Development and validation of a computer-based situational judgement test to assess medical students' communication skills in the field of shared decision making.

OBJECTIVE: To develop a computer-based test (CBT) measuring medical students' communication skills in the field of shared decision making (SDM) and to evaluate its construct validity. METHODS: The CBT was developed in the context of an experimental study comparing three different trainings for SDM (including e-learning and/or role-play) and a control group. Assessment included a CBT (Part A: seven context-poor questions, Part B: 15 context-rich questions) and interviews with two simulated patients (SP-assessment). Cronbach's α was used to test the internal consistency. Correlations between CBT and SP-assessment were used to further evaluate construct validity of the CBT. RESULTS: Seventy-two students took part in the study. Mean value for the CBT score was 72% of the total score. Cronbach's α was 0.582. After eliminating three items, Cronbach's α increased to 0.625. Correlations between the CBT and SP-assessment were low to moderate. The control group scored significantly lower than the training settings (p<0.001). CONCLUSION: The CBT was reliable enough to test for group differences. For summative assessment purposes, considerably more questions would be needed. PRACTICE IMPLICATIONS: We encourage teachers who particularly work with large student numbers to consider CBT as a feasible assessment method for cognitive aspects of communication skills.

The Questionnaire D-RECT German: Adaptation and testtheoretical properties of an instrument for evaluation of the learning climate in medical specialist training.

AIM: Boor et al developed and validated the questionnaire D-RECT (Dutch Residency Educational Climate Test ) to measure the clinical learning environment within the medical specialist training. In this study, a German version of this questionnaire (D-RECT German) is analyzed regarding testtheoretical properties. PROBLEM: Are the results of Boor et al replicable as a proof for validity of the questionnaire D-RECT? MATERIAL & METHODS: The study was performed as online survey using the questionnaire D-RECT German (50 items in 11 subscales). To determine item characteristics and internal consistency (Cronbach's α), item- and reliability analyses were performed. Furthermore, a confirmatory factor analysis was performed using a model for maximum-likelihood estimation to evaluate validity. RESULTS: This replication study on the psychometric properties of the D-RECT with 255 residents at 17 German hospitals revealed heterogeneous discriminatory power for all items and an internal consistency of Cronbach's α between 0.57 and 0.85. Within the confirmatory factor analysis, 6 items showed standardized regression coeffizients <0.5, two of them in the subscale "Attendings role". Furthermore, strong interdependencies (>0.7) were found between the subscales "Supervision", "Coaching" and "Attendings role". CONCLUSION: The present replication study with the D-RECT German showed structural differences with respect to factorial validity underpinning the need of further validation studies.

What motivates young physicians? - a qualitative analysis of the learning climate in specialist medical training.

BACKGROUND: Not least the much-invoked shortage of physicians in the current and the next generation has resulted in a wide range of efforts to improve postgraduate medical training. This is also in the focus of the current healthcare policy debate. Furthermore, quality and scope of available postgraduate training are important locational advantages in the competition for medical doctors. This study investigates the preferences and concerns that German house officers (HOs) have about their current postgraduate training. It also highlights how HOs evaluate the quality of their current postgraduate training and the learning environment. METHODS: HOs were asked to answer the question: "Which things are of capital importance to you personally in your medical training?", using a free text format. The survey was conducted web based (Lime survey) and all data was anonymized. Summarizing qualitative analyses were performed using the software tool MaxQDA. RESULTS: A total of 255 HOs participated in this study (female: n = 129/50.6 %; male: n = 126/49.4 %; age: 32 + 6 years) associated with 17 different German hospitals and from four medical specialties. Ten categories were generated from a total of 366 free text answers: 1. methodology of learning (n = 66), 2. supervision (n = 66), 3. learning structure (n = 61), 4. teaching competence (n = 37), 5. dedication (n = 34), 6. work climate (n = 29), 7. feedback/communication (n = 22), 8. challenge/patient safety (n = 21), 9. time/resources (n = 17), 10. personal security/safety (n = 13). CONCLUSIONS: HOs want a reliable and curriculum-guided learning structure. Different studying techniques should be used with sufficient (time) resources available in a trusting and communicative learning environment. Competent and dedicated instructors are expected to give individual and specific feedback to the HOs on individual strengths and deficits. Instructors should develop educational concepts in cooperation with the HOs and at the same time avoid excessive demands on HOs or hazards to patients.

May student examiners be reasonable substitute examiners for faculty in an undergraduate OSCE on medical emergencies?

