Learning Curves for Training in Ultrasonography-Based Examination of Umbilical Catheter Placement: A Piglet Study.

BACKGROUND: The training required for accurate assessment of umbilical catheter placement by ultrasonography (US) is unknown. OBJECTIVE: To describe the learning curve and provide an estimate of the accuracy of physicians' US examinations (US skills) and self-confidence when examining umbilical catheter tip placement. METHODS: Twenty-one physicians with minimal experience in US completed a 1.5-hour eLearning module. Ten piglets with catheters inserted in the umbilical vessels were used as training objects. Following eLearning each physician performed up to twelve 10-min US examinations of the piglets. Expert examinations were reference standards. Sensitivity and specificity of physicians' skills in detecting catheter tip placement by US was used to describe the learning curve. Self-confidence was reported by Likert scale after each examination. RESULTS: Physicians' detection of a correctly placed and misplaced umbilical artery catheter tip increased by an odds ratio of 1.6 (95% CI: 1.1, 2.3) and 3.6 (95% CI: 1.7, 7.8) per examination performed. A sensitivity of 0.97 (95% CI: 0.80, 0.99) and specificity of 0.95 (95% CI: 0.84, 0.99) was reached after 6 examinations. For the venous catheter, US skills in detecting a misplaced catheter tip increased with an odds ratio of 2.4 (95% CI: 1.2, 4.8) per US examination. Overall, performance and self-confidence plateaus were reached after 6 examinations. CONCLUSION: We found steep learning curves for targeted US examination of umbilical catheter placement. eLearning followed by 6 examinations was found to be adequate training to perform with a sufficiently high accuracy and self-confidence to allow for point-of-care use.

Distributed practice. The more the merrier? A randomised bronchoscopy simulation study.

INTRODUCTION: The distribution of practice affects the acquisition of skills. Distributed practice has shown to be more effective for skills acquisition than massed training. However, it remains unknown as to which is the most effective distributed practice schedule for learning bronchoscopy skills through simulation training. This study compares two distributed practice schedules: One-day distributed practice and weekly distributed practice. METHOD: Twenty physicians in training were randomly assigned to one-day distributed or weekly distributed bronchoscopy simulation practice. Performance was assessed with a pre-test, a post-test after each practice session, and a 4-week retention test using previously validated simulator measures. Data were analysed with repeated measures ANOVA. RESULTS: No interaction was found between group and test (F(4,72) <1.68, p>0.16), except for the measure 'percent-segments-entered', and no main effect of group was found for any of the measures (F(1,72)< 0.87, p>0.36), which indicates that there was no difference between the learning curves of the one-day distributed practice schedule and the weekly distributed practice schedule. DISCUSSION: We found no difference in effectiveness of bronchoscopy skills acquisition between the one-day distributed practice and the weekly distributed practice. This finding suggests that the choice of bronchoscopy training practice may be guided by what best suits the clinical practice.

The validity of student tutors' judgments in early detection of struggling in medical school. A prospective cohort study.

Early identification and support of strugglers in medical education is generally recommended in the research literature, though very little evidence of the diagnostic qualities of early teacher judgments in medical education currently exists. The aim of this study was to examine the validity of early diagnosis of struggling in medical school based on informal teacher judgements of in-class behavior. The study design was a prospective cohort study and the outcomes/truth criteria were anatomy failure and medical school drop out. Six weeks into an anatomy course, student tutors attempted to identify medical students, who they reckoned would fail the anatomy course or drop out, based on their everyday experiences with students in a large group educational setting. In addition, they were asked to describe the indicators of struggling they observed. Sixteen student tutors evaluated 429 medical students for signs of struggling. By week six, the student tutors were able to detect approximately 1/4-1/3 of the students who eventually failed or dropped out, and for ¾ of the strugglers they identified, they were correct in their judgments. Informal student tutor's judgements showed incremental validity for both outcomes when controlling for grades obtained in preceeding exams. Lack of participation, lack of commitment, poor academic performance, poor social interactions and general signs of distress were the main indicators of struggling identified. Teachers' informal judgements of in-class behavior may be an untapped source of information in the early identification of struggling medical students with added value above and beyond formal testing.

Dyad practice is efficient practice: a randomised bronchoscopy simulation study.

