Did we finally slay the evil dragon of cigarette smoking in the late 20th century?: unfortunately, the answer is no - the dragon is still alive and well in the 21st century and living in the third world. Shame on us!

If cigarettes were introduced as a new consumer product today, it is unlikely they would receive government regulatory approval. Cigarettes have proven biologic toxicities (carcinogenesis, atherogenesis, teratogenesis) and well-established causal links to human disease. Things were very different in 1913 when the R. J. Reynolds Tobacco Company introduced the first modern cigarette, the iconic Camel. By the early 1950s, definitive scientific reports linked cigarettes and human disease, but it was more than a half century later (2006) that cigarette manufacturers were found guilty by a federal court of deceptive product marketing regarding the health hazards of tobacco use. In the United States, cigarette smoking remains a major but slowly declining problem. But in developing countries, cigarette use is expanding tremendously. In global terms, the epidemic of smoking-caused disease is projected to increase rapidly in coming decades, not decline. Society may have begun to slowly win the smoking battle in the developed world, but we are resoundingly losing the global war on smoking. All is not lost! There is some good news! The 2003 Framework Convention on Tobacco Control, supported strongly by the American College of Chest Physicians, is the first global public health treaty of the new millennium. Many developed societies have begun planning to rid their countries of cigarettes in what is called the Endgame Strategy, and now is the time for the international medical community to help change tobacco policy to a worldwide endgame approach to rid all humanity of smoking-related diseases.

Short-term and long-term impact of the central line workshop on resident clinical performance during simulated central line placement.

INTRODUCTION: The Central Line Workshop (CLW) was introduced at our institution to better train residents in safe placement of the central venous catheter (CVC). This study sought to determine if immediate performance improvements from the CLW are sustained 3 months after the training for residents with various levels of experience. METHODS: Twenty-six emergency medicine residents completed the CLW, which includes online modules and experiential sessions in anatomy, ultrasound, sterile technique, and procedural task training. Demonstration of the synthesis of these skills including placement of both internal jugular and subclavian CVCs was assessed using a task trainer. Each resident was also tested approximately 3 months before and 3 months after the CLW. Residents were assessed using a validated CVC proficiency scale. RESULTS: Residents' CVC proficiency scores (percentage of items performed correctly during the assessment station) improved after CLW (0.6 vs. 0.93, P < 0.05). At 3 months after CLW testing, there was apparent skill decay from the CLW but overall improvement compared with baseline testing (0.6 vs. 0.8, P < 0.05). There was no significant difference in procedure time after CLW training. The postgraduate year 1 group showed the greatest improvement of CVC skill after CLW training. CONCLUSIONS: Resident CVC placement performance improved immediately after the CLW. Although performance 3 months after the CLW revealed evidence of skill decay, it was improved when compared with initial baseline assessment. Novice learners had the greatest benefit from the CLW.

Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: a randomized controlled trial.

OBJECTIVE: To evaluate a mastery learning, simulation-based curriculum for laparoscopic, totally extraperitoneal (TEP) inguinal hernia repair. BACKGROUND: Clinically relevant benefits from improvements in operative performance, time, and errors after simulation-based training are not clearly established. METHODS: After performing a baseline TEP in the OR, general surgery residents randomized to mastery learning (ML) or standard practice (SP) were reassessed during subsequent TEPs. The ML curriculum involved Web-based modules followed by training on a TEP simulator until expert performance was achieved. Operative time, performance, and patient outcomes adjusted for staff, resident participation, difficulty of repair, PGY-level, and patient comorbidities were compared between groups with mixed effects-ANOVA and generalized linear models. RESULTS: Fifty residents (PGY1-5) performed 219 TEP repairs on 146 patients. Baseline operative time, performance, and demographics were similar between groups. To achieve mastery, ML-residents (n = 26) required a median of 16 (range 7-27) simulated repairs. After training, TEPs performed by ML-residents were faster than those by SP-residents, with time corrected for participation (mean ± SD, 34 ± 8 minutes vs. 48 ± 14 minutes; difference -13; 95%CI, -18 to -8; P < 0.001). Operative performance scores (GOALS, scale 6-30) were better for ML residents (21.9 ± 2.8 vs. 18.3 ± 3.8; P = 0.001). Intraoperative complications (peritoneal tear, procedure conversion), postoperative complications (urinary retention, seroma), and need for overnight stay were less likely in the ML group (adjusted odds ratios 0.14, 0.04, and 0, respectively; all P < 0.05). CONCLUSIONS: A simulation-based ML curriculum decreased operative time, improved trainee performance, and decreased intra- and postoperative complications and overnight stays after laparoscopic TEP inguinal hernia repair. ClinicalTrials.gov Identifier: NCT01085500.

