performance deterioration in both transfer tests. Relative timing error revealed that the observation of no variability and relative timing variability produced greater performance at the post-test, 24h retention and relative timing transfer tests, but for the no variability group, deteriorated at absolute timing transfer test. The results suggest that the learning of absolute timing following observation unfolds irrespective of model variability. However, the learning of relative timing benefits from holding the absolute features constant, while the observation of no variability partially fails in transfer. We suggest learning by observing no variability and variable/erred models unfolds via similar neural mechanisms, although the latter benefits from the additional coding of information pertaining to movements that require a correction.

Enhancing technical skill learning through interleaved mixed-model observational practice.

A broad foundation of behavioural (Hayes et al. in Exp Brain Res 204(2): 199-206, 2010) and neurophysiological (Kohler et al. in Science 297(5582): 846-848, 2002) evidence has revealed that the acquisition of psychomotor skills, including those germane to clinical practice (Domuracki et al. in Med Educ 49(2): 186-192, 2015), can be facilitated through observational practice. Interestingly, research also reveals that learning via observation is greatest when the learner has the opportunity to view both error-free expert demonstrations and flawed novice demonstrations (Rohbanfard and Proteau in Exp Brain Res 215: 183-197, 2011). In this study, we explored whether the learning that results from the combined viewing of experts and novices is greater when the demonstrations are presented under observation schedules characterized by higher levels of contextual interference. To do so, we engaged participants in an observational learning study of the Fundamentals of Laparoscopic Surgery pots-and-beans task: a simulated procedure in which performers must move objects under precision constraints in the minimal access surgery environment. Each participant was randomized to one of three groups that engaged in identical physical and mixed-model observational practice of this skill, with the only difference being that one group's observation was presented in blocked fashion (low interference) while the other two groups' observations were presented in semi-interleaved (medium interference) and interleaved (high interference) fashions. Total errors and time-to-complete measures taken during physical practice blocks revealed that all three groups improved over the intervention. Further analyses revealed that the low interference group performed better immediately following the physical and observational practice intervention, but that the medium- and high-interference groups were conveyed a performance advantage in a transfer test conducted after a period of retention that challenged participants to perform in the opposite direction. The results are discussed with respect to the classic contextual interference effect (Shea and Morgan in J Exp Psychol 5(2): 179-187, 1979) and with particular relevance to clinical skills education.

The multiple process model of goal-directed reaching revisited.

Recently our group forwarded a model of speed-accuracy relations in goal-directed reaching. A fundamental feature of our multiple process model was the distinction between two types of online regulation: impulse control and limb-target control. Impulse control begins during the initial stages of the movement trajectory and involves a comparison of actual limb velocity and direction to an internal representation of expectations about the limb trajectory. Limb-target control involves discrete error-reduction based on the relative positions of the limb and the target late in the movement. Our model also considers the role of eye movements, practice, energy optimization and strategic behavior in limb control. Here, we review recent work conducted to test specific aspects of our model. As well, we consider research not fully incorporated into our earlier contribution. We conclude that a slightly modified and expanded version of our model, that includes crosstalk between the two forms of online regulation, does an excellent job of explaining speed, accuracy, and energy optimization in goal-directed reaching.

The relationship between perceived preceptor power use and student empowerment during clerkship rotations: a study of hidden curriculum.

CONTEXT: Medical learners are vulnerable to the social power used by preceptors. Furthermore, an individual's perceived level of personal empowerment has been identified as a predictor of positive behaviour in education environments. The degree to which medical students feel empowered in their clinical environments factors largely into how vulnerable they are to having their professional values influenced negatively by structural and cultural aspects of these environments. OBJECTIVES: The goal of this study was to explore the relationship between clerks' perceptions of personal empowerment and the social power employed by their preceptors. This research also investigates the prevalence of negative power use as a function of the hierarchical organisation of a clerkship rotation. METHODS: Validated power use and empowerment surveys were modified for clinical learning environments and administered to clerkship learners across six clerkship rotations. The outcomes of the two surveys were subjected to correlational analyses. Outcomes associated with the use of each type of perceived power were analysed to determine the influence of the relative involvement of residents and staff physicians in preceptorship. RESULTS: Correlational analyses revealed strong relationships between clerks' perceptions of preceptor power use and their own personal empowerment. Furthermore, although participants perceived significantly more pro-social preceptor uses of power, clerks perceived a higher prevalence of coercive power on rotations with high involvement of residents as preceptors. CONCLUSIONS: Clerks' perceptions of empowerment correlate positively with positive power bases and negatively with negative dimensions of preceptor power. This research has implications for the importance of the development of resident and faculty staff as educators, the identification of clerks who are vulnerable to ethical violation, and for a refined understanding of the transactional way in which power is experienced in a medical education context.