CONTEXT: Medical simulation training requires effective and efficient training strategies. Dyad practice may be a training strategy worth pursuing because it has been proven effective and efficient in motor skills learning. In dyad practice two participants collaborate in learning a task they will eventually perform individually. In order to explore the effects of dyad practice in a medical simulation setting, this study examined the effectiveness and efficiency of dyad practice compared with individual practice in the learning of bronchoscopy through simulation-based training. METHODS: A total of 36 students of medicine were randomly assigned to either individual practice or dyad practice. The training setting included video-based instruction, 10 bronchoscopy simulator cases and instructor feedback. Participants in the dyad practice group alternated between physical and observational practice and hence physically undertook only half of the training cases undertaken by participants who practised individually. Pre-, post- and delayed (3 weeks) retention tests were used to assess skills according to previously validated simulator measures. Data were analysed using repeated-measures analysis of variance (anova) on each dependent measure. RESULTS: A significant main effect of test was found for all measures (F2,67  > 23.32, p < 0.001), indicating improvement in performance from pre-tests to post-tests and retention tests. No interaction was found between test and group (F2,67  < 0.26, p > 0.49), indicating parallel learning curves. Most importantly, no main effect of group was found for any of the measures, indicating no difference between learning curves (F1,34  = 2.08, p < 0.16). CONCLUSIONS: Individual practice and dyad practice did not differ in their effectiveness for the acquisition of bronchoscopy skills through supervised simulation training. However, dyad practice proved more efficient than individual practice because two participants practising in dyads learned as much as one participant practising individually but required the same instructor resources and training time as the single learner.

Time matters--realism in resuscitation training.

BACKGROUND: The advanced life support guidelines recommend 2min of cardiopulmonary resuscitation (CPR) and minimal hands-off time to ensure sufficient cardiac and cerebral perfusion. We have observed doctors who shorten the CPR intervals during resuscitation attempts. During simulation-based resuscitation training, the recommended 2-min CPR cycles are often deliberately decreased in order to increase the number of scenarios. The aim of this study was to test if keeping 2-min CPR cycles during resuscitation training ensures better adherence to time during resuscitation in a simulated setting. METHODS: This study was designed as a randomised control trial. Fifty-four 4th-year medical students with no prior advanced resuscitation training participated in an extra-curricular one-day advanced life support course. Participants were either randomised to simulation-based training using real-time (120s) or shortened CPR cycles (30-45s instead of 120s) in the scenarios. Adherence to time was measured using the European Resuscitation Council's Cardiac Arrest Simulation Test (CASTest) in retention tests conducted one and 12 weeks after the course. RESULTS: The real-time group adhered significantly better to the recommended 2-min CPR cycles (time-120s) (mean 13; standard derivation (SD) 8) than the shortened CPR cycle group (mean 45; SD 19) when tested (p<0.001.) CONCLUSION: This study indicates that time is an important part of fidelity. Variables critical for performance, like adherence to time in resuscitation, should therefore be kept realistic during training to optimise outcome.

Effects of modelling examples in complex procedural skills training: a randomised study.

CONTEXT: Learning complex procedural skills, such as bronchoscopy, through simulation training, imposes a high cognitive load on novices. Example-based learning has been shown to be an effective way to reduce cognitive load and enhance learning outcomes. Prior research has shown that modelling examples, in which a human model demonstrates the skill to a learner, were effective for learning basic surgical skills. However, principles derived from simple skills training do not necessarily generalise to more complex skills. Therefore, the present study examined the effectiveness of integrating modelling examples into simulation training for a more complex procedural skill - bronchoscopy. Moreover, this study extended previous simulation studies by using a physical demonstration rather than video-based modelling examples. METHODS: Forty-eight medical students were randomised into a modelling group and a control group. They all practised on eight bronchoscopy simulation cases individually, followed by standardised feedback from an instructor. Additionally, the modelling group watched three modelling examples of the simulated bronchoscopy, performed by the instructor. These modelling examples were interspersed between cases. Assessments were carried out at pre-, post- and 3-week retention tests with simulator-measured performance metrics. The primary outcome measure was the percentage of segments entered/minute. Other measures were wall collisions, red-out, the percentage of segments entered and the time to completion. Group differences were examined using repeated measures analysis of variance (anova). RESULTS: A clear learning curve was observed for both groups, but as hypothesised, the modelling group outperformed the control group on all parameters except the percentage of segments entered on the post-test and retained this superiority at the retention test. For the primary outcome measure, the percentage of segments entered/minute, the modelling group achieved a 46% higher score at the post-test and a 43% higher score at the retention test. CONCLUSIONS: The present study shows, that integrating modelling examples into the curriculum of bronchoscopy simulation training optimises the role of the instructor and enhances novices' learning outcomes, presumably by optimising cognitive load during training.

[The CanMEDS' professional role is complex and needs redefinition in Denmark]. / Speciallægeuddannelsens rolle som professionel er kompleks og bør omdefineres.

