Simulation for Neonatal Endotracheal Intubation Training: How Different Is It From Clinical Practice?

INTRODUCTION: Neonatal endotracheal intubation is a critical skill that is difficult for learners to acquire even with simulation-based training (SBT). Trainees prefer clinical experiences over SBT. The objective of the study was to explore the differences between SBT and clinical practice in acquiring neonatal intubation skills to inform mannequin design and to improve fidelity. METHODS: A basic qualitative study using semistructured interviews was conducted to determine the experience of newly competent trainees (second- and third-year neonatal-perinatal medicine fellows) and their instructors in developing intubation skills. Participants were asked to compare learning through SBT with clinical practice in terms of context, equipment, and environment. Their responses were analyzed using an inductive approach. RESULTS: Thirty-two participants (20 fellows and 12 faculty) indicated that SBT does not equal the real experience. Specifically, the look, feel, and function of the simulators differ enough from the real patient and the clinical environmental that they do not elicit the desired learning responses. The clinical environment prompted heightened emotions and had a chaotic atmosphere that was not fully captured by SBT. Participants suggested that programs use SBT in the initial phases of training only to gain basic skills and they provided several solutions for mannequin and SBT session design. CONCLUSIONS: Simulation-based training does not fully prepare neonatal-perinatal medicine fellows for neonatal intubation. Mannequins with unique active features, such as multiple airway configurations, slipperiness, secretions, and softer textures should be developed. Realistic environments that replicate the interprofessional nature and stressors of the clinical environment might better prepare learners for the complexity of clinical practice.

The Resident Experience of an Obesity-Focused Home Visiting Curriculum.

BACKGROUND: The prevalence of obesity in the USA has risen to 39.8% of adults and 18.5% of children, yet there has not been a compensatory rise in residency training to reflect this epidemic. OBJECTIVES: To examine pediatric residents' lived experiences of completing a novel home visitation curriculum for children with obesity in resource-poor areas of Washington, DC. METHODS: Pediatric residents completed a home visiting curriculum consisting of four modules followed by two home visits to families with a child struggling with obesity. Within 2 weeks of completing the curriculum, individual interviews were conducted with participants about their experience. Inductive coding was used to analyze the data, followed by clustering and theming. RESULTS: Saturation was reached after individual interviews with 13 residents between 2013 and 2015. Five themes emerged describing the residents' experiences: (1) enhanced understanding of home and community life, (2) awareness of personal biases and assumptions, (3) challenges of losing control and not being intrusive, (4) deeper relationship and enhanced empathy with patient and family, and (5) changes in delivery of care. CONCLUSIONS: The findings from this study suggest that an obesity-focused home visiting curriculum may provide residents with a deeper understanding of social determinants of obesity and the opportunity to gain other necessary skills that may help them better care for individuals with obesity.

Factors Important to Top Clinical Performance in Emergency Medicine Residency: Results of an Ideation Survey and Delphi Panel.

OBJECTIVES: We explore attributes, traits, background, skills, and behavioral factors important to top clinical performance in emergency medicine (EM) residency. METHODS: We used a two-step process-an ideation survey with the Council of Emergency Medicine Residency Directors and a modified Delphi technique-to identify: 1) factors important to top performance, 2) preresidency factors that predict it, and 3) the best ways to measure it. In the Delphi, six expert educators in emergency care assessed the presence of the factors from the ideation survey results in their top clinical performers. Consensus on important factors that were exemplified in >60% of top performers were retained in three Delphi rounds as well as predictors and measures of top performance. RESULTS: The ideation survey generated 81 responses with ideas for each factor. These were combined into 89 separate factors in seven categories: attributes, personal traits, emergency department (ED)-specific skills and behaviors, general skill set, background, preresidency predictors, and ways to measure top performance. After three Delphi rounds, the panel achieved consensus on 20 factors important to top clinical performance. This included two attributes, seven traits, one general skill set, and 10 ED-specific skills and behaviors. Interview performance was considered the sole important preresidency predictor and clinical competency committee results the sole important measure of top performance. CONCLUSION: Our expert panel identified 20 factors important to top clinical performance in EM residency. Future work is needed to further explore how individuals learn and develop these factors.