OBJECTIVES: To compare the effect of student examiners (SE) to that of faculty examiners (FE) on examinee performance in an OSCE as well as on post-assessment evaluation in the area of emergency medicine management. METHODS: An OSCE test-format (seven stations: Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS), Trauma-Management (TM), Pediatric-Emergencies (PE), Acute-Coronary-Syndrome (ACS), Airway-Management (AM), and Obstetrical-Emergencies (OE)) was administered to 207 medical students in their third year of training after they had received didactics in emergency medicine management. Participants were randomly assigned to one of the two simultaneously run tracks: either with SE (n = 110) or with FE (n = 98). Students were asked to rate each OSCE station and to provide their overall OSCE perception by means of a standardized questionnaire. The independent samples t-test was used and effect sizes were calculated (Cohens d). RESULTS: Students achieved significantly higher scores for the OSCE stations "TM", "AM", and "OE" as well as "overall OSCE score" in the SE track, whereas the station score for "PE" was significantly higher for students in the FE track. Mostly small effect sizes were reported. In the post-assessment evaluation portion of the study, students gave significant higher ratings for the ACS station and "overall OSCE evaluation" in the FE track; also with small effect sizes. CONCLUSION: It seems quite admissible and justified to encourage medical students to officiate as examiners in undergraduate emergency medicine OSCE formative testing, but not necessarily in summative assessment evaluations.

Can today's house officers teach effectively? An assessment in undergraduate emergency training.

BACKGROUND: Previous publications describe house officers (HOs) as unaware of their ineffective teaching skills. OBJECTIVE: The aim of this study was to evaluate the role of teaching seniority in the comparison of teaching skills between HOs and faculty. MATERIALS AND METHODS: Ten HOs (F: n=4, M: n=6, age: 35.1±6.8 years) and nine faculty (F: n=3, M: n=6, age: 41.4±4.9 years) who actively teach undergraduate emergency medicine were immediately evaluated at the end of the course by their students using the questionnaire SFDP26. The questionnaire consists of one item on 'overall teaching effectiveness' (OTE) (1=very poor to 5=excellent) and 25 items measured on a five-point Likert scale (1-5=strongly disagree to strongly agree) divided into seven subscales: 1, 'establishing the learning climate' (LC); 2, 'control of session' (CS); 3, 'communication of goals' (CG); 4, 'facilitating understanding and retention' (UR); 5, 'evaluation' (E); 6, 'feedback' (FB) and 7, 'promoting self-directed learning' (SL). The sample included 173 medical students in their third year of training who were randomly assigned to the instructors. A Mann-Whitney U-test was used to calculate group-related differences (resident vs. teaching faculty). For significant differences, effect size was calculated (r=Z/√N). RESULTS: No sex-related differences were found. Significantly better ratings for HOs were found in subscales: 1, 'LC' (P=0.001; r=0.20); 2, 'CS' (P=0.037; r=0.15); 5, 'E' (P=0.007; r=0.20); 6, 'FB' (P=0.001; r=0.23); 7, 'SL' (P=0.004; r=0.24) and 'OTE' (P=0.027; r=0.26). CONCLUSION: From a learner's perspective, the quality of teaching provided by HOs was rated at least similar and mostly better overall than that provided by faculty. These findings contradict results from previous studies on the quality of HO teaching and therefore warrant further assessment.

The suitability of EIT to estimate EELV in a clinical trial compared to oxygen wash-in/wash-out technique.

INTRODUCTION: Open endotracheal suctioning procedure (OSP) and recruitment manoeuvre (RM) are known to induce severe alterations of end-expiratory lung volume (EELV). We hypothesised that EIT lung volumes lack clinical validity. We studied the suitability of EIT to estimate EELV compared to oxygen wash-in/wash-out technique. METHODS: Fifty-four postoperative cardiac surgery patients were enrolled and received standardized ventilation and OSP. Patients were randomized into two groups receiving either RM after suctioning (group RM) or no RM (group NRM). Measurements were conducted at the following time points: Baseline (T1), after suctioning (T2), after RM or NRM (T3), and 15 and 30 min after T3 (T4 and T5). We measured EELV using the oxygen wash-in/wash-out technique (EELVO2) and computed EELV from EIT (EELVEIT) by the following formula: EELVEITTx,y…=EELVO2+ΔEELI×VT/ΔZ. EELVEIT values were compared with EELVO2 using Bland-Altman analysis and Pearson correlation. RESULTS: Limits of agreement ranged from -0.83 to 1.31 l. Pearson correlation revealed significant results. There was no significant impact of RM or NRM on EELVO2-EELVEIT relationship (p=0.21; p=0.23). DISCUSSION: During typical routine respiratory manoeuvres like endotracheal suctioning or alveolar recruitment, EELV cannot be estimated by EIT with reasonable accuracy.

