Implementation of written structured feedback into a surgical OSCE.

BACKGROUND: Feedback is an essential element of learning. Despite this, students complain about receiving too little feedback in medical examinations, e.g., in an objective structured clinical examination (OSCE). This study aims to implement a written structured feedback tool for use in OSCEs and to analyse the attitudes of students and examiners towards this kind of feedback. METHODS: The participants were OSCE examiners and third-year medical students. This prospective study was conducted using a multistage design. In the first step, an unstructured interrogation of the examiners formed the basis for developing a feedback tool, which was evaluated and then adopted in the next steps. RESULTS: In total, 351 students and 51 examiners participated in this study. A baseline was created for each category of OSCE station and was supplemented with station-specific items. Each of these items was rated on a three-point scale. In addition to the preformulated answer options, each domain had space for individual comments. A total of 87.5% of the students and 91.6% of the examiners agreed or rather agreed that written feedback should continue to be used in upcoming OSCEs. CONCLUSION: The implementation of structured, written feedback in a curricular, summative examination is possible, and examiners and students would like the feedback to be constant.

The effect of video-assisted oral feedback versus oral feedback on surgical communicative competences in undergraduate training.

PURPOSE: Feedback can significantly improve future performance. Reviewing one's performance by video is discussed as useful adjunct to debriefing, particularly for non-technical skills. Communicative competencies are an essential part of daily clinical practice; thus should be taught and assessed during undergraduate training. The aim of this study was to compare the educational value of video-assisted feedback versus oral feedback in communicative competencies in the surgical context. METHODS: Fourth-year medical students completed a 210-min training unit of 'taking patient's history and obtaining informed consents prior to surgery' using role plays. Oral feedback was received directly thereafter using agenda-led, outcome-based guidelines (ALOBA). In the study group, the role plays were video-taped and reviewed thereafter. Afterwards, students completed two OSCE stations, where they were assessed regarding their communicative competencies and the content of the clinical scenario. RESULTS: One-hundred students (49 receiving video-assisted feedback, 51 oral) participated in the study. Those receiving video-assisted feedback performed significantly better in overall score in both OSCE stations (p < 0.001), in all five assessed communicative competencies at taking patient history (p = 0.029 or better), and in 2 of 5 items at obtaining informed consent (p = 0.008, <0.001). The educational effect size for both tasks was large. CONCLUSION: Using our methodology, video-assisted feedback offered a significant educational benefit over oral feedback alone during a simulated patient encounter in a surgical context.

Tailored ultrasound learning for acute care surgeons: a review of the MUSEC (Modular UltraSound ESTES Course) project.

PURPOSE: The European Society for Trauma and Emergency Surgery (ESTES) identified the need for general and trauma surgeons involved in the management of critically ill surgical patients to embrace and learn both basic and advanced US skills. A steering group was created to address this deficit. METHODS: Modular UltraSound ESTES Course (MUSEC) is a modular blended-learning course. It incorporates pre-test/post-test examinations, pre-course online materials, didactic and interactive lectures, interactive case scenarios discussion with pathological US clips, hands-on practice on healthy volunteer models, and on original phantoms for simulating both pathological US findings and practicing US-guided interventional maneuvers. Four independent modules were provided. Surgical decision-making didactics were also included in the course curriculum. Learning gain (Δ of the rating of pre-test and post-test) was calculated for each module. An anonymous post-course satisfaction survey was also administered (16 questions with a Likert's 5-point scale of evaluation). RESULTS: Twenty-three MUSEC Courses were run in a 30 months period, training 416 doctors from 29 countries. A total of 52 modules were delivered. The mean pre-test and post-test grades were 8.3/12 and 10.7/12, respectively, yielding a significant mean learning gain of 28.9 % (p = 0.001). Post-course satisfaction survey got an overall ranking of 4.5/5. CONCLUSIONS: MUSEC is an effective and original educational format, enjoyed by candidates, that fills an educational gap for tailored US education as a procedural skill to acute care surgeons. Ongoing revisions should reduce the current limitations and increase the educational value, in terms of number of modules and post-course credentialing.

["Practical clinical competence" - a joint programme to improve training in surgery]. / "Praktische klinische Kompetenz" - ein Verbundprojekt zur Verbesserung der chirurgischen Lehre.