Leadership Development Programs at Academic Health Centers: Results of a National Survey.

PURPOSE: To identify the prevalence and characteristics of faculty leadership development programs (LDPs) offered by North American academic health centers (AHCs) and to uncover gaps in leadership training. METHOD: Faculty development/affairs deans of the 161 Association of American Medical Colleges member schools were surveyed in 2015 on their approach to faculty leadership training. For AHCs delivering their own training, the survey included questions about LDP participants, objectives, curriculum, delivery, resources, and evaluation. The literature on leadership and leadership development was used to develop a taxonomy of leadership competencies, which formed the basis of the survey questions related to program content. Survey results were analyzed with descriptive statistics and chi-square analysis for categorical data. RESULTS: Of the 94 respondents (response rate 58%), 93 provided some form of leadership training and 61 provided a formal internal faculty LDP. Content was variable and rarely based on a specific leadership competency model. Although programs described innovative approaches to learning, lectures and case discussions were the predominant approaches. Evaluation beyond participant satisfaction was uncommon. CONCLUSIONS: Faculty LDPs were common, with some programs describing elements informed by the leadership literature. However, nationally programs can improve by basing content on a leadership competency model, incorporating multiple approaches to teaching, and implementing more rigorous program evaluation.

Systems Thinking and Systems-Based Practice Across the Health Professions: An Inquiry Into Definitions, Teaching Practices, and Assessment.

Phenomenon: Systems thinking is the cornerstone of systems-based practice (SBP) and a core competency in medicine and health sciences. Literature regarding how to teach or apply systems thinking in practice is limited. This study aimed to understand how educators in medicine, physical therapy, physician assistant, nursing, and speech-language pathology education programs teach and assess systems thinking and SBP. APPROACH: Twenty-six educators from seven different degree programs across the five professions were interviewed and program descriptions and relevant course syllabi were reviewed. Qualitative analysis was iterative and incorporated inductive and deductive methods as well as a constant comparison of units of data to identify patterns and themes. FINDINGS: Six themes were identified: 1) participants described systems thinking as ranging across four major levels of healthcare (i.e., patient, care team, organization, and external environment); 2) participants associated systems thinking with a wide range of activities across the curriculum including quality improvement, Inter-professional education (IPE), error mitigation, and advocacy; 3) the need for healthcare professionals to understand systems thinking was primarily externally driven; 4) participants perceived that learning systems thinking occurred mainly informally and experientially rather than through formal didactic instruction; 5) participants characterized systems thinking content as interspersed across the curriculum and described a variety of strategies for teaching and assessing it; 6) participants indicated a structured framework and inter-professional approach may enhance teaching and assessment of systems thinking. Insights: Systems thinking means different things to different health professionals. Teaching and assessing systems thinking across the health professions will require further training and practice. Tools, techniques, taxonomies and expertise outside of healthcare may be used to enhance the teaching, assessment, and application of systems thinking and SBP to clinical practice; however, these would need to be adapted and refined for use in healthcare.

Improving Communication Through Resident-Nurse Shadowing.