The CanMEDS roles were adapted in Denmark more than ten years ago. The complexity of the professional role is discussed from various aspects and put into perspective of the Danish culture and the Danish ethical rules for medical doctors. Redefinition of the role professional according to these aspects is recommended.

Objective structured assessment of technical competence in transthoracic echocardiography: a validity study in a standardised setting.

BACKGROUND: Competence in transthoracic echocardiography (TTE) is unrelated to traditional measures of TTE competence, such as duration of training and number of examinations performed. This study aims to explore aspects of validity of an instrument for structured assessment of echocardiographic technical skills. METHODS: The study included 45 physicians with three different clinical levels of echocardiography competence who all scanned the same healthy male following national guidelines. An expert in echocardiography (OG) evaluated all the recorded, de-identified TTE images blindly using the developed instrument for assessment of TTE technical skills. The instrument consisted of both a global rating scale and a procedure specific checklist. Two scores were calculated for each examination: A global rating score and a total checklist score. OG rated ten examinations twice for intra-rater reliability, and another expert rated the same ten examinations for inter-rater reliability. A small pilot study was then performed with focus on content validity. This pilot study included nine physicians who scanned three patients with different pathologies as well as different technical difficulties. RESULTS: Validity of the TTE technical skills assessment instrument was supported by a significant correlation found between level of expertise and both the global score (Spearman 0.76, p<0.0001) and the checklist score (Spearman 0.74, p<0.001). Both scores were able to distinguish between the three levels of competence that were represented in the physician group. Reliability was supported by acceptable inter- and intra-rater values. The pilot study showed a tendency to improved scores with increasing expertise levels, suggesting that the instrument could also be used when pathologies were present. CONCLUSIONS: We designed and developed a structured assessment instrument of echocardiographic technical skills that showed evidence of validity in terms of high correlations between test scores on a normal person and the level of physician competence, as well as acceptable inter- and intra-rater reliability scores. Further studies should, however, be performed to determine the adequate number of assessments needed to ensure high content validity and reliability in a clinical setting.

Young doctors' problem solving strategies on call may be improved.

INTRODUCTION: The first year following graduation from medical school is challenging as learning from books changes to workplace-based learning. Analysis and reflection on experience may ease this transition. We used Significant Event Analysis (SEA) as a tool to explore what pre-registration house officers (PRHOs) consider successful and problematic events, and to identify what problem-solving strategies they employ. MATERIAL AND METHODS: A senior house officer systematically led the PRHO through the SEA of one successful and one problematic event following a night call. The PRHO wrote answers to questions about diagnosis, what happened, how he or she contributed and what knowledge-gaining activities the PRHO would prioritise before the next call. RESULTS: By using an inductive, thematic data analysis, we identified five problem-solving strategies: non-analytical reasoning, analytical reasoning, communication with patients, communication with colleagues and professional behaviour. On average, 1.5 strategies were used in the successful events and 1.2 strategies in the problematic events. Most PRHOs were unable to suggest activities other than reading textbooks. CONCLUSION: SEA was valuable for the identification of PRHOs' problem-solving strategies in a natural setting. PRHOs should be assisted in increasing their repertoire of strategies, and they should also be helped to "learn to learn" as they were largely unable to point to new learning strategies. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Outcome (competency) based education: an exploration of its origins, theoretical basis, and empirical evidence.

Outcome based or competency based education (OBE) is so firmly established in undergraduate medical education that it might not seem necessary to ask why it was included in recommendations for the future, like the Flexner centenary report. Uncritical acceptance may not, however, deliver its greatest benefits. Our aim was to explore the underpinnings of OBE: its historical origins, theoretical basis, and empirical evidence of its effects in order to answer the question: How can predetermined learning outcomes influence undergraduate medical education? This literature review had three components: A review of historical landmarks in the evolution of OBE; a review of conceptual frameworks and theories; and a systematic review of empirical publications from 1999 to 2010 that reported data concerning the effects of learning outcomes on undergraduate medical education. OBE had its origins in behaviourist theories of learning. It is tightly linked to the assessment and regulation of proficiency, but less clearly linked to teaching and learning activities. Over time, there have been cycles of advocacy for, then criticism of, OBE. A recurring critique concerns the place of complex personal and professional attributes as "competencies". OBE has been adopted by consensus in the face of weak empirical evidence. OBE, which has been advocated for over 50 years, can contribute usefully to defining requisite knowledge and skills, and blueprinting assessments. Its applicability to more complex aspects of clinical performance is not clear. OBE, we conclude, provides a valuable approach to some, but not all, important aspects of undergraduate medical education.

Emotions in veterinary surgical students: a qualitative study.

