Haptics: The Science of Touch As a Foundational Pathway to Precision Education and Assessment.

ABSTRACT: Clinical touch is the cornerstone of the doctor-patient relationship and can impact patient experience and outcomes. In the current era, driven by an ever-increasing infusion of point-of-care technologies, physical exam skills have become undervalued. Moreover, touch and hands-on skills have been difficult to teach due to inaccurate assessments and difficulty with learning transfer through observation. In this article, the authors argue that haptics, the science of touch, provides a unique opportunity to explore new pathways to facilitate touch training. Furthermore, haptics can dramatically increase the density of touch-based assessments without increasing human rater burden-essential for realizing precision assessment. The science of haptics is reviewed, including the benefits of using haptics-informed language for objective structured clinical examinations. The authors describe how haptic devices and haptic language have and can be used to facilitate learning, communication, documentation and a much-needed reinvigoration of physical examination, and touch excellence at the point of care. The synergy of haptic devices, artificial intelligence, and virtual reality environments are discussed. The authors conclude with challenges of scaling haptic technology in medical education, such as cost and translational needs, and opportunities to achieve wider adoption of this transformative approach to precision education.

Trainees' Perspectives on the Next Era of Assessment and Precision Education.

ABSTRACT: The next era of assessment in medical education promises new assessment systems, increased focus on ensuring high-quality equitable patient care, and precision education to drive learning and improvement. The potential benefits of using learning analytics and technology to augment medical training abound. To ensure that the ideals of this future for medical education are realized, educators should partner with trainees to build and implement new assessment systems. Coproduction of assessment systems by educators and trainees will help to ensure that new educational interventions are feasible and sustainable. In this paper, the authors provide a trainee perspective on 5 key areas that affect trainees in the next era of assessment: (1) precision education, (2) assessor education, (3) transparency in assessment development and implementation, (4) ongoing evaluation of the consequences of assessment, and (5) patient care data as sources of education outcomes.As precision education is developed, it is critical that trainees understand how their educational data are collected, stored, and ultimately utilized for educational outcomes. Since assessors play a key role in generating assessment data, it is important that they are prepared to give high-quality assessments and are continuously evaluated on their abilities. Transparency in the development and implementation of assessments requires communicating how assessments are created, the evidence behind them, and their intended uses. Furthermore, ongoing evaluation of the intended and unintended consequences that new assessments have on trainees should be conducted and communicated to trainees. Finally, trainees should participate in determining what patient care data are used to inform educational outcomes. The authors believe that trainee coproduction is critical to building stronger assessment systems that utilize evidence-based educational theories for improved learning and ultimately better patient care.

Does the location of short-arm cast univalve effect pressure of the three-point mould?

PURPOSE: Forearm and distal radius fractures are among the most common fractures in children. Many fractures are definitively treated with closed reduction and casting, however, the risk for re-displacement is high (7% to 39%). Proper cast application and the three-point moulding technique are modifiable factors that improve the ability of a cast to maintain the fracture reduction. Many providers univalve the cast to accommodate swelling. This study describes how the location of the univalve cut impacts the pressure at three-point mould sites for a typical dorsally displaced distal radius fracture. METHODS: We placed nine force-sensing resistors on an arm model to collect pressure data at the three-point mould sites. Sensory inputs were sampled at 15 Hz. Cast padding and a three-point moulded short arm fibreglass cast was applied. The cast was then univalved on the dorsal, volar, radial or ulnar aspect. Pressure recordings were obtained throughout the procedure. RESULTS: A total of 24 casts were analyzed. Casts univalved in the sagittal plane (dorsal or volar surface) retained up to 16% more pressure across the three moulding sites compared with casts univalved in the coronal plane (radial or ulnar border). CONCLUSION: Maintaining pressure at the three-point mould prevents loss of reduction at the fracture site. This study shows that univalving the cast dorsally or volarly results in less pressure loss at moulding sites. This should improve the chances of maintaining fracture reductions when compared with radial or ulnar cuts in the cast. Sagittal plane univalving of forearm casts is recommended.

Translating motion tracking data into resident feedback: An opportunity for streamlined video coaching.