BACKGROUND: Previously, reduced resident hours, multiple ways to communicate (text paging, calling), and fewer opportunities for face-to-face communication had led to increased frustration from residents and nurses in our institution about communicating and prioritizing patient care needs. It was thought that a shared understanding and improved teamwork and communication between residents and nurses might be achieved if the residents could watch the nurses' workflow and observe their care priorities. OBJECTIVES: To understand the experience of residents and nurses who had participated in a novel 4-hour nurse shadowing experience conducted during the first year of pediatric medical residency in a children's hospital. METHODS: We undertook a basic interpretive qualitative study by using semistructured interviews to formally evaluate the shadowing program by examining the experiences of both the first-year residents and the nurses being shadowed. Residents and nurses who had participated in the past 3 years were eligible for inclusion in the study. RESULTS: Seven themes emerged that supported the overarching theme of improving communication between residents and nurses. Shadowing led to improved resident understanding and appreciation of nurses' work. Both residents and nurses experienced enhanced relationships as they discussed opportunities to improve care delivery. Residents reported practice changes after shadowing a nurse. Peer relationships formed among the dyads that extended beyond the shadowing experience. CONCLUSIONS: Shadowing a nurse proved to be a valuable experience that had an impact on participants and potentially a positive impact on patient care.

Curiosity and critical thinking: identifying child abuse before it is too late.

OBJECTIVE: We reviewed medical records to identify factors contributing to not recognizing child abuse in cases where it was subsequently identified. DESIGN/METHODS: Eighteen cases of delayed diagnosis of physical abuse were reviewed for qualitative themes. Missed abuse was defined by prior medical encounters that revealed findings concerning for physical abuse that were not recognized. RESULTS: Clinical limitations contributing to a delay in diagnosis included inattention to skin and subconjunctival findings, acceptance of inadequate explanations for injuries, no history obtained from verbal children, insufficient exploration of signs and symptoms, nonadherence to the maltreatment pathway, and incorrect diagnoses from radiologic examinations. System-based limitations included limited medical record access or completeness and admission to less-than-optimal settings. CONCLUSIONS: Having a greater index of suspicion for abuse may mitigate missed opportunities. With variability of medical training in child abuse, the factors we identified can be used as learning objectives for continuing medical education.

How learning transfers: a study of how graduates of a faculty education fellowship influenced the behaviors and practices of their peers and organizations.

PURPOSE: Faculty development programs have been criticized for their limited assessment methods, focused only on the learners and limited to satisfaction measures or self-reported behavior changes. Assessment of organizational impact is lacking. This study explored the impact of faculty education fellowship graduates on their organization and how that impact occurred. METHOD: The design was a qualitative study of 13 departments across three institutions, partnered with the George Washington University School of Medicine and Health Sciences. In-depth interviews with 13 supervisors and 25 peers of graduates were conducted in fall 2012 to examine graduates' organizational impact related to program purposes: enhancing teaching skills, pursuing scholarship in education, and developing leadership potential. Triangulation, purposive sampling, rich descriptions, and member checks minimized bias and optimized transferability. RESULTS: A model of how graduates of a faculty education fellowship transfer learning to peers and their organizations emerged. Analysis of interview responses showed that in the presence of environmental facilitators, graduates exhibited enhanced confidence and five new behaviors. Graduates raised peer awareness, leading to changes in individual and group practices and development of shared peer understanding. Analysis suggests they facilitated a culture of continuous learning around teaching, scholarship, and leadership. CONCLUSIONS: This study enhances traditional assessment of faculty education fellowship programs by examining the impact that graduates had on peers and work groups. A model is proposed for how graduates interact with and impact work group processes and practices. This model can facilitate more comprehensive program assessments, which can demonstrate program impact beyond the individual participant.

Anatomical knowledge retention in third-year medical students prior to obstetrics and gynecology and surgery rotations.

