A multisite randomized trial of implicit versus explicit modeling in clinical teaching.

PURPOSE: Faculty modeling of desired behaviors has historically been a part of the apprenticeship model of clinical teaching, yet little is known about best practices for modeling. This study compared the educational impact of implicitly versus explicitly modeled communication skills among U.S. medical students. METHOD: Fourth-year medical students from six U.S. academic medical centers were randomly assigned one simulated clinical encounter in which faculty provided either implicit or explicit modeling of important communication skills. Outcomes were assessed by electronic surveys immediately before and after the simulations. Students were blinded to the purpose of the study. RESULTS: Students in the explicit arm were more likely to correctly cite two of the three key specific communication elements modeled by faculty: deliberate body position (53.3% vs. 18.6%, p < 0.001) and summarizing patient understanding (62.2% vs. 11.6%, p < 0.001). More students in the explicit study arm reported faculty 'demonstrated a key behavior that they wanted me to be able to perform in the future' (93.2% versus 62.8%, p = 0.002). Participating faculty stated they would modify their teaching approach in response to their experiences in the study. CONCLUSIONS: In a multi-center randomized trial, explicit faculty role-modeling led to greater uptake of communication knowledge, greater recognition of skills, and a greater sense that faculty expected these skills to be adopted by students. These results must be considered in the context, however, of a simulated environment and a short timeframe for assessing learning with students who volunteered for a simulated experience.

Scheduled Intravenous Acetaminophen Improves Patient Satisfaction With Postcraniotomy Pain Management: A Prospective, Randomized, Placebo-controlled, Double-blind Study.

BACKGROUND: Postcraniotomy pain can be difficult to manage with opioids due to opioid-related side effects, including drowsiness, nausea/vomiting, confusion, and pupillary changes, potentially masking the signs of postoperative neurological deterioration. Intravenous (IV) acetaminophen, a nonopioid analgesic, has been reported to have opioid-sparing effects after abdominal and orthopedic surgeries. This study investigates whether IV acetaminophen has similar effects after craniotomy. MATERIALS AND METHODS: In this prospective, randomized, placebo-controlled, double-blind clinical trial, 100 adult patients scheduled to undergo supratentorial craniotomy for excision of a brain mass were randomized to receive either IV acetaminophen or placebo preincision and then every 6 hours for a total of 24 hours after surgery. Total 24-hour opioid consumption, pain scores, satisfaction with overall pain management, time to meet postanesthesia care unit discharge criteria, and incidence of opioid-related side effects were compared. RESULTS: There was no difference in the 24-hour postoperative opioid consumption in morphine equivalents between the IV acetaminophen group (median, 11 mg; n=45) and the placebo group (median, 10.1 mg; n=41). No statistically significant difference of visual analog scale pain score was observed between 2 treatment groups. Patient satisfaction with overall postoperative pain management was significantly higher in the IV acetaminophen group than the placebo group on a 1 to 10 scale (8.1±0.4 vs. 6.9±0.4; P=0.03). There was no significant difference in secondary outcomes, including the incidence of opioid-related side effects. CONCLUSIONS: IV acetaminophen, as adjunctive therapy for craniotomy procedures, did not show an opioid-sparing effect in patients for the 24 hours after craniotomy; however, it was associated with improved patient satisfaction regarding overall pain control.

Flexible optical intubation via the Ambu Aura-i vs blind intubation via the single-use LMA Fastrach: a prospective randomized clinical trial.

