Evaluating the impact of a virtual international global surgery conference as a means for global surgery and health education.

Objective: Global Surgery was established as a specialty in the 1980s to improve worldwide surgical care and delivery; however, despite having significant importance, a lack of exposure remains within undergraduate and postgraduate training schemes. This study aims to evaluate the impact of a free international virtual Global Surgery conference in raising interest, awareness and knowledge for medical and allied healthcare professional students, surgical trainees and surgeons worldwide. Design: A free one-day international Global Surgery conference was organised in May 2021 and broadcast on a worldwide delegate online platform; there were seven keynote presentations. Registered delegates completed pre-and post-conference questionnaires. Data were collected including country of origin, training/professional level, Likert (1-5) scale ratings of conference keynote topics and VAS (0-10) scores for overall conference evaluation. Furthermore, qualitative feedback in relation to positive feedback and ideas for improvement was also invited, and in cases where multiple feedback was given, was categorised separately. Setting: The study was undertaken by the St Andrew's Anglia Ruskin (StAAR) Research Group, School of Medicine, Anglia Ruskin University, Chelmsford, UK. Participants: There were 230 registered delegates; the attendance rate was 81.7% (188/230), representing a variety of different training/professional levels from 50 countries. For attendees, the questionnaire response rate was 88.8% (167/188). Results: There was a significant increase in knowledge improvement regarding six conference topics, with five achieving a median (IQR) post-conference Likert score of 5(1) and one achieving a score of 4(1) (p < 0.001). Average confidence and knowledge remained unchanged on the use of social media to access worldwide surgical education (p = 0.667). Overall, the conference received high satisfaction (9.4/10) and recommendation (9.5/10) ratings. Conclusion: Our findings support the concept of free Global Surgery virtual conference integration into medical and allied healthcare professional student curricula worldwide, to promote early awareness and facilitate the growth of the healthcare 'workforce of tomorrow'.

Career intentions and perceptions of general practice on entry to medical school: baseline findings of a longitudinal survey at three UK universities.

BACKGROUND: Medical graduates from the universities of Oxford and Cambridge have a lower intention to become GPs compared with other UK medical graduates. It is not clear to what extent this difference is present on admission to medical school. AIM: To compare the career intention and influencing factors of students on admission to different UK medical schools. DESIGN & SETTING: First year of a 6-year prospective cohort study of medical students admitted in autumn 2020 to the three East of England medical schools: University of East Anglia (UEA), University of Cambridge (UOC), and Anglia Ruskin University (ARU). METHOD: An online survey instrument was administered at the beginning of the first year. This measured self-reported career interests and various influencing factors, including perceptions of general practice. RESULTS: UOC students declared a lower intention to become a doctor, a higher likelihood of choosing careers in pathology and public health, and a much lower likelihood of becoming a GP than students of UEA or ARU (all at P<0.001). In all three schools, the phrases least associated with general practice were 'opportunities for creativity/innovation' and 'research/academic opportunities', whereas the phrases most associated with general practice were 'favourable working hours' and 'flexibility'. However, research/academic opportunities were far more important, and favourable working hours far less important, to UOC students (P<0.001 for both) than to students of UEA or ARU. CONCLUSION: UOC students' lower intention to become a GP appears to be present on entry to medical school. This may be explained in part by these students placing a higher importance on research/academic opportunities, combined with the widely held perception that GP careers lack these opportunities.

COVID-19 Pandemic-Medical Education Adaptations: the Power of Students, Staff and Technology.

The coronavirus pandemic has profoundly changed the way medical education is delivered globally. Our group reports an insight into the adaptations and innovations made by the School of Medicine at Anglia Ruskin University.

Impact of Simulation Training on Undergraduate Clinical Decision-making in Emergencies: A Non-blinded, Single-centre, Randomised Pilot Study.