BACKGROUND: We hypothesized that differences in motion data during a simulated laparoscopic ventral hernia repair (LVH) can be used to stratify top and lower tier performers and streamline video review. MATERIALS AND METHODS: Surgical residents (N = 94) performed a simulated partial LVH repair while wearing motion tracking sensors. We identified the top ten and lower ten performers based on a final product quality score (FPQS) of the repair. Two blinded raters independently reviewed motion plots to identify patterns and stratify top and lower tier performers. RESULTS: Top performers had significantly higher FPQS (23.3 ± 1.2 vs 5.7 ± 1.6 p < 0.01). Raters identified patterns and stratified top performers from lower tier performers (Rater 1 χ2 = 3.2 p = 0.07 and Rater 2 χ2 = 2.0 p = 0.16). During video review, we correlated motion plots with the relevant portion of the procedure. CONCLUSION: Differences in motion data can identify learning needs and enable rapid review of surgical videos for coaching.

Sensors and Psychomotor Metrics: A Unique Opportunity to Close the Gap on Surgical Processes and Outcomes.

The surgical process remains elusive to many. This paper presents two independent empirical investigations where psychomotor skill metrics were used to quantify elements of the surgical process in a procedural context during surgical tasks in a simulated environment. The overarching goal of both investigations was to address the following hypothesis: Basic motion metrics can be used to quantify specific aspects of the surgical process including instrument autonomy, psychomotor efficiency, procedural readiness, and clinical errors. Electromagnetic motion tracking sensors were secured to surgical trainees' (N = 64) hands for both studies, and several motion metrics were investigated as a measure of surgical skill. The first study assessed performance during a bowel repair and laparoscopic ventral hernia (LVH) repair in comparison to a suturing board task. The second study assessed performance in a VR task in comparison to placement of a subclavian central line. The findings of the first study support our subhypothesis that motion metrics have a generalizable application to surgical skill by showing significant correlations in instrument autonomy and psychomotor efficiency during the suturing task and bowel repair (idle time: r = 0.46, p < 0.05; average velocity: r = 0.57, p < 0.05) and the suturing task and LVH repair (jerk magnitude: r = 0.36, p < 0.05; bimanual dexterity: r = 0.35, p < 0.05). In the second study, performance in VR (steering and jerkiness) correlated to clinical errors (r = 0.58, p < 0.05) and insertion time (r = 0.55, p < 0.05) in placement of a subclavian central line. Both gross (dexterity) and fine motor skills (steering) were found to be important as well as efficiency (i.e., idle time, duration, velocity) when seeking to understand the quality of surgical performance. Both studies support our hypotheses that basic motion metrics can be used to quantify specific aspects of the surgical process and that the use of different technologies and metrics are important for comprehensive investigations of surgical skill.

Use of sensors to quantify procedural idle time: Validity evidence for a new mastery metric.

BACKGROUND: Quantification of mastery is the first step in using objective metrics for teaching. We hypothesized that during orotracheal intubation, top tier performers have less idle time compared to lower tier performers. METHODS: At the Anesthesiology 2018 Annual Meeting, 82 participants intubated a normal airway simulator and a burnt airway simulator. The movements of the participant's laryngoscope were quantified using electromagnetic motion sensors. Top tier performers were defined as participants who intubated both simulators successfully in less than the median time for each simulator. Idle time was defined as the duration of time when the laryngoscope was not moving. RESULTS: Top performers showed less Idle Time when intubating the normal airway compared to lower tier performers (14.5 ± 9.8 seconds vs 34.0 ± 52.0 seconds, respectively P < .01). Likewise, top performers showed less Idle Time when intubating the burnt airway compared to lower tier performers (18.6 ± 15.2 seconds vs 63.4 ± 59.11 seconds; P < .01). Comparing performance on the burnt airway to the normal airway, there was a difference for lower tier performers (63.4 ± 59.1 seconds vs 34.0 ± 52.0 seconds; P < .01) but not for top tier performers (18.6 ± 15.2 seconds vs 14.5 ± 9.8 seconds; P = .07). CONCLUSION: Similar to our previous findings with other procedures, Idle Time was shown to have known group validity evidence when comparing top performers with lower tier performers. Further, Idle Time was correlated with procedure difficulty in our prior work. We observed statistically significant differences in Idle Times for lower tier performers when comparing the normal airway to the burnt airway but not for top tier performers. Our findings support the continued exploration of Idle Time for development of objective assessment and curricula.

Screening surgical residents' laparoscopic skills using virtual reality tasks: Who needs more time in the sim lab?

