Opinion and Special Articles: Stress when performing the first lumbar puncture may compromise patient safety.

OBJECTIVE: To quantify physician stress levels when performing lumbar puncture (LP) and explore operator stress effect on patient outcomes. METHODS: This was a cross-sectional, multicenter study. Novices, intermediates, and experts in performing LP were recruited from 4 departments of neurology and emergency medicine. Stress was measured before and during performance of the LP using cognitive appraisal (CA), State-Trait Anxiety Inventory-Short (STAI-S) questionnaire, and the heart rate variability measure low frequency/high frequency index (LF/HF ratio). Patient-related outcomes were pain, confidence in the operator, and postdural puncture headache (PDPH). RESULTS: Forty-six physicians were included in the study: 22 novices, 12 intermediates, and 12 experts. Novices had the highest stress level and experts the lowest measured by cognitive appraisal and STAI-S before and during LP performance (p < 0.001 for all comparisons). Novices had the highest sympathetic tonus indicated by the highest LF/HF ratio before (p = 0.004) and during (p = 0.056) LP performance. Physician stress level was not significantly related to patients' pain. However, there was a significant relationship between STAI-S during the procedure and patient confidence in the operator (regression coefficient = -0.034, p = 0.008). High physician heart rate during the procedure significantly increased the odds of PDPH (odds ratio = 1.17, p = 0.036). CONCLUSION: Novice stress levels were high before and during performance of LP. Stress was significantly related to patient confidence in the operator and risk of PDPH. Simulation-based training should be considered to reduce novice residents' stress levels and increase patient safety.

Diagnostic flexible pharyngo-laryngoscopy: development of a procedure specific assessment tool using a Delphi methodology.

PURPOSE: Proper training and assessment of skill in flexible pharyngo-laryngoscopy are central in the education of otorhinolaryngologists. To facilitate an evidence-based approach to curriculum development in this field, a structured analysis of what constitutes flexible pharyngo-laryngoscopy is necessary. Our aim was to develop an assessment tool based on this analysis. METHODS: We conducted an international Delphi study involving experts from twelve countries in five continents. Utilizing reiterative assessment, the panel defined the procedure and reached consensus (defined as 80% agreement) on the phrasing of an assessment tool. RESULTS: FIFTY PANELISTS COMPLETED THE DELPHI PROCESS. THE MEDIAN AGE OF THE PANELISTS WAS 44 YEARS (RANGE 33-64 YEARS). MEDIAN EXPERIENCE IN OTORHINOLARYNGOLOGY WAS 15 YEARS (RANGE 6-35 YEARS). TWENTY-FIVE WERE SPECIALIZED IN LARYNGOLOGY, 16 WERE HEAD AND NECK SURGEONS, AND NINE WERE GENERAL OTORHINOLARYNGOLOGISTS. AN ASSESSMENT TOOL WAS CREATED CONSISTING OF TWELVE DISTINCT ITEMS.: Conclusion The gathering of validity evidence for assessment of core procedural skills within Otorhinolaryngology is central to the development of a competence-based education. The use of an international Delphi panel allows for the creation of an assessment tool which is widely applicable and valid. This work allows for an informed approach to technical skills training for flexible pharyngo-laryngoscopy and as further validity evidence is gathered allows for a valid assessment of clinical performance within this important skillset.

Optimizing Residents' Performance of Lumbar Puncture: An RCT Comparing the Effect of Preparatory Interventions on Performance and Self-Confidence.

BACKGROUND: Lumbar puncture is often associated with uncertainty and limited experience on the part of residents; therefore, preparatory interventions can be essential. There is growing interest in the potential benefit of videos over written text. However, little attention has been given to whether the design of the videos impacts on subsequent performance. OBJECTIVE: To investigate the effect of different preparatory interventions on learner performance and self-confidence regarding lumbar puncture (LP). DESIGN: Randomized controlled trial in which participants were randomly assigned to one of three interventions as preparation for performing lumbar puncture: 1) goal- and learner-centered video (GLV) presenting procedure-specific process goals and learner-centered information; 2) traditional video (TV) providing expert-driven content, but no process goals; and 3) written text (WT) with illustrations. PARTICIPANTS AND MAIN MEASURES: Participants were PGY-1 doctors without LP experience. After the preparatory intervention, participants performed an LP in a simulated setting with a standardized patient and an assistant. Two content experts, blinded to participant group allocation, assessed video recordings of the performance using the Lumbar Puncture Assessment Tool (LumPAT) and an overall global rating. Participants rated their self-confidence immediately prior to performing the procedure. The primary outcome was the difference in LumPAT scores among groups. KEY RESULTS: A total of 110 PGY-1 doctors were included. Results demonstrated significant differences in LumPAT mean scores among the three groups: GLV, 42.8; TV, 40.6; WT, 38.1 (p = 0.01). The global rating scores were highest in the GLV group (p = 0.026). Self-confidence scores differed significantly among the three groups (p = 0.003), with the TV group scoring the highest. There were no significant correlations between self-confidence scores and performance scores in any of the groups. CONCLUSION: A video designed with procedure-specific process goals and learner-centered information resulted in better subsequent LP performance than a traditionally designed video or written text. Participants' self-confidence was not predictive of their actual performance.