Introduction There is an increasing evidence base for the use of simulation-based medical education. Simulation is superior to more didactic methods for teaching a range of technical and non-technical skills, and students report they often derive more educational value from it compared with other teaching methods. There is currently limited evidence that simulation training improves clinical decision-making and, therefore, this pilot study sought to explore this further. Methods Students were randomised to take part in either five classroom tutorials and simulation training sessions or five classroom tutorials and an online e-learning module. On completion of the teaching, students all undertook an unseen assessment scenario (managing a simulated patient with anaphylaxis), where they were scored using a weighted marking scheme. The time taken to make decisions and student-reported confidence in decisions were also measured. Results 14/14 simulation-group participants and 12/14 e-learning-group participants completed the post-learning assessment. The simulation group identified anaphylaxis and gave adrenaline more quickly (p 0.008 and 0.005, respectively), and this cohort was more confident in making the diagnosis (p 0.044). There was no statistically significant difference between weighted global assessment scores for each group (p 0.705). The e-learning group called for help more quickly (p.0.049), although fewer students in this group called for help (five vs. nine). There was no statistical difference in confidence in decisions to administer adrenaline or call for help (p 0.539 and 0.364 respectively). Conclusions Participants who undertook simulation training were able to more confidently and quickly identify the diagnosis and initiate emergency treatment. However, there was not a statistically significant difference between groups using an overall weighted score. Using simulation to train students to perform better in emergencies and improve their decision-making shows promise but a further quantitative study is required.

Evaluating team decision-making as an emergent phenomenon.

BACKGROUND: The complexity of modern clinical practice has highlighted the fallibility of individual clinicians' decision-making, with effective teamwork emerging as a key to patient safety. Dual process theory is widely accepted as a framework for individual decision-making, with type 1 processes responsible for fast, intuitive and automatic decisions and type 2 processes for slow, analytical decisions. However, dual process theory does not explain cognition at the group level, when individuals act in teams. Team cognition resulting from dynamic interaction of individuals is said to be more resilient to decision-making error and greater than simply aggregated cognition. METHODS: Clinicians were paired as teams and asked to solve a cognitive puzzle constructed as a drug calculation. The frequency at which the teams made incorrect decisions was compared with that of individual clinicians answering the same question. RESULTS: When clinicians acted in pairs, 63% answered the cognitive puzzle correctly, compared with 33% of clinicians as individuals, showing a statistically significant difference in performance (χ2 (1, n=116)=24.329, P<0.001). Based on the predicted performance of teams made up of the random pairing of individuals who had the same propensity to answer as previously, there was no statistical difference in the actual and predicted teams' performance. CONCLUSIONS: Teams are less prone to making errors of decision-making than individuals. However, the improved performance is likely to be owing to the effect of aggregated cognition rather than any improved decision-making as a result of the interaction. There is no evidence of team cognition as an emergent and distinct entity.

Assessing the association between thinking dispositions and clinical error.

BACKGROUND: Dual-process theory suggests that type 1 thinking results in a propensity to make 'intuitive' decisions based on limited information. Type 2 processes, on the other hand, are able to analyse these initial responses and replace them with rationalised decisions. Individuals may have a preference for different modes of rationalisation, on a continuum from careful to cursory. These 'dispositions' of thinking reside in type 2 processes and may result in error when the preference is for 'quick and casual' decision-making. METHODS: We asked clinicians to answer a cognitive puzzle to which there was an obvious, but incorrect, answer, to measure their propensity for 'quick and casual' decision-making. The same clinicians were also asked to report the number of clinical errors they had committed in the previous two weeks. We hypothesised an association between committing error and settling for an incorrect answer, and that the cognitive puzzle would have predictive capability. RESULTS: 90 of 153 (59%) clinicians reported that they had committed error, while 103 (67%) gave the incorrect 'intuitive' answer to the cognitive puzzle. There was no statistically significant difference between clinicians who committed error and answered incorrectly, and those who did not and answered correctly (χ2(1, n=1153)=0.021, p=0.885). CONCLUSIONS: The prevalence of clinical error in our study was higher than previously reported in the literature, and the propensity for accepting intuitive solutions was high. Although the cognitive puzzle was unable to predict who was more likely to commit error, the study offers insights into developing other predictive models for error.