INTRODUCTION: Practical clinical competence is, as a result of the complexity of the required skills and the immediate consequences of their insufficient mastery, fundamentally important for undergraduate medical education. However, in the daily clinical routine, undergraduate training competes with patient care and experimental research, mostly to the disadvantage of the training of clinical skills and competencies. All students have to spend long periods in compulsory surgical training courses during their undergraduate studies. Thus, surgical undergraduate training is predestined to exemplarily develop, analyse and implement a training concept comprising defined learning objectives, elaborated teaching materials, analysed teaching methods, as well as objective and reliable assessment methods. THE PROJECT: The aim of this project is to improve and strengthen undergraduate training in practical clinical skills and competencies. The project is funded by the German Federal Ministry of Education and Research with almost two million Euro as a joint research project of the medical faculties of the universities of Frankfurt/Main, Gießen and Marburg, in collaboration with the German Society of Surgery, the German Society of Medical Education and the German Medical Students' Association. Nine packages in three pillars are combined in order to improve undergraduate medical training on a methodical, didactic and curricular level in a nation-wide network. Each partner of this network provides a systematic contribution to the project based on individual experience and competence. Based on the learning objectives, which were defined by the working group "Education" of the German Society of Surgery, teaching contents will be analysed with respect to their quality and will be available for both teachers and students as mobile learning tool (first pillar). The existing surgical curricula at the cooperating medical faculties will be analysed and teaching methods as well as assessment methods for clinical skills will be evaluated regarding their methodological quality and evidence. The existing surgical curricula will be revised and adapted on the basis of these results (second pillar). Qualification programmes for physicians will be implemented in order to improve both undergraduate education and the attractiveness of educational research, the required teaching quality will be imparted in a nationwide "train-the-teacher" program for surgical clinical skills (third pillar).

[Implementation of the laryngeal tube for prehospital airway management: training of 1,069 emergency physicians and paramedics]. / Implementierung des Larynxtubus im präklinischen Atemwegsmanagement: Ausbildung von 1069 Notärzten und Rettungsassistenten.

OBJECTIVE: The European Resuscitation Council recommends that only rescuers experienced and well-trained in airway management should perform endotracheal intubation. Less trained rescuers should use alternative airway devices instead. Therefore, a concept to train almost 1,100 emergency physicians (EP) and emergency medical technicians (EMT) in prehospital airway management using the disposable laryngeal tube suction (LTS-D) is presented. METHODS: In five operational areas of emergency medicine services in Germany and Switzerland all EPs and EMTs were trained in the use of the LTS-D by means of a standardized curriculum in the years 2006 and 2007. The main focus of the training was on different insertion techniques and LTS-D use in children and infants. Subsequently, all prehospital LTS-D applications from 2008 to 2010'were prospectively recorded. RESULTS: None of the 762 participating EMTs and less than 20% of the EPs had previous clinical experience with the LTS-D. After the theoretical (practical) part of the training, the participants self-assessed their personal familiarity in using the LTS-D with a median value of 8 (8) and a range of 2-10 (range 1-10) of 10 points (1: worst, 10: best). Within the 3-year follow-up period the LTS-D was used in 303 prehospital cases of which 296 were successfully managed with the device. During the first year the LTS-D was used as primary airway in more than half of the cases, i.e. without previous attempts of endotracheal intubation. In the following years such cases decreased to 40% without reaching statistical significance. However, the mean number of intubation attempts which failed before the LTS-D was used as a rescue device decreased significantly during the study period (2008: 2.2 ± 0.3; 2009: 1.6 ± 0.4; 2010: 1.7 ± 0.3). CONCLUSION: A standardized training concept enabled almost 1,100 rescuers to be trained in the use of an alternative airway device and to successfully implement the LTS-D into the prehospital airway management algorithm. Because the LTS-D recently became an accepted alternative to endotracheal intubation in difficult airway scenarios, the number of intubation attempts before considering an alternative airway device is steadily decreasing.