Interstitial fluid shifts in simulated long-haul flights monitored by a miniature ultrasound device.

BACKGROUND: Long-haul flights (LHF) are known to be connected with an increased risk of deep vein thrombosis. There is still some lack of clarity about the impact of hypoxia and lower levels of air pressure and humidity on passengers during flight. This cross-over study researched interstitial fluid shifts traced by measurements of tissue thickness (TT) under controlled simulated conditions of a LHF. METHODS: There were 18 male volunteers (28.4 +/- 8.1 yr) who were subjected to both procedure 1 (altitude: 2500 m/humidity: 15%)and procedure 2 (altitude: 0 m/humidity: 50%), each lasting 8 h. Measurements forTT at tibia (TT-t) and forehead sites (TT-f) were made using a miniature A-mode ultrasonic device. Fluid intake, bodyweight, heart rate, oxygen saturation, and systolic and diastolic blood pressure were recorded over time. Blood samples were collected before (t0) and after 8 h (t8) to analyze plasma viscosity (PV). RESULTS: We found an increased TT-t over time at an altitude of 0 m (t0: 4.8 +/- 1.2; t8: 5.2 +/- 1.3) and 2500 m (t0: 4.7 +/- 1.2; t8: 5.3 +/- 1.2), respectively, without differences between study groups. TT-f increased significantly over time at 2500 m (t0: 4.6 +/- 0.8; t8: 4.9 +/- 0.8) with significantly higher TT compared to 0 m at t8 (4.5 +/- 0.7). No further significant differences were found. CONCLUSION: This study suggests that the controlled variable "sitting position" seems to have the strongest influence on leg edema formation during LHF. PV appears not to be affected as long as passengers receive adequate fluid intake. Further studies should be conducted to investigate different methods of preventing venous congestion. These pre-emptive efforts could be tested easily using a miniature handheld ultrasound device.

The Questionnaire "SFDP26-German": a reliable tool for evaluation of clinical teaching?

AIMS: Evaluation of the effectiveness of clinical teaching is an important contribution for the quality control of medical teaching. This should be evaluated using a reliable instrument in order to be able to both gauge the status quo and the effects of instruction. In the Stanford Faculty Development Program (SFDP), seven categories have proven to be appropriate: Establishing the Learning Climate, Controlling a Teaching Session, Communication of Goals, Encouraging Understanding and Retention, Evaluation, Feedback and Self-directed Learning. Since 1998, the SFDP26 questionnaire has established itself as an evaluation tool in English speaking countries. To date there is no equivalent German-language questionnaire available which evaluates the overall effectiveness of teaching. QUESTION: Development and theoretical testing of a German-language version of SFDP26 (SFDP26-German),Check the correlation of subscale of SFDPGerman against overall effectiveness of teaching. METHODS: 19 anaesthetists (7 female, 12 male) from the University of Lübeck were evaluated at the end of a teaching seminar on emergency medical care using SFDP-German. The sample consisted of 173 medical students (119 female (68.8%) and 54 male (31.2%), mostly from the fifth semester (6.6%) and sixth semester (80.3%). The mean age of the students was 23±3 years. RESULTS: The discriminatory power of all items ranged between good and excellent (r(it)=0.48-0.75). All subscales displayed good internal consistency (α=0.69-0.92) and significant positive inter-scale correlations (r=0.40-0.70). The subscales and "overall effectiveness of teaching" showed significant correlation, with the highest correlation for the subscale "communication of goals (p< 0.001; r = 0.61). CONCLUSION: The analysis of SFDP26-German confirms high internal consistency. Future research should investigate the effectiveness of the individual categories on the overall effectiveness of teaching and validate according to external criteria.

Immunomodulatory effects of Sanglifehrin A in the innate and acquired immune response of neonatal whole blood cells.