The Effectiveness of Medical Simulation in Teaching Medical Students Critical Care Medicine: A Systematic Review and Meta-Analysis.

STATEMENT: We aimed to assess effectiveness of simulation for teaching medical students critical care medicine and to assess which simulation methods were most useful. We searched AMED, EMBASE, MEDLINE, Education Resources Information Centre, British Education Index, Australian Education Index, and bibliographies and citations, in July 2013. Randomized controlled trials comparing effectiveness of simulation with another educational intervention, or no teaching, for teaching medical students critical care medicine were included. Assessments for inclusion, quality, and data extraction were duplicated and results were synthesized using meta-analysis.We included 22 randomized control trials (n = 1325). Fifteen studies comparing simulation with other teaching found simulation to be more effective [standardized mean difference (SMD) = 0.84; 95% confidence interval (CI) = 0.43 to 1.24; P < 0.001; I = 89%]. High-fidelity simulation was more effective than low-fidelity simulation, and subgrouping supported high-fidelity simulation being more effective than other methods. Simulation improved skill acquisition (SMD = 1.01; 95% CI = 0.49 to 1.53) but was no better than other teaching in knowledge acquisition (SMD = 0.41; 95% CI = -0.09 to 0.91).

Development of Education and Research in Anesthesia and Intensive Care Medicine at the University Teaching Hospital in Lusaka, Zambia: A Descriptive Observational Study.

BACKGROUND: Data from 2006 show that the practice of anesthesia at the University Teaching Hospital in Lusaka, Zambia was underdeveloped by international standards. Not only was there inadequate provision of resources related to environment, equipment, and drugs, but also a severe shortage of staff, with no local capability to train future physician anesthetic providers. There was also no research base on which to develop the specialty. This study aimed to evaluate patient care, education and research to determine whether conditions had changed a decade later. METHODS: A mix of qualitative data and quantitative data was gathered to inform the current state of anesthesia at the University Teaching Hospital, Lusaka, Zambia. Semistructured interviews were conducted with key staff identified by purposive sampling, including staff who had worked at the hospital throughout 2006 to 2015. Further data detailing conditions in the environment were collected by reviewing relevant departmental and hospital records spanning the study period. All data were analyzed thematically, using the framework described in the 2006 study, which described patient care, education, and research related to anesthetic practice at the hospital. RESULTS: There have been positive developments in most areas of anesthetic practice, with the most striking being implementation of a postgraduate training program for physician anesthesiologists. This has increased physician anesthesia staff in Zambia 6-fold within 4 years, and created an active research stream as part of the program. Standards of monitoring and availability of drugs have improved, and anesthetic activity has expanded out of operating theaters into the rest of the hospital. A considerable increase in the number of cesarean deliveries performed under spinal anesthetic may be a marker for safer anesthetic practice. Anesthesiologists have yet to take responsibility for the management of pain. CONCLUSIONS: The establishment of international partnerships to support postgraduate training of physician anesthetists in Zambia has created a significant increase in the number of anesthesia providers and has further developed nearly all aspects of anesthetic practice. The facilitation of the training program by a global health partnership has leveraged high-level support for the project and provided opportunities for North-South and international learning.

Constructing diagnostic likelihood: clinical decisions using subjective versus statistical probability.

BACKGROUND: Although physicians are highly trained in the application of evidence-based medicine, and are assumed to make rational decisions, there is evidence that their decision making is prone to biases. One of the biases that has been shown to affect accuracy of judgements is that of representativeness and base-rate neglect, where the saliency of a person's features leads to overestimation of their likelihood of belonging to a group. This results in the substitution of 'subjective' probability for statistical probability. METHODS: This study examines clinicians' propensity to make estimations of subjective probability when presented with clinical information that is considered typical of a medical condition. The strength of the representativeness bias is tested by presenting choices in textual and graphic form. Understanding of statistical probability is also tested by omitting all clinical information. RESULTS: For the questions that included clinical information, 46.7% and 45.5% of clinicians made judgements of statistical probability, respectively. Where the question omitted clinical information, 79.9% of clinicians made a judgement consistent with statistical probability. There was a statistically significant difference in responses to the questions with and without representativeness information (χ2 (1, n=254)=54.45, p<0.0001). CONCLUSIONS: Physicians are strongly influenced by a representativeness bias, leading to base-rate neglect, even though they understand the application of statistical probability. One of the causes for this representativeness bias may be the way clinical medicine is taught where stereotypic presentations are emphasised in diagnostic decision making.