OSCE circuit performance effects: Does circuit order influence scores?

It is not uncommon for medical students to raise concerns over the difficulty of a single station within an Objective Structured Clinical Examination (OSCE), particularly when they feel they were subject to an unfair situation. Indeed, test developers also share these concerns about the possibility that a single extremely difficult station may impact student performance on the station that follows. As a reaction to the concerns of both students and examiners, we conducted a study, analyzing the scores of multiple OSCEs. Although our analyses did not support the complaints of unfairness targeted at the OSCE, we feel it is a rather enlightening story nevertheless, and one worth sharing.

The impact of an arts-based programme on the affective and cognitive components of empathic development.

Medical education research demonstrates that empathic behaviour is amenable to positive change when targeted through educational programmes. This study evaluates the impact of an arts-based intervention designed to nurture learner empathy through the provision of facilitated visual literacy activities. Health Sciences students (N=19) were assigned to two learning groups: a group that participated in a visual literacy programme at the McMaster Museum of Art and a control group that participated in the normal Health Sciences curriculum. All participants completed an inter-reactivity index, which measures empathy on affective and cognitive levels, prior to and following the programme. Those individuals assigned to the visual literacy programme also completed open-ended questions concerning the programme's impact on their empathic development. The index scores were subjected to independent within-group, between-test analyses. There was no significant impact of the programme on the participants' overall empathic response. However, sub-component analyses revealed that the programme had a significant positive effect on cognitive aspects of empathy. This finding was substantiated by the narrative reports. The study concludes that the affective focus of humanities-based education needs to be enhanced and recommends that learners are educated on the different components that comprise the overall empathic response.

The impacts of observing flawed and flawless demonstrations on clinical skill learning.

OBJECTIVES: Clinical skills expertise can be advanced through accessible and cost-effective video-based observational practice activities. Previous findings suggest that the observation of performances of skills that include flaws can be beneficial to trainees. Observing the scope of variability within a skilled movement allows learners to develop strategies to manage the potential for and consequences associated with errors. This study tests this observational learning approach on the development of the skills of central line insertion (CLI). METHODS: Medical trainees with no CLI experience (n = 39) were randomised to three observational practice groups: a group which viewed and assessed videos of an expert performing a CLI without any errors (F); a group which viewed and assessed videos that contained a mix of flawless and errorful performances (E), and a group which viewed the same videos as the E group but were also given information concerning the correctness of their assessments (FA). All participants interacted with their observational videos each day for 4 days. Following this period, participants returned to the laboratory and performed a simulation-based insertion, which was assessed using a standard checklist and a global rating scale for the skill. These ratings served as the dependent measures for analysis. RESULTS: The checklist analysis revealed no differences between observational learning groups (grand mean ± standard error: [20.3 ± 0.7]/25). However, the global rating analysis revealed a main effect of group (d.f.2,36 = 4.51, p = 0.018), which describes better CLI performance in the FA group, compared with the F and E groups. CONCLUSIONS: Observational practice that includes errors improves the global performance aspects of clinical skill learning as long as learners are given confirmation that what they are observing is errorful. These findings provide a refined perspective on the optimal organisation of skill education programmes that combine physical and observational practice activities.

Family medicine residents' practice intentions: Theory of planned behaviour evaluation.

OBJECTIVE: To assess residents' practice intentions since the introduction of the College of Family Physicians of Canada's Triple C curriculum, which focuses on graduating family physicians who will provide comprehensive care within traditional and newer models of family practice. DESIGN: A survey based on Ajzen's theory of planned behaviour was administered on 2 occasions. SETTING: McMaster University in Hamilton, Ont. PARTICIPANTS: Residents (n = 135) who were enrolled in the Department of Family Medicine Postgraduate Residency Program at McMaster University in July 2012 and July 2013; 54 of the 60 first-year residents who completed the survey in 2012 completed it again in 2013. MAIN OUTCOME MEASURES: The survey was modeled so as to measure the respondents' intentions to practise with a comprehensive scope; determine the degree to which their attitudes, subjective norms, and perceptions of control about comprehensive practice influence those intentions; and investigate how these relationships change as residents progress through the curriculum. The survey also queried the respondents about their intentions with respect to particular medical services that underpin comprehensive practice. RESULTS: The responses indicate that the factors modeled by the theory of planned behaviour survey account for 60% of the variance in the residents' intentions to adopt a comprehensive scope of practice upon graduation, that there is room for curricular improvement with respect to encouraging residents to practise comprehensive care, and that targeting subjective norms about comprehensive practice might have the greatest influence on improving resident intentions. CONCLUSION: The theory of planned behaviour presents an effective approach to assessing curricular effects on resident practice intentions while also providing meaningful information for guiding further program evaluation efforts in the Department of Family Medicine at McMaster University.