A surgical educational environment is potentially stressful and can negatively affect students' learning. The aim of the present study was to investigate the emotions experienced by veterinary students in relation to their first encounter with live-animal surgery and to identify possible sources of positive and negative emotions, respectively. During a Basic Surgical Skills course, 155 veterinary fourth-year students completed a survey. Of these, 26 students additionally participated in individual semi-structured interviews. The results of the study show that students often experienced a combination of emotions; 63% of students experienced negative emotions, while 58% experienced positive ones. In addition, 61% of students reported feeling excited or tense. Students' statements reveal that anxiety is perceived as counterproductive to learning, while excitement seems to enhance students' focus and engagement. Our study identified the most common sources of positive and negative emotions to be "being able to prepare well" and "lack of self-confidence," respectively. Our findings suggest that there are factors that we can influence in the surgical learning environment to minimize negative emotions and enhance positive emotions and engagement, thereby improving students' learning.

Anxiety in veterinary surgical students: a quantitative study.

The surgical educational environment is potentially stressful and this can negatively affect students' learning. The aim of this study was to investigate whether veterinary students' level of anxiety is higher in a surgical course than in a non-surgical course and if pre-surgical training in a Surgical Skills Lab (SSL) has an anxiety reducing effect. Investigations were carried out as a comparative study and a parallel group study. Potential participants were fourth-year veterinary students who attended a surgical course (Basic Surgical Skills) and a non-surgical course (Clinical Examination Skills); both courses were offered in multiple classes (with a total of 171 students in 2009 and 156 students in 2010). All classes in 2009 participated in the SSL stage of the Basic Surgical Skills course before performing live-animal surgery, and one class (28 students) in 2010 did not. Two validated anxiety questionnaires (Spielberger's state-trait anxiety inventory and Cox and Kenardy's performance anxiety questionnaire) were used. Anxiety levels were measured before the non-surgical course (111 students from 2009) and before live-animal surgery during the surgical course (153 students from 2009 and 28 students from 2010). Our results show that anxiety levels in veterinary students are significantly higher in a surgical course than in a non-surgical course (p<.001), and that practicing in a SSL helps reduce anxiety before live-animal surgery (p<.005).

Selected determinants may account for dropout risks among medical students.

INTRODUCTION: The dropout level from the Danish medical schools is high, but we have only little insight into this problem. The purpose of this study was to qualify the ongoing discussions concerning dropout. MATERIAL AND METHODS: In this retrospective cohort study, relevant variables were extracted from the established database of Aarhus University for the 639 students initiating medicine studies between 1 January 1999 and 31 December 2000. A multivariate pre-admission and post-admission model was examined. RESULTS: Of the 639 medical students, 20% dropped out. Most students dropped out during their first year. The type of admission exam was a strong predictor of dropout in the pre-admission model, whereas previous higher education protected against dropout. Obtaining leave was a very strong predictor of dropout in the post-admission model, whereas high grades protected against dropout. CONCLUSION: The dropout rate has been decreasing during the past decade. Young people considering studying medicine could be advised to choose natural science subjects in high school, and a number of research questions concerning preparedness for medical school are worth pursuing. Leave or very low grades during the first and second study years might serve as red flags to supervisors. FUNDING: Study research was funded by Aarhus University. TRIAL REGISTRATION: Not relevant, register-based research with no biological human material cannot be notified to the Danish Committee System. The Danish Data Protection Agency allows schools to conduct anonymized, non-sensitive, educational analyses without notification.

Limited intervention improves technical skill in focus assessed transthoracic echocardiography among novice examiners.

BACKGROUND: Previous studies addressing teaching and learning in point-of-care ultrasound have primarily focussed on image interpretation and not on the technical quality of the images. We hypothesized that a limited intervention of 10 supervised examinations would improve the technical skills in Focus Assessed Transthoracic Echocardiography (FATE) and that physicians with no experience in FATE would quickly adopt technical skills allowing for image quality suitable for interpretation. METHODS: Twenty-one physicians with no previous training in FATE or echocardiography (Novices) participated in the study and a reference group of three examiners with more than 10 years of experience in echocardiography (Experts) was included. Novices received an initial theoretical and practical introduction (2 hours), after which baseline examinations were performed on two healthy volunteers. Subsequently all physicians were scheduled to a separate intervention day comprising ten supervised FATE examinations. For effect measurement a second examination (evaluation) of the same two healthy volunteers from the baseline examination was performed. RESULTS: At baseline 86% of images obtained by novices were suitable for interpretation, on evaluation this was 93% (p = 0.005). 100% of images obtained by experts were suitable for interpretation. Mean global image rating on baseline examinations was 70.2 (CI 68.0-72.4) and mean global image rating after intervention was 75.0 (CI 72.9-77.0), p = 0.0002. In comparison, mean global image rating in the expert group was 89.8 (CI 88.8-90.9). CONCLUSIONS: Improvement of technical skills in FATE can be achieved with a limited intervention and upon completion of intervention 93% of images achieved are suitable for clinical interpretation.