[An educational skills programme for undergraduate training in orthopaedic and trauma surgery]. / Lehrzielkatalog im Pflicht- und Wahlbereich des Praktischen Jahres für die Inhalte des Faches "Orthopädie und Unfallchirurgie"

INTRODUCTION: Practical training on clinical cases and work with patients is one of the most important steps within the educational programme of undergraduates. Until now a general programme with specific learning targets for undergraduate training in orthopedic and trauma surgery is lacking. MATERIAL AND METHOD: In this article we present an educational skills programme developed by a national committee composed of specialists in the field of orthopaedic and trauma surgery. This programme is based on existing guidelines of German medical universities. RESULTS: The facultative and obligatory guidelines developed by the national committee are presented. CONCLUSION: The presented learning programme contains chapters regarding the increasing requirements within the field of orthopaedic and trauma surgery and provides reproducible contents with the possibility for learning control.

[Gender-specific evaluation of student's career planning during medical study in terms of orthopaedic trauma]. / Geschlechtsspezifische Wahrnehmung des orthopädisch-unfallchirurgischen Berufsbilds während des Medizinstudiums.

BACKGROUND: Due to recent changes in the medical licencing act as well as to the introduction of a new model-course programme for medical studies, careers in medicine have become increasingly more attractive. However, there is still a dramatic shortage in younger generation physicians, especially within the surgical fields. The goal of this cross-sectional study was the gender-specific assessment of the ideal career wishes of students during medical school, with a focus being placed in orthopaedic trauma surgery. MATERIALS AND METHODS: During the winter semester of 2010/2011 an online questionnaire (www.surveymonkey.com) was created for students enrolled in their 3rd to 12th semester (n=887). The questionnaire consisted of 50 questions [Likert scale (LS); 5 = agree, 1 = disagree] along with 10 free response questions. The scope of these questions ranged from personal career goals, within the context of their learning environment, to general life goals and planning. With regard to career choice, a differentiation was made between students' ideal career choices/subjects (IS), which were based solely on personal affinity, and so-called reality-based subjects (RS), which students considered more practical and to which they were more likely to apply in the future. RESULTS: The response rate was 36,4% (n=323, 23,4 years, 6.3 semesters, 226 [70.0%] female [f] and 97 [30.0%] male [m]). A total of 206 students (63.8%; m=55.7% vs. f=66.7%; p=0.047) were able to pinpoint an IS, this percentage increased with increasing semester number (p=0.048). Overall, 29.1% of students indicated that their IS lay in the field of orthopaedic trauma, while 20.0% of men and 19.1% of women saw it as a realistic career path (RS). Throughout the course of their studies, from the 3rd semester to their practical year, a declining tendency was observed regarding the agreement between ideal and realistic career paths. Particularly evident was a decreasing interest in the field of orthopaedic trauma, beginning around the 9th semester and during the practical year, especially among the female student population. The reason for this shift seems multifactorial, ranging from concerns about family planning as well as the work load in a male-dominated field. By the time students enter their practical year, 13.5% of women and 15.4% of men were still certain in their choice to pursue a career in orthopaedic trauma (RS). CONCLUSIONS: It seems that there is great interest in the fields of orthopaedic trauma among both female and male students in the middle portion of their studies. Women, especially, tend to prefer a specialisation in this operative field early in the course of their studies. However, this pool of potential successors decreases dramatically with time, due to personal experiences garnered on the wards, expectations regarding career paths (male-dominated, long hours) as well as concerns about family planning. The most dramatic shift seems to occur during the practical year.

[Undergraduate education in orthopaedic and trauma surgery - a nationwide survey in Germany]. / Die studentische Lehre im gemeinsamen Fach Orthopädie-Unfallchirurgie - eine deutschlandweite Statuserhebung.

AIM: Musculoskeletal conditions consume enormous resources and costs, and their incidence is increasing worldwide. Therefore, an appropriate education of medical students about these conditions is required. This study examines the extent of medical education in orthopaedic and trauma surgery in Germany. MATERIAL AND METHODS: A questionnaire comprising 7 topics (curriculum design, lecture, practical training, e-learning, examination, evaluation, resources) with a total of 44 items was sent to all assistant lecturers in orthopaedic and trauma surgery at the 37 medical schools in Germany. RESULTS: The survey attained a return rate of 76 % for orthopaedic surgery and 81 % for trauma surgery, respectively. Medical training in musculoskeletal conditions represents with an average of 38.4 hours of lectures and further 55.9 hours of practical training less than 6 % of the entire undergraduate medical education. This study demonstrates a high inhomogeneity regarding the curriculum design when comparing the different German medical schools not only in total training time but also regarding its contents. E-learning as additional teaching method is only offered in 39 % of orthopaedic training and in 47 % of the trauma surgery training. Practical examinations like the OSCE are offered at 8 medical schools for orthopaedic training and 15 schools for trauma surgical training, respectively. CONCLUSION: Medical training in musculoskeletal conditions is very inhomogeneous and requires further improvement and standardisation regarding quantity and implementation.