Surgical anatomy is taught early in medical school training. The literature shows that many physicians, especially surgical specialists, think that anatomical knowledge of medical students is inadequate and nesting of anatomical sciences later in the clinical curriculum may be necessary. Quantitative data concerning this perception of an anatomical knowledge deficit are lacking, as are specifics as to what content should be reinforced. This study identifies baseline areas of strength and weakness in the surgical anatomy knowledge of medical students entering surgical rotations. Third-year medical students completed a 20-25-question test at the beginning of the General Surgery and Obstetrics and Gynecology rotations. Knowledge of inguinal anatomy (45.3%), orientation in abdominal cavity (38.8%), colon (27.7%), and esophageal varices (12.8%) was poor. The numbers in parentheses are the percentage of questions answered correctly per topic. In comparing those scores to matched test items from this cohort as first-year students in the anatomy course, the drop in retention overall was very significant (P = 0.009) from 86.9 to 51.5%. Students also scored lower in questions relating to pelvic organs (46.7%), urogenital development (54.0%), pulmonary development (17.8%), and pregnancy (17.8%). These data showed that indeed, knowledge of surgical anatomy is poor for medical students entering surgical clerkships. These data collected will be utilized to create interactive learning modules, aimed at improving clinically relevant anatomical knowledge retention. These modules, which will be available to students during their inpatient surgical rotations, connect basic anatomy principles to clinical cases, with the ultimate goal of closing the anatomical knowledge gap.

Design for learning: adapting the microscopic anatomy laboratory to adult learners.

Medical school curricula are undergoing transformational change in response to calls for integrating content across courses and years to enable better retention and application and for individualizing learning to meet the diverse backgrounds and thus differing needs of students. To address the related teaching challenges, faculty can employ solid principles of adult learning and instructional design and use teaching strategies that stimulate different learning styles. We developed laboratory sessions that follow a learner-centered instructional design model we refer to as "PLHET," reflecting the steps of preparing, linking, hooking, engaging, and transferring learning, and also applied teaching strategies that reflect Kolb's four styles of learning (accommodative, divergent, assimilative, and convergent). We utilized a group learning format to promote active learning, teamwork, and self-direction. Preliminary data based on student surveys of laboratory activity show positive responses. In the future, we will test the hypothesis that this design will improve medical students' performance.

Implementing the leadership development plans of faculty education fellows: a structured approach.

The literature about medical education faculty fellowship programs, which have grown in popularity, quantifies program characteristics, provides exemplars, and reports on delivery strategies. Evaluation is generally limited to satisfaction measures, with a few longitudinal studies of postprogram achievements, but none on the process of making these changes.The authors describe the development of faculty members' postfellowship leadership plans and a structured process to support plan implementation. They also compare the implementation of initiatives specified in individual leadership development plans of two cohorts of faculty. The participants were graduates of a fellowship program at the George Washington University School of Medicine and Health Sciences. One cohort participated in a structured process of monthly reciprocal peer coaching, followed by journaling and quarterly interviews with the program director; a second cohort functioned as a comparison with no structured process supporting them. (Study years are not provided because they could inadvertently lead to the identification of the participants.) Despite similar implementation challenges expressed by both cohorts, the cohort participating in the structured process implemented 23% more of their planned initiatives, including 2 times as many educational leadership initiatives and 3.5 times as many initiatives related to developing new curriculum. The combination of plan development, reciprocal peer coaching, journaling, and interview discussions provided faculty with focus, structure, and personal support. This structured process supporting leadership plan development and implementation can be easily transferred to other fellowship programs in medical education, adapted for use with residents and fellows, and used in similar development programs.

Effecting curricular change through comprehensive course assessment: using structure and process to change outcomes.

Effective curriculum oversight requires periodic assessment and continuous improvement of individual course offerings as well as their overall integration. The literature indicates that most course review processes do not use the breadth of information available or sufficiently encourage faculty feedback and reflection, limiting the value derived. Suggestions for which data to include in the course evaluations are available in the literature; however, there is little guidance on effective course review structures and processes. In this article, the authors discuss a course review process revised as part of a comprehensive reform of the George Washington University School of Medicine and Health Sciences undergraduate medical school curriculum management structure. The process improvements incorporated evaluation practices grounded in the medical and higher education literatures and included changes to the data reviewed as well as the review timing, participants, and structure. The revised process uses a broad array of information, requires significant faculty participation, and uses questioning, writing, and dialogue to encourage faculty reflection and learning. Course directors indicate that the process helps them focus, and the information and the perspectives of others lead to reflection and new ideas. Through the process, course directors have changed course content and teaching methods, improved assessments of learning, and expanded course integration across the curriculum. The procedural and content elements of the process can be easily transferred to other medical schools and are applicable to other curricular reform projects across the continuum of medical education.