Previous investigations have shown the immunosuppressive activity of the immunophilin-binding macrolide Sanglifehrin A (SFA). In adults, SFA also exerts anti-inflammatory properties in lipopolysaccharide (LPS)-stimulated whole blood cultures. It was the aim of this study to investigate whether the unique properties of SFA are also present in the neonatal immune system, as neonates are susceptible to serious infection due to an immaturity of immune responses. We used a whole blood assay to investigate the impact of SFA on T-cell proliferation and secretion of T-cell cytokines upon Anti-CD3/Anti-CD28 costimulation. In addition, interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-alpha) secretion was assessed in whole blood monocytes after LPS stimulation. Furthermore, the influence of SFA on LPS-induced signal transduction pathways, specifically the activity of p42/44, p38 and Ap-1, was assessed in neonatal PBMCs. Neonatal cord blood lymphocytes were found to have a diminished IL-4, IL-6, TNF-alpha and interferon-gamma (IFN-gamma) production upon Anti-CD3/Anti-CD28 costimulation compared to adult whole blood lymphocytes. In contrast, no significant differences were noted for either IL-2 production or proliferation of CD4+ cells. Upon addition of 1000nM SFA to neonatal whole blood cultures, a significant inhibition of both, T-cell cytokine secretion and proliferation was demonstrated. In line with data from adult whole blood cultures, SFA proved to be a strong inhibitor of LPS-induced expression of IL-6 and TNF-alpha in the neonatal whole blood system. In signal transduction studies of the LPS pathway, a potent inhibition of the protein kinase p42/44 was demonstrated. SFA was also shown to block nuclear translocation of the transcription factor Ap-1. SFA was proved to have inhibitory effects on innate and acquired immune response of neonatal whole blood cells. The protein kinase p42/44 and the transcription factor Ap-1 were demonstrated to be potential key molecules for the anti-inflammatory effect of SFA.

Automated continuous chest compression for in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity: a report of five cases.

Of patients with in-hospital cardiac arrest, those with pulseless electrical activity (PEA) have the worst outcome. Especially in these patients effective chest compressions according to the guidelines may be the key strategy to improve survival. Recently, a novel automatic mechanical chest compression device (LUCAS-CPR) has been shown to ensure effective continuous compressions without interruption during transport, diagnostic procedures and in the catheter laboratory, and may thus significantly improve outcome after resuscitation of in-hospital cardiac arrest. We report here on the first five well documented cases of in-hospital resuscitation of PEA using the LUCAS-CPR compression device.

Effects of ciclosporin A, tacrolimus and sirolimus on cytokine production in neonatal immune cells.

BACKGROUND: It was the aim of this study to evaluate the effects of the well-known immunosuppressive drugs ciclosporin A (CsA), tacrolimus and sirolimus on the intracytoplasmic cytokine expression of neonatal immune cells. METHODS: Immunosuppressive drugs were added to whole blood cultures of neonatal cord blood samples (n = 17) and peripheral blood samples of adults (n = 17) in vitro prior to stimulation of lymphocytes with phorbol 12-myristate 13-acetate (PMA)/ionomycin or monocytes. RESULTS: Upon exposure to ciclosporin A (500 ng/mL) or tacrolimus (25 ng/mL) the number of cytokine expressing T cells was almost completely blocked in neonatal T cells while sirolimus (10 ng/mL) only inhibited intracytoplasmatic tumour necrosis factor alpha (TNF-alpha) expression (mean% positive cells; 4.0 +/- 2.1% vs. 1.09 +/- 0.6%, p = 0.003), but mildly stimulated the intracellular expression of interleukin (IL)-2 (24.4 +/- 6.5% vs. 28.1 +/- 7.1%, p = 0.041). In cord blood lymphocytes, the inhibitory effect of ciclosporin A and tacrolimus was dose-dependent (e.g. IL-2: control, 12.3 +/- 5.33%, ciclosporin A 5 ng/mL, 10.1 +/- 5.5%; 50 ng/mL, 7.1 +/- 4.7%; 500 ng/mL, 1.2 +/- 0.3%; tacrolimus 0.25 ng/mL, 9.3 +/- 4.9%; 2.5 ng/mL, 6.1 +/- 3.3%; 25 ng/mL, 1.0 +/- 0.6%), while the function of adult lymphocytes was only impaired at high doses of both compounds. In contrast, the number of cytokine expressing monocytes was not influenced by ciclosporin A and tacrolimus except for a minor decrease of TNF-alpha producing neonatal monocytes after addition of tacrolimus (17.9% vs. 13.9%, p = 0.031). Interestingly, sirolimus was shown to inhibit intracellular IL-6 production in adults (63.1 +/- 12.7% vs. 52.0 +/- 16.0%, p = 0.005), but in neonatal monocytes intracellular IL-6 expression was stimulated (53.5 +/- 22.0% vs. 64.7 +/- 19.1%, p = 0.041). CONCLUSIONS: The potent dose-dependent inhibitory effect of ciclosporin A and tacrolimus in cord blood lymphocytes provides the basis for further studies on functional immaturity of the neonatal immune system and for future strategies to optimize umbilical cord blood transplantion. Sirolimus was demonstrated to have a distinct effect on neonatal immune cells as shown by increased expression of IL-2 in lymphocytes and IL-6 in monocytes, while only lymphocytic TNF-alpha expression was inhibited.