[Admission tests for medical education]. / Optagelsesprøver på medicinstudiet.

This state of the art article explores what is known from the international and Danish literature on admission criteria as predictors of success in medical education. Previous academic performance is the best known predictor of medical students' grades. Poorer entry qualifications, broadly defined, are associated with dropout in medical education. Admission interviews may have a small additive explanatory effect on medical students' grades, but the effect on dropout has barely been investigated. Admission interviews are a challenge for the feasibility, reliability and validity of medical student selection. Admission variables in use should be supported by predictive validity.

Visual expertise in paediatric neurology.

BACKGROUND: Visual expertise relies on perceptive as well as cognitive processes. At present, knowledge of these processes when diagnosing clinical cases mainly stems from studies with still pictures. In contrast, patient video cases constitute a dynamic diagnostic challenge that may simulate seeing and diagnosing a patient in person. AIMS: This study investigates visual attention and the concomitant cognitive processes of clinicians diagnosing authentic paediatric video cases. METHODS: A total of 43 clinicians with varying levels of expertise took part in this cross-sectional study. They diagnosed four brief video recordings of children: two with seizures and two with disorders imitating seizures. We used eye tracking to investigate time looking at relevant areas in the video cases and a concurrent think-aloud procedure to explore the associated clinical reasoning processes. RESULTS: More experienced clinicians were more accurate in visual diagnosis and spent more of their time looking at relevant areas. At the same time, they explored data less, yet they built and evaluated more diagnostic hypotheses. CONCLUSIONS: Clinicians of varying expertise analyse patient video cases differently. Clinical teachers should take these differences into account when optimising educational formats with patient video cases.

The relationship between immediate relevant basic science knowledge and clinical knowledge: physiology knowledge and transthoracic echocardiography image interpretation.

Two major views on the relationship between basic science knowledge and clinical knowledge stand out; the Two-world view seeing basic science and clinical science as two separate knowledge bases and the encapsulated knowledge view stating that basic science knowledge plays an overt role being encapsulated in the clinical knowledge. However, resent research has implied that a more complex relationship between the two knowledge bases exists. In this study, we explore the relationship between immediate relevant basic science (physiology) and clinical knowledge within a specific domain of medicine (echocardiography). Twenty eight medical students in their 3rd year and 45 physicians (15 interns, 15 cardiology residents and 15 cardiology consultants) took a multiple-choice test of physiology knowledge. The physicians also viewed images of a transthoracic echocardiography (TTE) examination and completed a checklist of possible pathologies found. A total score for each participant was calculated for the physiology test, and for all physicians also for the TTE checklist. Consultants scored significantly higher on the physiology test than did medical students and interns. A significant correlation between physiology test scores and TTE checklist scores was found for the cardiology residents only. Basic science knowledge of immediate relevance for daily clinical work expands with increased work experience within a specific domain. Consultants showed no relationship between physiology knowledge and TTE interpretation indicating that experts do not use basic science knowledge in routine daily practice, but knowledge of immediate relevance remains ready for use.

Medical graduates feel well-prepared for clinical work.

INTRODUCTION: The purpose of this study was to assess the coherence between the undergraduate medical program at Aarhus University and the foundation year. MATERIAL AND METHODS: This cross-sectional questionnaire survey included 503 doctors graduated from Aarhus University from the winter of 2007/2008 to the summer of 2009. RESULTS: The response rate was 73%. Approximately 73% of the respondents were in their foundation year or their first year of specialist training and 83% generally felt well-prepared. Respondents found that most of the learning outcomes of the undergraduate medical curriculum at Aarhus University are important for junior doctors. More than 90% of the respondents estimated that they were sufficiently prepared when it came to core outcomes such as history taking and physical examination. Five issues diverged considerably in importance stated and preparedness experienced: suggestion of diagnoses, initiation of treatment, pharmacotherapy, handling of own emotions and structuring of own learning. Also, 40% stated that their clerkships had only had little value in preparing them for their foundation year. CONCLUSION: Overall, graduates felt well-prepared and characterized the education coherent. However, the study raises major questions concerning clerkships and competence in treatments, pharmacotherapy and the more personal aspects of professionalism. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.