BACKGROUND: This study investigated the possibility of using virtual reality perceptual-motor tasks as a screening tool for laparoscopic ability. We hypothesized that perceptual-motor skills assessed using virtual reality will correlate with the quality of simulated laparoscopic ventral hernia repair. MATERIALS AND METHODS: Surgical residents (N = 37), performed 2 virtual reality perceptual-motor tasks: (1) force matching and (2) target tracking. Participants also performed a laparoscopic ventral hernia repair on a simulator and final product quality score, and endoscopic visualization errors were calculated. Correlational analysis was performed to assess the relationship between performance on virtual reality tasks and laparoscopic ventral hernia repair. RESULTS: Residents with poor performance on force matching in virtual reality-"peak deflection" (r = -0.34, P < .05) and "summation distance" (r = -0.36, P < .05)-had lower final product quality scores. Likewise, poor performance in virtual reality-based target tracking-"path length" (r = -0.49, P < .05) and "maximum distance" (r = -0.37, P < .05)-correlated with a lower final product quality score. CONCLUSION: Our findings support the notion that virtual reality could be used as a screening tool for perceptual-motor skill. Trainees identified as having poor perceptual-motor skill can benefit from focused curricula, allowing them to hone personal areas of weakness and maximize technical skill.

Arterial duplex for diagnosis of peripheral arterial emboli.

BACKGROUND: Whether duplex ultrasound (DUS) imaging alone can be used to successfully plan revascularization for peripheral arterial embolism (PAE) is unknown. This study evaluated the utility of DUS imaging alone for the diagnosis and treatment of PAE. METHODS: Patients with cardiogenic PAE to the lower or upper extremities during a 20-year period were retrospectively evaluated. Patients with visceral or cerebral PAE were excluded. Diagnosis by DUS imaging alone was compared with contrast angiography (CA) or computed tomography angiography (CTA). Patient demographics, use of intraoperative CA, need for reintervention, length of revascularization procedure, and rate of fasciotomy and amputation were compared. Mean peak systolic velocity (PSV; cm/s) measured at the proximal, middle, and distal segment of each artery from the common femoral to the distal tibial arteries was also compared with surgical outcomes. RESULTS: We identified 203 extremities in 182 patients with PAE. Preoperative imaging was obtained in 89%, including DUS imaging alone (44%), CA (37%), and CTA (7%). DUS imaging was used more frequently than CA or CTA in women, older patients, patients with congestive heart failure, upper extremity PAE, and patients on antiplatelet agents preoperatively. Use of intraoperative CA, need for reintervention, rate of fasciotomy and limb loss, and hospital length of stay were similar between the two groups. No upper extremities required amputation. Patients with lower extremity emboli who underwent fasciotomy had lower mean PSVs than those free from fasciotomy at the popliteal (4 ± 6 cm/s vs 31 ± 62 cm/s; P = .03), anterior tibial (1 ± 3 cm/s vs 10 ± 16 cm/s; P = .004), and posterior tibial (2 ± 3 cm/s vs 9 ± 15 cm/s; P = .03) arteries. The 30-day mortality for the series was 25% with a median follow-up of 7.4 months. The only predictor of 30-day mortality on multivariate analysis was tobacco use (odds ratio, 3.1; 95% confidence interval, 1.4-7.0). CONCLUSIONS: Surgical outcomes and survival for patients evaluated by preoperative DUS imaging alone for PAE are equivalent to patients evaluated with CA or CTA. PSVs in the tibiopopliteal arteries may predict the need for fasciotomy. Preoperative DUS imaging alone is sufficient for operative planning in patients with symptoms suggestive of PAE.

The role of axillofemoral bypass in current vascular surgery practice.

BACKGROUND: In the era of increasing endovascular approaches for aortoiliac disease, we sought to determine the role of axillofemoral bypass in contemporary practice. METHODS: All axillofemoral bypasses performed at our institution from 2006 to 2013 were reviewed for indication, patency, and survival and compared with our prior published series before the widespread use of endovascular techniques (1996 to 2001). RESULTS: During the study period, 90 bypasses (29 axillofemoral and 61 axillobifemoral) bypasses were performed. The number of procedures performed decreased from an average of 24 to 12 procedures per year in historical and contemporary groups, respectively. Indications have changed significantly with more urgent or emergent procedures. Overall patency at 1 and 2 years was 74.6% and 67.8%, respectively. Median survival was 40.3 months, with overall survival 67.0% and 54.2% at 1 and 2 years, respectively. CONCLUSIONS: Axillofemoral bypass is an increasingly uncommon procedure and more likely performed for limb salvage in urgent or emergent settings.

