Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review.

Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.

A comparison of 3- and 4-option multiple-choice items for medical subspecialty in-training examinations.

BACKGROUND: The American Board of Anesthesiology piloted 3-option multiple-choice items (MCIs) for its 2020 administration of 150-item subspecialty in-training examinations for Critical Care Medicine (ITE-CCM) and Pediatric Anesthesiology (ITE-PA). The 3-option MCIs were transformed from their 4-option counterparts, which were administered in 2019, by removing the least effective distractor. The purpose of this study was to compare physician performance, response time, and item and exam characteristics between the 4-option and 3-option exams. METHODS: Independent-samples t-test was used to examine the differences in physician percent-correct score; paired t-test was used to examine the differences in response time and item characteristics. The Kuder and Richardson Formula 20 was used to calculate the reliability of each exam form. Both the traditional (distractor being selected by fewer than 5% of examinees and/or showing a positive correlation with total score) and sliding scale (adjusting the frequency threshold of distractor being chosen by item difficulty) methods were used to identify non-functioning distractors (NFDs). RESULTS: Physicians who took the 3-option ITE-CCM (mean = 67.7%) scored 2.1 percent correct higher than those who took the 4-option ITE-CCM (65.7%). Accordingly, 3-option ITE-CCM items were significantly easier than their 4-option counterparts. No such differences were found between the 4-option and 3-option ITE-PAs (71.8% versus 71.7%). Item discrimination (4-option ITE-CCM [an average of 0.13], 3-option ITE-CCM [0.12]; 4-option ITE-PA [0.08], 3-option ITE-PA [0.09]) and exam reliability (0.75 and 0.74 for 4- and 3-option ITE-CCMs, respectively; 0.62 and 0.67 for 4-option and 3-option ITE-PAs, respectively) were similar between these two formats for both ITEs. On average, physicians spent 3.4 (55.5 versus 58.9) and 1.3 (46.2 versus 47.5) seconds less per item on 3-option items than 4-option items for ITE-CCM and ITE-PA, respectively. Using the traditional method, the percentage of NFDs dropped from 51.3% in the 4-option ITE-CCM to 37.0% in the 3-option ITE-CCM and from 62.7% to 46.0% for the ITE-PA; using the sliding scale method, the percentage of NFDs dropped from 36.0% to 21.7% for the ITE-CCM and from 44.9% to 27.7% for the ITE-PA. CONCLUSIONS: Three-option MCIs function as robustly as their 4-option counterparts. The efficiency achieved by spending less time on each item poses opportunities to increase content coverage for a fixed testing period. The results should be interpreted in the context of exam content and distribution of examinee abilities.

A Departmentally Developed Agreement to Improve Faculty-Resident Feedback.

Background: Feedback from faculty to residents is important for the development of the resident. Effective feedback between faculty and residents requires trust between the two parties. An agreement between faculty and residents was developed to determine whether it would improve resident satisfaction with feedback. Methods: Groups of faculty and residents met to discuss expectations and barriers to feedback. Based on this information, the two groups developed a Feedback Agreement that was edited and approved by the entire Department of Anesthesiology. The Feedback Agreement was presented in meetings with the faculty and the residents. To assess satisfaction with feedback, the Accreditation Council for Graduate Medical Education resident survey was used, as it assesses resident satisfaction with various aspects of the program, and was compared before and after the agreement. Results: The satisfaction scores with feedback before the Feedback Agreement were statistically lower than scores for the specialty and for all residents in training programs. Satisfaction rose from 53% of 76 respondents (average score of 3.5 in 2020 to 2021) to 74% of 78 respondents being satisfied or extremely satisfied (average score of 4.0 in 2021 to 2022; P = .03). This score was not statistically different from residents in Anesthesiology programs or all residents in training programs. Conclusions: The development of a Feedback Agreement improved resident satisfaction with faculty feedback as assessed by the Accreditation Council for Graduate Medical Education resident survey.

First-Year Results of the American Board of Anesthesiology's Objective Structured Clinical Examination for Initial Certification.