Assessment of Residents Readiness to Perform Lumbar Puncture: A Validation Study.

BACKGROUND: Lumbar puncture is a common procedure in many specialties. The procedure serves to diagnose life-threatening conditions, often requiring rapid performance. However, junior doctors possess uncertainties regarding performing the procedure and frequently perform below expectations. Hence, proper training and assessment of performance is crucial before entering clinical practice. OBJECTIVE: To develop and collect validity evidence for an assessment tool for lumbar puncture performance, including a standard to determine when trainees are ready for clinical practice. DESIGN: Development of a new tool, based on clinician interviews and a literature review, was followed by an explorative study to gather validity evidence. PARTICIPANTS AND MAIN MEASURES: We interviewed 12 clinicians from different specialties. The assessment tool was used to assess 11 doctors at the advanced beginners' level and 18 novices performing the procedure in a simulated, ward-like setting with a standardized patient. Procedural performance was assessed by three content experts. We used generalizability theory to explore reliability. The discriminative ability of the tool was explored by comparing performance scores between the two groups. The contrasting groups method was used to set a pass/fail standard and the consequences of this was explored. KEY RESULTS: The interviews identified that in addition to the technical aspects of the procedure, non-technical elements involving planning and conducting the procedure are important. Cronbach's alpha = 0.92, Generalizability-coefficient was 0.88 and a Decision-study found one rater was sufficient for low-stakes assessments (G-coefficient 0.71). The discriminative ability was confirmed by a significant difference between the mean scores of novices, 40.9 (SD 6.1) and of advanced beginners, 47.8 (SD 4.0), p = 0.004. A standard of 44.0 was established which was consistent with the raters' global judgments of pass/fail. CONCLUSION: We developed and demonstrated strong validity evidence for the lumbar puncture assessment tool. The tool can be used to assess readiness for practice.

Direct ophthalmoscopy on YouTube: analysis of instructional YouTube videos' content and approach to visualization.

BACKGROUND: Direct ophthalmoscopy is well-suited for video-based instruction, particularly if the videos enable the student to see what the examiner sees when performing direct ophthalmoscopy. We evaluated the pedagogical effectiveness of instructional YouTube videos on direct ophthalmoscopy by evaluating their content and approach to visualization. METHODS: In order to synthesize main themes and points for direct ophthalmoscopy, we formed a broad panel consisting of a medical student, junior and senior physicians, and took into consideration book chapters targeting medical students and physicians in general. We then systematically searched YouTube. Two authors reviewed eligible videos to assess eligibility and extract data on video statistics, content, and approach to visualization. Correlations between video statistics and contents were investigated using two-tailed Spearman's correlation. RESULTS: We screened 7,640 videos, of which 27 were found eligible for this study. Overall, a median of 12 out of 18 points (interquartile range: 8-14 key points) were covered; no videos covered all of the 18 points assessed. We found the most difficulties in the approach to visualization of how to approach the patient and how to examine the fundus. Time spent on fundus examination correlated with the number of views per week (Spearman's ρ=0.53; P=0.029). CONCLUSION: Videos may help overcome the pedagogical issues in teaching direct ophthalmoscopy; however, the few available videos on YouTube fail to address this particular issue adequately. There is a need for high-quality videos that include relevant points, provide realistic visualization of the examiner's view, and give particular emphasis on fundus examination.

Preconceptions influence women's perceptions of information on breast cancer screening: a qualitative study.

BACKGROUND: Screening for breast cancer has been subject to intense debate in recent decades regarding benefits and risks. Participation in breast cancer screening should be based on informed choice, and most countries approach this by sending information leaflets with invitations to attend screening. However, very little attention has been paid to the decision-making process and how the information leaflets are used and understood by women. The aim of this study is twofold. First, we use a theoretical framework to explore how the framing of information influences the intention to participate in breast cancer screening. Second, we discuss how information and attitudes held prior to receiving the invitation influence the perception of the balance between the benefits and risks harms of screening. METHODS: We used a qualitative design and interviewed six women who were soon to receive their first invitation to participate in the breast screening programme in Denmark. The selected women received a copy of the official information leaflet 1 week before we interviewed them. The six women were interviewed individually using an interview guide based on the theory of planned behaviour. We used meaning condensation for our initial analysis, and further analysis was guided by the theory of cognitive dissonance. RESULTS: For our participants, the decision-making process was dominated by the attitudes of the women's circle of acquaintances and, to a lesser extent, by the information that accompanied the screening invitation. Information that conflicted with attitudes the women already held was actively disregarded. The risk of overdiagnosis as a potentially harmful effect of participation in mammography screening was unknown to the women in our study. An isolated framing effect was not found. CONCLUSION: Women have expectations about breast cancer screening that are formed before they receive information from the screening programme. These expectations compromise the perception of balance between screening benefits and potential harmful effects. They also influence the perception of the information in the breast screening leaflet. The phenomenon of overdiagnosis is unknown to the women.