Avoidable perioperative mortality at the University Teaching Hospital, Lusaka, Zambia: a retrospective cohort study.

PURPOSE: Perioperative mortality has fallen in both high- and low-income countries over the last 50 years. An evaluation of avoidable perioperative mortality can provide valuable lessons to improve care; however, there is relatively little recent data from the Least Developed Countries in the world. We aimed to compare recent avoidable perioperative mortality in Lusaka, Zambia, with historical data from 1987. METHODS: We conducted a retrospective cohort study by identifying perioperative deaths within days of surgery and comparing the operating room and mortuary registers for the 2012 calendar year. Multiple independent raters from anesthesiology and surgery/obstetrics gynecology reviewed case notes, when available, to identify avoidable causes of death. RESULTS: Of the 18,010 surgical patients in 2012, 114 were identified as having died perioperatively within six days of surgery. Fifty-nine files were available for further analysis (52% of identified perioperative deaths). Eighteen (30%) of these cases were assessed as avoidable, 19 cases (32%) probably avoidable, 14 cases (24%) unavoidable, and eight cases (14%) unclear. Thirty-one (53%) cases had surgical factors contributing to death, 19 (32%) cases had anesthesia factors, and 18 (30%) cases had systems factors. Most of the avoidable deaths were attributed to multiple factors. Key factors leading to the avoidable deaths were delays in surgery, lack of the availability of blood, and poor postoperative care. CONCLUSIONS: Most deaths were avoidable, suggesting that patient outcomes in low-resource settings can be improved within current resources. The multifactorial nature of avoidability implies that an interprofessional approach is required to improve the quality of care.

Peer training and co-learning in global health care.

BACKGROUND: The Zambia Anaesthesia Development Project (ZADP) is a an international health care partnership between the UK and Zambia, designed to mutually benefit anaesthetic registrars from both countries in aspects deficient in their native training schemes. CONTEXT: The ZADP evolved from an initial plan to support a new anaesthesia training programme in Zambia, with visiting trainees providing continuity that was missing from short-term consultant visits. The primary goal of the project was to improve patient safety and care by delivering teaching, and by developing management, leadership and governance structures. An important reciprocal goal was to provide a unique training experience for a UK registrar in a resource-poor environment, including the resulting clinical and non-clinical challenges. This model adds a useful dimension to the educational support provided, and also embodies the principle of co-development IMPLICATIONS: The ZADP and the Zambia Master of Medicine (MMed) Anaesthesia programme provides an example of a cross-cultural peer-directed co-learning model that benefits trainees from developed and developing postgraduate training programmes. This synergistic model is one that could be applied to other educational initiatives supported from overseas. This model not only adds a useful dimension to the educational support provided, but also embodies the principle of co-development that is so important to the sustainability of such projects.

Using expert consensus to develop a simulation course for faculty members.

BACKGROUND: Effective learning from simulation-based training depends on expert facilitation by skilled faculty members, but there are few guidelines upon which to base simulation development. A collaborative approach was taken in the East of England to determine the agreed content of such a course. METHODS: A modified Delphi method was used to determine consensus amongst the simulation-provider leads in the East of England on what should be the essential elements of a training course for faculty members. A questionnaire designed by a steering group was circulated to the consensus group, and their responses were used to modify subsequent questionnaires. There was enough agreement after two rounds not to require a third round. RESULTS: After two rounds there was high level of agreement that the educational content should include scenario design, creating a supportive learning environment, structured debriefing formats, human factors, educational feedback and communication. There was also agreement on preferred teaching methods, minimum qualification and continuing development for faculty members. There was moderate agreement on the prior experience required of faculty members, and no agreement on the costs of courses. Effective learning from simulation-based training depends upon expert facilitation by skilled faculty members DISCUSSION: By using a consensus method to determine the content and format of a simulation development course designed for faculty members, there is agreement in the East of England on what constitutes an educationally sound programme. This should provide assurance to both simulation providers and commissioners of education that despite the absence of guidelines, there is an agreed practice standard for simulation-based training in the region.

