National survey of neonatal transfusion practices: II. Blood component therapy.

Neonatal transfusion practices during 1989 of 452 institutions involved in transfusing infants were surveyed by questionnaire. Most respondents (77%) transfused fresh frozen plasma appropriately (ie, primarily to treat coagulation disorders). However, 11% stated that their most frequent use of fresh frozen plasma was solely to treat hypovolemia, a practice generally not recommended. Seventy-eight percent of respondents transfused platelets to treat bleeding infants with blood platelet counts of less than 50 x 10(9)/L; 84% gave platelets to sick, premature neonates with counts of less than 50 x 10(9)/L whether or not bleeding was evident. Only 35% of respondents transfused granulocytes for neonatal sepsis; most institutions used buffy coats isolated from units of blood--a product readily available, but of questionable efficacy when compared with leukapheresis granulocytes. Ninety-three percent of respondents provided blood components with low risk of transmitting cytomegalovirus: components from seronegative donors were used by 84%, leukocyte-reduced products by 6%, and a combination by 10%. Thirteen percent of respondents gave gamma-irradiated blood components to all and 46% gave them to some neonates to prevent graft vs host disease. Forty-one percent did not routinely irradiate. Ten percent of respondents used leukocyte reduction instead of gamma irradiation to prevent graft vs host disease, a practice currently not advocated. Thus, national transfusion practices for neonates are variable, controversial, and, occasionally, other than those usually recommended. Additional research and educational efforts are needed to ensure optimal transfusion therapy.

National survey of neonatal transfusion practices: I. Red blood cell therapy.

Neonatal blood component transfusion practices during 1989 were surveyed via a questionnaire developed by the Pediatric Hemotherapy Committee of the American Association of Blood Banks. Of 1790 questionnaires mailed, 452 were selected to form the database for this analysis because they were from institutions in which neonates were transfused. Nearly all institutions contained intensive care units directed by neonatologists and were involved in the management of high-risk infants. Results from institutions serving as the primary pediatric teaching hospital of a medical school were compared with those with no medical school affiliation. Thirty-six percent of primary pediatric teaching hospitals and 52% of hospitals with no medical school affiliation performed pretransfusion testing in excess of that required, resulting in additional blood loss in neonates. Sixty-six percent of primary pediatric teaching hospitals used fresh frozen plasma to adjust the hematocrit of red blood cell concentrates prior to transfusion (a practice increasing donor exposure), compared with only 29% of hospitals with no medical school affiliation. The usual indication for small-volume red blood cell transfusions in severely ill neonates was to maintain a desired hematocrit level, whereas for stable infants, red blood cell transfusions were given to treat symptomatic anemia, rather than to maintain a predetermined hematocrit. As found in 1985, neonatal transfusion practices in 1989 were variable. However, improvements have occurred since 1985 to suggest that further research and educational efforts may serve to promote even better neonatal transfusion therapy.

Comparison of a videodisc system with a conventional film file for medical student teaching.

PURPOSE: The authors assessed the effectiveness of a videodisc film file compared with a conventional film file for teaching radiology to medical students. METHODS: Fourth-year medical students (N = 134) studied 116 cases selected from the American College of Radiology Learning File. Half the students studied 58 skeletal cases using conventional films and half studied the same cases on a videodisc system. Student groups were then switched and those who studied skeletal cases on films studied 58 chest cases on videodisc and vice versa. Students received the same skeletal and chest tests and completed a questionnaire. RESULTS: For both skeletal and chest radiology, students studying films scored minimally higher than students using the videodisc. Students rated films superior to the videodisc for amount learned, convenience of use, and ability to detect lesions. CONCLUSIONS: Conventional film and videodisc methods resulted in similar levels of learning; however, students perceived conventional films to be a superior learning experience.

Gross anatomy instruction with diagnostic images.

A new module of instruction for diagnostic imaging with emphasis on cross-sectional anatomy was developed within the existing course of gross anatomy for freshmen medical students. Two lectures introduced radiation protection, radiology history, and the basic principles of computed tomography, magnetic resonance imaging, ultrasound, and radiograph image production. Six radiographic anatomy correlation sessions allowed student-teacher interaction while studying viewbox images in a "hands on" fashion. Relevant exhibits complemented cadaver dissection. Testing established that significant improvement occurred in the students' ability to identify anatomic structures on diagnostic images.