Predicting international medical graduate success on college certification examinations: responding to the Thomson and Cohl judicial report on IMG selection.

OBJECTIVE: To determine predictors of international medical graduate (IMG) success in accordance with the priorities highlighted by the Thomson and Cohl judicial report on IMG selection. DESIGN: Retrospective assessment using regression analyses to compare the information available at the time of resident selection with those trainees' national certification examination outcomes. SETTING: McMaster University in Hamilton, Ont. PARTICIPANTS: McMaster University IMG residents who completed the program between 2005 and 2011. MAIN OUTCOME MEASURES: Associations between IMG professional experience or demographic characteristics and examination outcomes. RESULTS: The analyses revealed that country of study and performance on the Medical Council of Canada Evaluating Examination are among the predictors of performance on the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada certification examinations. Of interest, the analyses also suggest discipline-specific relationships between previous professional experience and examination success. CONCLUSION: This work presents a useful technique for further improving our understanding of the performance of IMGs on certification examinations in North America, encourages similar interinstitutional analyses, and provides a foundation for the development of tools to assist with IMG education.

The influence of visual feedback and prior knowledge about feedback on vertical aiming strategies.

Two experiments were conducted to examine time and energy optimization strategies for movements made with and against gravity. In Experiment 1, the authors manipulated concurrent visual feedback, and knowledge about feedback. When vision was eliminated upon movement initiation, participants exhibited greater undershooting, both with their primary submovement and their final endpoint, than when vision was available. When aiming downward, participants were more likely to terminate their aiming following the primary submovement or complete a lower amplitude corrective submovement. This strategy reduced the frequency of energy-consuming corrections against gravity. In Experiment 2, the authors eliminated vision of the hand and the target at the end of the movement. This procedure was expected to have its greatest impact under no-vision conditions where no visual feedback was available for subsequent planning. As anticipated, direction and concurrent visual feedback had a profound impact on endpoint bias. Participants exhibited pronounced undershooting when aiming downward and without vision. Differences in undershooting between vision and no vision were greater under blocked feedback conditions. When performers were uncertain about the impending feedback, they planned their movements for the worst-case scenario. Thus movement planning considers the variability in execution, and avoids outcomes that require time and energy to correct.

Information processing, specificity of practice, and the transfer of learning: considerations for reconsidering fidelity.

Much has been made in the recent medical education literature of the incorrect characterization of simulation along a continuum of low to high fidelity (Cook et al. JAMA 306(9): 978-988, 2011; Norman et al. Med Educ 46(7): 636-647, 2012; Teteris et al. Adv Health Sci Educ 17(1): 137-144, 2012). For the most part, the common definition within the medical education community has been that simulations that present highly realistic performance characteristics, contexts, and scenarios are referred to as high-fidelity, while simulations that reduce to-be-learned skills to simpler constructs or constituent parts are referred to as low-fidelity. The issue with this is that highly-realistic has tended to mean the degree to which the simulation looks like the criterion context with little regard for what features of the simulation are in fact relevant to the skill that the educator hopes to teach. The inherent assumption that high fidelity simulations lead to better learning-an assumption for which there is a lack of supporting evidence (Norman et al. Med Educ 46(7): 636-647, 2012)-only exacerbates the problem. So much so that some have suggested that the term be abandoned all together (Hamstra et al. Acad Med J Assoc Am Med Coll 2014). While, it is true that fidelity and its importance are misconstrued in the medical education literature, the construct, defined classically as the degree of faithfulness that exists between two entities, is still fundamental to understanding the effectiveness that any one simulation might have in preparing learners for clinical performance. However, the concept of simulation fidelity must be recast in terms of the fundamental information processing events that underpin human performance.