STUDY OBJECTIVE: This study was designed to compare the Ambu Aura-i to the single-use LMA Fastrach regarding time to intubation, success rate, and airway morbidity in patients undergoing elective surgery requiring general anesthesia. DESIGN: Prospective, randomized controlled trial. SETTING: Academic medical center. PATIENTS: Sixty-five adult patients scheduled for elective surgery requiring general anesthesia. INTERVENTIONS: Patients were randomized into 2 groups. Group A (n=33) were intubated using Ambu Aura-i and the Ambu aScope 2, a disposable flexible intubating scope, whereas those in group B (n=33) were blindly intubated using the Intubating Laryngeal Mask Airway (ILMA). MEASUREMENTS: First-attempt intubation success rate, overall intubation success rate, time to intubation, incidence of airway morbidity. MAIN RESULTS: The data demonstrated that time for endotracheal intubation in the ILMA group was significantly shorter than in the Ambu Aura-i group (P<.05). There was no difference in the first-attempt intubation success rate (Aura-i=26/33, 78.8%; ILMA=27/33, 81.8%; P=.757) or the overall intubation success rate (Aura-i=29/33, 87.9%; ILMA=31/33, 93.9%; P=.392) between the groups. Four patients (12%) in the Ambu Aura-i group had a failed intubation; 1 was due to a failure of the aScope monitor, whereas 3 were due to inability to visualize the glottis. Two patients (7%) in the ILMA group had a failed intubation due to esophageal intubation. There was no statistically significant difference in airway morbidity between the 2 groups. CONCLUSIONS: The data suggest that intubation with the ILMA is faster but that first-attempt and overall intubation success rates were comparable in both groups. The results suggest that although the flexible intubating scope-guided Aura-i does not outperform blind intubation via the ILMA, the technique is comparable in terms of first-attempt and overall intubation success rate.

Reliability of a faculty evaluated scoring system for anesthesiology resident applicants (Original Investigation).

STUDY OBJECTIVE: To assess reliability and reproducibility of a recently instituted anesthesiology resident applicant interview scoring system at our own institution. DESIGN: Retrospective evaluation of 2 years of interview data with a newly implemented scoring system using randomly assigned interviewing faculty. SETTING: Interview scoring evaluations were completed as standard practice in a large academic anesthesiology department. SUBJECTS: All anesthesiology resident applicants interviewed over the 2013/14 and 2014/15 seasons by a stable cohort of faculty interviewers. Data collection blinded for both interviewers and interviewees. INTERVENTIONS: None for purposes of study - collation of blinded data already used as standard practice during interview process and analysis. MEASUREMENTS: None specific to study. MAIN RESULTS: Good inter-rater faculty reliability of interview scoring (day-of) and excellent inter-faculty reliability of application review (pre-interview). CONCLUSIONS: Development of a department-specific interview scoring system including many elements beyond traditional standardized tests shows good-excellent reliability of faculty scoring of both the interview itself (including non-technical skills) and the application resume.

Endotrol-tracheal tube assisted endotracheal intubation during video laryngoscopy.

Video laryngoscopes allow indirect visualization of the glottis and provide superior views of the glottis compared to direct laryngoscopes in patients with both normal and difficult airways, but it may be difficult to advance the endotracheal tube (ETT) through the vocal cords into the trachea, unless a stylet is used. We propose that the Endotrol(®) ETT may be an effective tool to facilitate video laryngoscope-assisted orotracheal intubation without the use of a stylet. After obtaining written and oral informed consent, 60-adult patients scheduled for elective surgery requiring general anesthesia with orotracheal intubation were enrolled. Patients were randomized, respectively, to 1 of 4 groups: Group A(1), (15 patients): McGrath(®) with Endotrol(®) ETT; Group A(2), (15 patients): McGrath(®) with GlideRite(®)-styletted standard ETT; Group B(1), (15 patients): GlideScope(®) with Endotrol(®) ETT; Group B(2), (15 patients): GlideScope(®) with GlideRite(®)-styletted standard ETT. Statistical analysis was performed with Stata (Stata Corp v10, College Station). Mean time to intubation was longer in the Endotrol(®) groups compared to the GlideRite(®) groups: 60.1 (31.6) vs. 44.4 (27.6) s (p < 0.05). It was subjectively more difficult to intubate using the Endotrol(®) than with a GlideRite(®)-styletted ETT (difficulty score median [range] 2 [1-5] vs. 1 [1-3], respectively). Three intubations using the Endotrol(®) were characterized as difficult, whereas there were no difficult intubations with the GlideRite(®)stylet. The Endotrol(®) ETT, as compared to a standard ETT with a non-malleable stylet, is associated with longer intubation times and a subjective increase in difficulty of use. It may, however, still be a clinically viable alternative in video laryngoscope-assisted orotracheal intubation when use of a rigid stylet is undesirable.