Effectiveness of teaching radiologic image interpretation in gross anatomy. A long-term follow-up.

This prospective study was designed to gauge the effectiveness of teaching radiologic interpretation during a gross anatomy course for first-year medical students by measuring short- and long-term ability to identify normal anatomic structures on radiologic diagnostic images. The evaluation required students to identify normal anatomic structures on radiographs, computed tomographs, ultrasonograms, and magnetic resonance images (MRIs). The assessments were made before (pre-test) and during (post-test) the experimental radiology portion of the gross anatomy course. The students were then retested 14 to 17 months later (long term). The pre-test correct response rate of 17% improved to 88% on the post-tests. After 14 to 17 months, the students had a 74% correct response rate on the same images and anatomic structures. This high level of long-term retention documents the effectiveness of integrating diagnostic radiologic imaging into normal gross anatomy instruction.

Cardiac anatomy instruction by ultrafast computed tomography versus cadaver dissection.

RATIONALE AND OBJECTIVES: This prospective study was designed to determine to what extent an ultrafast computed tomography (UFCT) videotape of the heart could enhance or substitute for cadaver dissection in teaching anatomy to first-year medical students. METHODS: A student population (n = 180) was randomized into four groups. Group 1 (control) received no instruction, group 2 viewed the videotape, group 3 participated in cardiac dissection, and group 4 performed cardiac dissection and viewed the videotape. After randomized instruction, each group was tested with 10 UFCT static cardiac images and 8 cardiac cadaver specimens. A different population consisting of nonrandomized fourth-year medical students also was tested. RESULTS: The results point to an interaction between instruction and the manner in which it was assessed. There was more carryover from the videotape-acquired knowledge to specimens than from dissection-acquired knowledge to UFCT images. CONCLUSIONS: Cardiac UFCT instruction resulted in dramatically improved image testing performance. This image-acquired knowledge was not sufficiently transferred to cardiac specimen identification; thus, videotape instruction should not replace dissection for teaching cardiac anatomy. Video provided instruction benefits beyond that gained through general clinical experience.

The instructional effectiveness of a radiology multimedia textbook (HyperLung) versus a standard lecture.

RATIONALE AND OBJECTIVES: Information overload is a significant problem for the modern radiologist. This prospective study compares the instructional effectiveness of a multimedia textbook (HyperLung) with a lecture. HyperLung is a radiologic multimedia textbook about imaging diffuse lung disease created using a multimedia authoring tool, the Annotator (the University of Iowa Second Look Computing, Iowa City, IA), on the Apple Macintosh computer (Apple Computer, Cupertino, CA). METHODS: Forty-nine staff physicians and residents in the Department of Radiology were randomized to receive instruction either by HyperLung or by a lecture. The instructional content was the same in both groups, and both groups were tested before and after instruction. The actual time spent in each instructional situation was recorded. RESULTS: The instructional effectiveness of the multimedia textbook and lecture was equal. The instructional efficiency of HyperLung was only 60% of the lecture. Users of the multimedia textbook found it enjoyable and straightforward to use. CONCLUSIONS: Multimedia textbooks have a promising future in radiology education.

Diagnostic image use by nonradiologist lecturers in an introductory clinical medicine course.

RATIONALE AND OBJECTIVES: A curriculum-tracking study was designed to determine the type and amount of diagnostic imaging used by nonradiologists teaching an Introduction to Clinical Medicine (ICM) course to second-year medical students. METHODS: Two second-year medical students independently recorded the type and number of images shown, the length of the lecture, the departmental affiliation of the lecturer, and the amount of time devoted to either didactic radiology or radiologic images during each of 288 lectures in the 1990 ICM course. RESULTS: A total of 35.2% of the lectures presented some type of diagnostic image, and 7.0% of all lecture time was devoted to radiology. No mammography or diagnostic nonangiographic interventional images were shown. CONCLUSIONS: The results suggest that a more consistent and uniform presentation of diagnostic images across disciplines is required, emphasizing the need for more coordination of radiology instruction through consultation with the Department of Radiology.