Evaluating the impact of simulation on translational patient outcomes.

INTRODUCTION: A long and rich research legacy shows that under the right conditions, simulation-based medical education (SBME) is a powerful intervention to increase medical learner competence. SBME translational science demonstrates that results achieved in the educational laboratory (T1) transfer to improved downstream patient care practices (T2) and improved patient and public health (T3). METHOD: This is a qualitative synthesis of SBME translational science research (TSR) that employs a critical review approach to literature aggregation. RESULTS: Evidence from SBME and health services research programs that are thematic, sustained, and cumulative shows that measured outcomes can be achieved at T1, T2, and T3 levels. There is also evidence that SBME TSR can yield a favorable return on financial investment and contributes to long-term retention of acquired clinical skills. The review identifies best practices in SBME TSR, presents challenges and critical gaps in the field, and sets forth a TSR agenda for SBME. CONCLUSIONS: Rigorous SBME TSR can contribute to better patient care and improved patient safety. Consensus conference outcomes and recommendations should be presented and used judiciously.

Simulation-based objective assessment discerns clinical proficiency in central line placement: a construct validation.

BACKGROUND: Central venous catheterization (CVC) is associated with patient risks known to be inversely related to clinician experience. We developed and evaluated a performance assessment tool for use in a simulation-based central line workshop. We hypothesized that instrument scores would discriminate between less experienced and more experienced clinicians. METHODS: Participants included trainees enrolled in an institutionally mandated CVC workshop and a convenience sample of faculty attending physicians. The workshop integrated several experiential learning techniques, including practice on cadavers and part-task trainers. A group of clinical and education experts developed a 15-point CVC Proficiency Scale using national and institutional guidelines. After the workshop, participants completed a certification exercise in which they independently performed a CVC in a part-task trainer. Two authors reviewed videotapes of the certification exercise to rate performance using the CVC Proficiency Scale. Participants were grouped by self-reported CVC experience. RESULTS: One hundred and five participants (92 trainees and 13 attending physicians) participated. Interrater reliability on a subset of 40 videos was 0.71, and Cronbach a was 0.81. The CVC Proficiency Scale Composite score varied significantly by experience: mean of 85%, median of 87% (range 47%-100%) for low experience (0-1 CVCs in the last 2 years, n = 27); mean of 88%, median of 87% (range 60%-100%) for moderate experience (2-49 CVCs, n = 62); and mean of 94%, median of 93% (range 73%-100%) for high experience (> 49 CVCs, n = 16) (P = .02, comparing low and high experience). CONCLUSIONS: Evidence from multiple sources, including appropriate content, high interrater and internal consistency reliability, and confirmation of hypothesized relations to other variables, supports the validity of using scores from this 15-item scale for assessing trainee proficiency following a central line workshop.

Simulation for clinical research trials: a theoretical outline.

Although medical simulation has not been shown to directly save lives, mounting evidence highlights its ability to decrease clinical protocol violations, increase adherence to guidelines, decrease time to competence, enhance team performance, and increase patient safety. These clinical insights suggest that simulation might offer similar improvements in the design, enrollment, and execution of complex phase 3 clinical research trials. This article provides a theoretical outline of why and how this could be done. Matching the simulation technique with the specific trial uses well-established principles from adult education and process engineering. The goal is to give participants the experiential and emotional involvement that fosters complex thought. Simulation can facilitate "dry runs," role playing, analysis of videos, and "what-if" discussions. Simulated interviews with actors might help with obtaining informed consent and thereby boost enrollment. Simulated phone calls might help with reporting adverse outcomes. Full-body mannequins might be used to confirm that teams can coordinate multiple complex steps. Overall, the goal of simulation in clinical trials is to maximize realism while minimizing logistics and cost. While increased study is needed, this technique has considerable potential to decrease the risk to enrolled patients and to increase the accuracy of study data. Simulation provides an effective tool for immersive, interactive and reflective experiences. Overall, if simulation represents a "revolution in healthcare" then clinicians, patients, and now researchers, all stand to gain.