Learning clinical versus leadership competencies in the emergency department: strategies, challenges, and supports of emergency medicine residents.

BACKGROUND: Emergency medicine residents are expected to master 6 competencies that include clinical and leadership skills. To date, studies have focused primarily on teaching strategies, for example, what attending physicians should do to help residents learn. Residents' own contributions to the learning process remain largely unexplored. The purpose of this study was to explore what emergency medicine residents believe helps them learn the skills required for practice in the emergency department. METHODS: This qualitative study used semistructured interviews with emergency medicine residents at a major academic medical center. Twelve residents participated, and 11 additional residents formed a validation group. We used phenomenologic techniques to guide the data analysis and techniques such as triangulation and member checks to ensure the validity of the findings. RESULTS: We found major differences in the strategies residents used to learn clinical versus leadership skills. Clinical skill learning was approached with rigor and involved a large number of other physicians, while leadership skill learning was unplanned and largely relied on nursing personnel. In addition, with each type of skills, different aspects of the residents' personalities, motivation, and past nonclinical experiences supported or challenged their learning process. CONCLUSION: The approaches to learning leadership skills are not well developed among emergency medicine residents and result in a narrow perspective on leadership. This may be because of the lack of formal leadership training in medical school and residency, or it may reflect assumptions regarding how leadership skills develop. Substantial opportunity exists for enhancing emergency medicine residents' learning of leadership skills as well as the teaching of these skills by the attending physicians and nurses who facilitate their learning.

It's your own risk: medical students' perspectives on online professionalism.

BACKGROUND: U.S. medical schools have reported unprofessional online content by medical students. To inform institutional policies and curricula, we conducted a qualitative study exploring medical student perspectives on online posting. METHOD: Six focus groups were conducted with students from a single institution in November 2009. Interviews were recorded, transcribed, and analyzed using qualitative methods. RESULTS: Sixty-four students participated. Besides HIPAA violations and illegal activities, students disagreed as to what was inappropriate to post. They experienced online identity conflicts and described ambivalence toward Facebook. Students were concerned about online activity risks and lack of personal control. Their postings were guided by common sense and what they believed was expected from medical students. Students desired recommendations for appropriate content and suggested raising awareness through discussion. CONCLUSIONS: Medical students viewed online postings through a lens of personal risk. They desired recommendations but were sensitive to feeling controlled by their school.

A qualitative study of the meaning of physical examination teaching for patients.

BACKGROUND: Physical examination teaching using actual patients is an important part of medical training. The patient experience undergoing this type of teaching is not well-understood. OBJECTIVE: To understand the meaning of physical examination teaching for patients. DESIGN: Phenomenological qualitative study using semi-structured interviews. PARTICIPANTS: Patients who underwent a physical examination-based teaching session at an urban Veterans Affairs Medical Center. APPROACH: A purposive sampling strategy was used to include a diversity of patient teaching experiences. Multiple interviewers triangulated data collection. Interviews continued until new themes were no longer heard (total of 12 interviews). Interviews were recorded and transcribed verbatim. Coding was performed by two investigators and peer-checked. Themes were identified and meanings extracted from themes. KEY RESULTS: Seven themes emerged from the data: positive impression of students; participation considered part of the program; expect students to do their job: hands-on learning; interaction with students is positive; some aspects of encounter unexpected; range of benefits to participation; improve convenience and interaction. Physical examination teaching had four possible meanings for patients: Tolerance, Helping, Social, and Learning. We found it possible for a patient to move from one meaning to another, based on the teaching session experience. CONCLUSIONS: Physical examination teaching can benefit patients. Patients have the potential to gain more value from the experience based on the group interaction.