A modern series of acute aortic occlusion.

OBJECTIVE: Acute aortic occlusion (AAO) is a rare condition associated with substantial morbidity and mortality. The most recent large series was published over 15 years ago and included patients from the 1980s. Previous studies reported up to 50% of AAOs are caused by embolization, with a mortality rate approaching 50%. We reviewed our recent experience with AAOs to identify current etiologies and outcomes in a contemporary series of patients with AAOs. METHODS: Current Procedural Terminology codes and data from a prospectively maintained vascular surgical database were used to identify patients with acute occlusion of the native aorta between 2005 and July 2013. AAOs secondary to trauma, dissection, or graft occlusion were excluded. RESULTS: We identified 29 patients with AAOs treated at our institution. Twenty-three patients were transferred from referring hospitals with a mean transfer time of 3.9 hours (range, 0.5-7.5 hours). Twenty-two presented with occlusion below the renal arteries and seven with occlusion extending above the renal arteries. Resting motor/sensory lower extremity deficits were noted in 17 patients. Eight patients presented with complete paraplegia. Etiology was felt to be aortoiliac thrombosis in 22 cases, embolic occlusion in 2, and indeterminate in 5. Surgical revascularization was performed in 26 cases (extra-anatomic bypass in 18, thromboembolectomy in 5, and aortobifemoral bypass in 3 patients. Three patients had no intervention. Acute renal failure developed in 15 patients and rhabomyolysis in 10 patients. Fasciotomy was performed in 19 extremities. Nine extremities were amputated in six patients. Overall mortality was 34% with a 30-day mortality of 24% and a postprocedure mortality of 15%. CONCLUSIONS: AAO is an infrequent but devastating event. The dominant etiology of AAOs is now thrombotic occlusion. Despite advances in vascular surgery and critical care over the past 2 decades, associated morbidity and mortality remain substantial with high rates of limb loss, acute renal failure, rhabdomyolysis, and death. Mortality may be improved with expeditious extra-anatomic bypass.

Medical comorbidities but not interventions adversely affect survival in patients with intermittent claudication.

OBJECTIVE: Intermittent claudication (IC) is common and associated with decreased survival. While patients with IC infrequently progress to critical limb ischemia (CLI), many elect to pursue intervention initially or during follow-up. However, controversy exists as to whether intervention in patients with IC adversely impacts survival or limb salvage. The purpose of this study was to characterize patient demographics and comorbidities with respect to differences in survival and limb salvage among patients who elect no intervention (NI) vs those electing immediate intervention (II) or delayed intervention (DI) for IC. METHODS: Patients referred to a university practice for limb ischemia were identified via a query of the electronic medical record from 2007 to 2011. Patients with prior lower extremity interventions or CLI were excluded. IC patients were classified according to intervention: NI during follow-up, II, and DI. Patient demographics, Charlson morbidity index, survival, and reintervention rates were analyzed. RESULTS: A total of 262 of 1320 patients met inclusion criteria. Thirty patients with possible IC were believed to have nonarterial related symptoms. Study patients included 132 with NI, 62 with II, and 38 with DI. DI patients were younger and less frequently diabetic (median age, 65.5 years, 63.5 years, 58.0 years; P = .002; diabetes, 43.2%, 39.5%, 22.6%; P = .02 for NI, II, and DI, respectively). NI patients had higher Charlson comorbidity scores (P < .05). Hypertension, hyperlipidemia, and diabetes were associated with decreased survival in all groups (P < .05). Median survival was greatest for DI patients and least for NI patients (NI 92 months, II 95 months, DI 143 months; log-rank = .015). Primary patency of interventions at 1 and 5 years were equal for II and DI patients (1 year, II 80% vs DI 79%; 5 years, II 45% vs DI 50%; P = .9). Reintervention was common with rates similar between the II and DI groups (P > .05). Four of 38 DI patients required minor amputation for progression to CLI. There were no major amputations in any group. CONCLUSIONS: Progression to CLI is uncommon in IC. Survival of claudicants is decreased by diabetes, hypertension, and hyperlipidemia but not by intervention for IC. Reintervention is common in treated IC patients but no different among those undergoing II and DI. Intervention did not lead to major amputation. II or DI in IC patients does not affect survival or major amputation.