In 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate an Objective Structured Clinical Examination (OSCE) into its initial certification examination system. Previously, the ABA's staged examination system consisted of 2 written examinations (the BASIC and ADVANCED examinations) and the Standardized Oral Examination (SOE). The OSCE and the existing SOE are now 2 separate components of the APPLIED Examination. This report presents the results of the first-year OSCE administration. A total of 1410 candidates took both the OSCE and the SOE in 2018. Candidate performance approximated a normal distribution for both the OSCE and the SOE, and was not associated with the timing of the examination, including day of the week, morning versus afternoon session, and order of the OSCE and the SOE. Practice-based Learning and Improvement was the most difficult station, while Application of Ultrasonography was the least difficult. The correlation coefficient between SOE and OSCE scores was 0.35 ([95% confidence interval {CI}, 0.30-0.39]; P < .001). Scores for the written ADVANCED Examination were modestly correlated with scores for the SOE (r = 0.29 [95% CI, 0.25-0.34]; P < .001) and the OSCE (r = 0.15 [95% CI, 0.10-0.20]; P < .001). Most of the candidates who failed the SOE passed the OSCE, and most of the candidates who failed the OSCE passed the SOE. Of the 1410 candidates, 77 (5.5%) failed the OSCE, 155 (11.0%) failed the SOE, and 25 (1.8%) failed both. Thus, 207 (14.7%) failed at least 1 component of the APPLIED Examination. Adding an OSCE to a board certification examination system is feasible. Preliminary evidence indicates that the OSCE measures aspects of candidate abilities distinct from those measured by other examinations used for initial board certification.

Awareness and Aortocaval Obstruction in Obstetric Anesthesia.

Awareness during general anesthesia for cesarean delivery continues to be a major problem. The key to preventing awareness is strict attention to anesthetic technique. The prevalence and implications of aortocaval compression have been firmly established. Compression of the vena cava is a real occurrence when assuming the supine position. Relief of this compression most likely does not occur until the patient is turned 30°, which is not feasible for performing cesarean delivery. Although it is still wise to tilt the patient, the benefit of this tilt may not be as great as once thought.

Postdural Puncture Headache: An Evidence-Based Approach.

Headache after dural puncture is a common complication accompanying neuraxial anesthesia. The proposed cause is loss of cerebrospinal fluid through the puncture into the epidural space. Although obstetric patients are at risk for the development of this headache because of female gender and young age, there is a difference in the obstetric population. Women who deliver by cesarean delivery have a lower incidence of headache after dural puncture compared with those who deliver vaginally. Treatment of postdural puncture headache is an epidural blood patch. Departments should develop protocols for management of accidental dural puncture, including appropriate follow-up and indications for further management.

Postdural puncture headache: a headache for the patient and a headache for the anesthesiologist.

PURPOSE OF REVIEW: To identify newly identified risk factors for the development of a postdural puncture headache (PDPH) as well as to outline the key points in the management of unintentional dural puncture and of PDPH. RECENT FINDINGS: The lack of experience of the proceduralist and a vaginal delivery are two risk factors that increase the risk of the patient developing a PDPH. The use of intrathecal catheters for the prevention of a headache is not of value, although an intrathecal catheter may prove to be the best method for providing analgesia for the patient. When performing an epidural blood patch, the optimal amount of blood is 20  ml, as long as the patient does not develop the symptoms of back pain or leg pain during the injection. SUMMARY: Many practitioners do not practice an evidence-based approach to the management of unintentional dural puncture and PDPH. Written institutional protocols are important to insure that patients receive the optimal care.

The adult learner: is it necessary to understand for teaching in anesthesiology.

Educators came to realize what internists and pediatricians have known all along: adults and children are not the same. They differ in physiology, pharmacology, and learning. To approach teaching of the adult learner as one would a child is likely to fail. To effectively design and execute a curriculum for the adult, the teacher must consider the role of personal experience, learning preparedness, learning orientation, and motivation to learn. Although these principles may seem novel, they represent good judgment when teaching the adult. The key factor for the educator is to determine the needs of the adult (which is typically based upon personal experience) and then design and implement a curriculum based upon these needs. This approach is backward from the approach used in children in which the curriculum is established without any input from the learner. One other means to improve success is to foster personal reflection upon the teaching by the adult learner. This reflection may develop from carefully phrased questions, from activities in applying the knowledge, or from within the learner. By helping the learner to reflect, the true goals of the teaching may be achieved and the teacher is rewarded by having a more knowledgeable provider, who is able to use and to question the new knowledge. The cycle of adult learning is completed but also starts again.

The teaching of professionalism during residency: why it is failing and a suggestion to improve its success.

Professionalism is one of the core competencies to be taught and evaluated during residency. A review of the literature suggests that professionalism is not completely understood or practiced. The teaching of professionalism has been incorporated into the educational programs for residents. However, residents learn from two curriculums: the stated curriculum and a hidden curriculum. The hidden curriculum represents the actions observed by the resident of the faculty in the hospital. The impact of this hidden curriculum upon professional behavior by the resident is significant. Due to the hidden curriculum, a possible means of improving professionalism involves the development of a program for faculty. This program must include not only topics but time for personal reflection of one's knowledge and actions. Self-reflection allows for the development of a true understanding and practice of professionalism and may improve professional behavior.