Teaching in daily clinical practice: a necessary evil or an opportunity? Doctors as teachers.

Teaching is an important part of our medical role as physicians. Though all doctors are usually well prepared for their clinical roles, few are trained to teach. It can be demonstrated that improved teaching performance leads to better learning outcomes for students and doctors. However, clinical teaching faces many challenges and problems. The series "Teaching in daily clinical practice," which commences with this article, will describe basic educational principles that are applicable in all phases of the learning and teaching of students, junior doctors and speciality trainees.

Teaching in daily clinical practice: how to teach in a clinical setting.

Teaching in the clinical setting is challenging; however, it is the location where students apply their learned facts and learn skills and attitudes most effectively. In order to improve clinical teaching, it is important to know and implement the principles of adult learning. The clinical teacher should know or assess the learners' prior knowledge and skills, as well as their stage of learning, before starting a new teaching session. The learners should be actively involved in the clinical processes. Questions to probe students' deeper understanding and capability to analyze, synthesize, and apply medical knowledge should be an important part of clinical teaching. Regular structured feedback is an important part of any learning experience.

[Undergraduate training in orthopaedic and trauma surgery: analysis of contextual and structural implementation models for undergraduate training in the newly combined specialty]. / Die Lehre in Orthopädie und Unfallchirurgie im klinischen Studienabschnitt und im Praktischen Jahr (PJ).

AIM: The fusion of orthopaedic and trauma surgery into a combined specialty requires a new evaluation of postgraduate and undergraduate training. This study presents a structured analysis of the implementation possibilities for undergraduate training. METHOD: After defining 3 implementation alternatives for both clinical training and last year electives, SWOT analyses were performed. RESULTS. The SWOT analysis demonstrates for each of these 6 implementation models the strengths, weaknesses, opportunities and threats. CONCLUSION: In order to strengthen undergraduate training in the "new" specialty all medical faculties should discuss and define their implementation concepts.

Tracheal intubation using the mobile C-MAC video laryngoscope or direct laryngoscopy for patients with a simulated difficult airway.

BACKGROUND: Several studies have shown that video laryngoscopy enhances the laryngeal view in patients with apparently normal and anticipated difficult airways. The utility of the novel, portable, battery-powered C-MAC video laryngoscope is unproven, but its design makes it potentially useful for emergency situations. We hypothesized that, in patients with a simulated difficult airway created by means of a rigid cervical immobilization collar, the rate of glottic views considered "failed" under direct laryngoscopy could be significantly reduced with the C-MAC video laryngoscope. METHODS: Following power analysis and ethical approval, 43 adults undergoing surgery under general anesthesia were studied. First, direct laryngoscopy was performed with the naked eye with and without applying external laryngeal pressure (BURP maneuver). The best-obtained view was graded by the laryngoscopist without looking at the video monitor. A second anesthesiologist, who was blinded to the laryngeal view obtained under direct laryngoscopy, graded the laryngeal view on the video monitor. A difficult airway was then created and the laryngoscopy sequence repeated. Endotracheal intubation was then attempted under video-aided visualization. RESULTS: In patients with a normal airway, the glottic view was considered as "good" in the vast majority of patients (40-43/43; 93-100%) regardless of the laryngoscopy technique used. When a difficult airway was created, the glottic view was graded as "failed" in 30/43 (70%) and 16/43 (37%) of patients under direct laryngoscopy without and with the BURP maneuver, respectively (P=0.0047). Using video laryngoscopy, significantly fewer laryngoscopic views were graded as "failed" without (14%, P<0.0001) and with the BURP maneuver (5%, P=0.0003) compared to direct laryngoscopy. Endotracheal tube placement was successful in 88% of patients with a difficult airway. CONCLUSION: The C-MAC video laryngoscope effectively enhanced the laryngeal view in patients with limited inter-incisor distance and eliminated cervical spine clearance. However, endotracheal tube placement failed in 5/43 patients despite a mostly good laryngeal view.