Faculty experiences regarding a global partnership for anesthesia postgraduate training: a qualitative study.

PURPOSE: Partnerships for postgraduate medical education between institutions in high-income countries and low- and middle-income countries are increasingly common models that can create capacity in human resources for health. Nevertheless, data are currently limited to guide the development of this kind of educational program. METHODS: We conducted semi-structured interviews with visiting and local faculty members in the externally supported University of Zambia Master of Medicine Anesthesia Program. Interviews were thematically analyzed with qualitative methodology. RESULTS: Respondents spoke of differences in clinical practice, including resource limitations, organizational issues, presentation and comorbidities of patients, surgical techniques, and cultural issues relating to communication and teamwork. A key theme was communication amongst distributed visiting faculty. Infrequent face-to-face meetings jeopardized programmatic learning and the consistency of teaching and assessment. Co-learning was considered central to the development of a new program, as visiting faculty had to adapt to local challenges while establishing themselves as visiting experts. An ongoing challenge for faculty was determining when to adapt to the local context to facilitate patient care and when to insist on familiar standards of practice in order to advocate for patient safety. CONCLUSIONS: As a new and evolving program, the findings from this study highlight challenges and opportunities for faculty as part of a partnership for postgraduate medical education. Since maintaining an effective faculty is essential to ensure the sustainability of any teaching program, this work may help other similar programs to anticipate and overcome potential challenges.

A new partnership for anesthesia training in Zambia: reflections on the first year.

PURPOSE: A new postgraduate anesthesiology residency program has been founded as a North-South partnership between the United Kingdom (UK) and Zambia. The project aims to train physician anesthesiologists in Lusaka in an attempt to address the high perioperative mortality associated with anesthesia as well as to provide better professional support for clinical officer anesthesiologists. PRINCIPLE FINDINGS: We present a detailed description of our experiences in establishing a new global health partnership and reflect on the outcomes of the first year of the training program. The formal healthcare partnership between the UK and Zambian governments began in 2009. Funded by the UK Department for International Development and managed by the Tropical Health and Education Trust, a four-year postgraduate Masters in Medicine (Anesthesia) degree was offered beginning in 2011. A volunteer faculty of consultant anesthesiologists from the United Kingdom and Canada has provided teaching support. There are plans to improve continuity by using senior UK trainees in Out Of Program attachments. To date, eight postgraduate Zambian doctors have successfully completed the first year of training and progress into their second year. CONCLUSION: On reflection, some of the lessons learned were very specific to local circumstances and could have been appreciated only after starting the program - flexibility and responsiveness early in the program have been very necessary. Nonetheless, our findings enhance existing knowledge about establishing and conducting global health partnerships in anesthesia.

Follow-up of patients with tracheal ring fractures secondary to antegrade percutaneous dilational tracheostomy.

BACKGROUND AND OBJECTIVE: There are several different techniques commonly used to perform percutaneous dilational tracheostomy, and this explains the wide variation in the follow-up data especially with regard to tracheal stenosis. Our aim was to clarify whether tracheal ring fracture (TRF) led to a higher incidence of tracheal stenosis. METHODS: This retrospective, observational study examines two techniques: Blue Rhino and PercuTwist. Patients with documented evidence of TRF were followed up by an experienced ear, nose and throat consultant and their tracheas examined with nasoendoscopy. RESULTS: Of the 207 patients who underwent percutaneous dilational tracheostomy, there were 16 TRFs. Of these, four were in the Blue Rhino group and 12 in the PercuTwist group. There were no reported cases of tracheal stenosis at follow-up. CONCLUSION: In this group of patients, TRF was not associated with the subsequent development of tracheal stenosis.