Iatrogenic delirium and coma: a "near miss".

A 66-year-old woman was cared for at two referral institutions following a witnessed cardiac arrest in a local emergency department. Despite aggressive initial care, she failed to regain consciousness during a 28-day course. Based on an erroneous neurologic diagnosis of anoxic encephalopathy, pessimism regarding likelihood of improvement existed, prompting clinical consideration of withdrawal of care. The correct diagnosis of iatrogenic drug-induced coma alternating with drug-induced delirium only became apparent after the IV administration of repeated doses of a benzodiazepine antagonist. The patient and husband (co-authors) provide insights often unheard within care circles.

Simulation medicine in intensive care and coronary care education.

The training of physician learners in intensive care and coronary care medicine presents several unique challenges that are particularly suited to simulation-based medical education (SBME) solutions. Intensive care medical educators seek to provide evidence-based medical education and comprehensive clinical exposure for learners in the setting of maximal individual patient comfort and safety. This represents both a practical and ethical dilemma for educators - one that SBME can partially solve in a way that provides significant advantages over conventional "bedside" training, particularly in the intensive care setting among critically ill patients.

The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills.

PURPOSE: To develop and evaluate a participant rating scale for assessing high performance teamwork skills in simulation medicine settings. METHODS: In all, 107 participants in crisis resource management (CRM) training in a multidisciplinary medical simulation center generated 273 ratings of key CRM skills after participating in two or three simulation exercises. These data were analyzed using Rasch and traditional psychometric approaches to develop the 16-item Mayo High Performance Teamwork Scale (MHPTS). Sensitivity to change as a result CRM training was also evaluated. RESULTS: The MHPTS showed satisfactory internal consistency and construct validity by Rasch (person reliability = 0.77; person separation = 1.85; item reliability = 0.96; item separation = 5.04) and traditional psychometric (Cronbach's alpha = 0.85) indicators. The scale demonstrated sensitivity to change as a result of CRM training (pretraining mean = 21.44 versus first posttraining rating mean = 24.37; paired t = -4.15, P < 0.0001; first posttraining mean = 24.63 versus second posttraining mean = 26.83; paired t = -4.31 P < 0.0001). CONCLUSIONS: The MHPTS provides a brief, reliable, practical measure of CRM skills that can be used by participants in CRM training to reflect on and evaluate their performance as a team. Further evaluation of validity and appropriateness in other simulation and medical settings is desirable.

Internal medicine resident education in the medical intensive care unit: the impact on education and patient care of a scheduling change for didactic sessions.

OBJECTIVE: Modifications in residency educational programs are needed to comply with the work-hour limitations introduced by the Accreditation Council for Graduate Medical Education. The objective of this study was to determine the impact of rescheduling critical care didactic sessions on medicine residents' education during their medical intensive care unit (MICU) rotation and on outcomes. DESIGN: A pilot program of nonrandomized design. SETTING: A graduate school of medicine. PATIENTS: All patients admitted during the study periods who authorized their medical records to be reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We instituted a pilot program that replaced the daily traditional 1-hour post-rounds didactic session with an 8:00 am 30-min session, conducted before work rounds, on weekdays from July 2003 through December 2003. The residents' end-of-rotation examination scores were used to assess the impact on education. The pilot period residents' examination results were compared with the examination results from July 2002 through December 2002. To evaluate the effect on patient care, the Acute Physiology Score, Acute Physiology and Chronic Health Evaluation III score, and predicted and observed lengths of MICU and hospital stay of all patients during these two study periods were abstracted and compared. Forty-eight residents were included in each period of the study. The residents' performance on the examination at the end of MICU rotation improved when the didactic session was moved to 8:00 am (67.9 +/- 13.8 vs. 73.9 +/- 12.1; p = .0270). The statistically significant improvement was limited to the first-year residents. There were 751 and 903 patients, respectively, admitted to the MICU during the 2002 and 2003 study periods. There were no significant differences in Acute Physiology Score and Acute Physiology and Chronic Health Evaluation III score between patients admitted during the two study periods. The observed hospital mortality rate was lower during the second period. There were no statistically significant differences in the adjusted length of MICU and hospital stay between the two periods. CONCLUSION: Early morning didactic sessions improve the educational experience of internal medicine residents rotating in the MICU without compromising patient care.