Evaluation of a computer-based program for teaching cardiac anatomy.

RATIONALE AND OBJECTIVES: The authors determined to what extent a computer-based program could enhance or substitute for cadaver dissection in teaching cardiac anatomy to first-year medical students. METHODS: First-year medical students (n = 175) were randomized into four groups. Group 1 (control) received no instruction, group 2 participated in cardiac dissection, group 3 viewed the computer application, and group 4 performed cardiac dissection and then viewed the computer application. Each group was tested with 10 ultrafast computed tomographic static images and 8 cardiac cadaver specimens. RESULTS: The computer program plus dissection was superior to either the computer program alone or dissection alone; however, the results varied according to the subtest used to assess the outcomes. CONCLUSIONS: Cardiac computer instruction after dissection resulted in dramatically improved image testing performance. However, computer instruction should not replace dissection for teaching cardiac anatomy.

Problem-based learning in ophthalmology: a pilot program for curricular renewal.

OBJECTIVES: To gain experience with problem-based learning as a demonstration project in a medical school's curriculum renewal effort and determine if using a single facilitator to circulate among the small groups would yield positive results. DESIGN: We developed 16 cases around 4 ophthalmic problems that were used in 3-hour small-group sessions during the Introduction to Clinical Medicine semester of the second-year curriculum. A single faculty member facilitated the small groups of 4 students each that were created by self-division at each of 5 sessions. SETTING: A state-supported large Midwestern medical school. PARTICIPANTS: All students (N = 75) enrolled in the Introduction to Clinical Medicine course prior to their standard introductory ophthalmology lectures. MAIN OUTCOME MEASURES: A 5-item pretest, related to each of that day's clinical problems, was administered at the beginning and again at the end of the session as a posttest. A satisfaction questionnaire with Likert-type questions was also completed by the students at the close of the session. RESULTS: Knowledge scores showed statistically significant gains with a mean of 1.7 points. Student satisfaction was very positive--85% stated that they learned more than they would have in the traditional format and 93% agreed that they enjoyed the problem-based learning format. CONCLUSIONS: A single facilitator successfully managed small groups of students in a modified problem-based learning format that produced significant knowledge gains and high student satisfaction. This positive experience was one of the factors that led to adoption of problem-based learning into the curriculum.

Problem-based learning: a review of literature on its outcomes and implementation issues.

The effects of problem-based learning (PBL) were examined by conducting a meta-analysis-type review of the English-language international literature from 1972 to 1992. Compared with conventional instruction, PBL, as suggested by the findings, is more nurturing and enjoyable; PBL graduates perform as well, and sometimes better, on clinical examinations and faculty evaluations; and they are more likely to enter family medicine. Further, faculty tend to enjoy teaching using PBL. However, PBL students in a few instances scored lower on basic sciences examinations and viewed themselves as less well prepared in the basic sciences than were their conventionally trained counterparts. PBL graduates tended to engage in backward reasoning rather than the forward reasoning experts engage in, and there appeared to be gaps in their cognitive knowledge base that could affect practice outcomes. The costs of PBL may slow its implementation in schools with class sizes larger than 100. While weaknesses in the criteria used to assess the outcomes of PBL and general weaknesses in study design limit the confidence one can give conclusions drawn from the literature, the authors recommend that caution be exercised in making comprehensive, curriculum-wide conversions to PBL until more is learned about (1) the extent to which faculty should direct students throughout medical training, (2) PBL methods that are less costly, (3) cognitive-processing weaknesses shown by PBL students, and (4) the apparent high resource utilization by PBL graduates.

The validity of lecturer ratings by students and trained observers.

This study sought to determine to what degree student ratings of specific lecturer characteristics relate to trained observer ratings of such characteristics and to identify the distinguishing delivery characteristics of highly rated lecturers. The 15 lowest-rated lecturers and the 15 highest-rated lecturers, based on the mean ratings of students from two consecutive years (1982 and 1983) in a large multi-instructor course, served as the target group. Blinded non-student raters observed the lectures in 1984 (two per lecture) and completed quantitative and qualitative forms. For all six subscores from the quantitative form, statistically significant differences between the lecturers given the highest and lowest ratings were obtained. It is concluded that the students' ratings were stable across the three years; the independent observers discriminated between the lecturers the students rated the highest and the lowest; voice presentation characteristics discriminated the most effectively; and nonmedical non-student observers are potentially a useful source of information regarding faculty teaching skills.

Student health policies of U.S. medical schools.

BACKGROUND: Medical students are at risk of exposure to bloodborne pathogens, yet few data are available about U.S. medical schools' policies to protect students. METHOD: A cross-sectional survey of the student affairs deans at the 126 U.S. medical schools was conducted in May 1994. A confidential questionnaire inquired about policies regarding vaccination for hepatitis B virus (HBV), blood and body-fluid exposures, universal precautions training, and health and disability insurance for students. RESULTS: A total of 108 (86%) of the schools participated in the survey. Most (99, 92%) required either HBV vaccination, evidence of immunity, or a signed waiver refusing vaccination. Nearly all (94, 87%) required health insurance, and almost all (101, 94%) offered a plan (at a mean cost of $690 annually), but fewer schools (69, 64%) offered disability insurance. The schools frequently held students responsible for the costs of HBV vaccination (73, 68%), postexposure serologic testing (22, 20%), and treatment of training-related medical problems (43, 40%). CONCLUSION: Most medical schools comply with current recommendations for preventing training-related exposures to bloodborne pathogens, illness, and injury, but students face a substantial financial responsibility for these services at a time when many have large debts. Many schools do not have disability insurance readily available for students. Medical schools should review their student health policies to protect students adequately.

A survey to identify deficiencies in transfusion medicine education.

Medical faculty, blood center directors, and technologists were surveyed to assess current opinions of knowledge deficiencies in transfusion medicine among medical school graduates, housestaff, and practicing physicians. Over 90% of those responding believed additional training in transfusion medicine was needed. Nine categories of deficiencies were identified, with more than 40% of respondents' comments reflecting concern about the lack of knowledge of the use of blood and blood components. Clinical faculty and blood bankers differed in their assessments of the knowledge deficiencies in two of the nine categories. Information obtained in this survey is relevant to educational development in transfusion medicine.

Teaching a screening musculoskeletal examination: a randomized, controlled trial of different instructional methods.

PURPOSE: To develop and test a program to teach a rapid screening musculoskeletal examination. METHOD: In 1995, 191 medical and physician assistant students were randomized to four intervention groups: written materials only (n = 47), written materials and videotape (n = 46), written materials and small-group sessions facilitated by fourth-year medical students (n = 55), and all three methods (n = 43). Assessments, in the form of a written test and standardized patient examinations, were conducted before the interventions (n = 40 randomly selected students), seven to ten days and again three months after the interventions (n = all 191 students), and 16 months after the interventions (n = 103 students). RESULTS: While the four intervention groups' written test scores were approximately equal, their scores on the standardized patient examination differed significantly. The students taught in small groups demonstrated significantly superior examination skills compared with the students taught with written material or videotape at seven to ten days and retained this relative superiority after three and 16 months (p < .0001). CONCLUSION: Small-group instruction with hands-on supervised practice is superior to more passive instructional methods for teaching musculoskeletal examination skills and can be successfully delivered by trained senior medical student facilitators with minimal direct expenditure of faculty time.

Resident learning and knowledge retention from resident-prepared chest radiology conferences.

RATIONALE AND OBJECTIVES: The authors assessed resident learning and retention of knowledge from resident-prepared chest radiology conferences. MATERIALS AND METHODS: Radiology residents presented five chest conferences to their peers during a 5-month interval; the conferences were modeled on a case presentation format. Tests were given 5 minutes before each conference (pretest) and immediately after each conference (posttest). The tests were readministered as a final examination 6 months later, at which time the residents were asked to evaluate the conference format. RESULTS: Conference attendance ranged from six to 11 residents. Mean posttest scores were statistically significantly higher than mean pretest scores (P < .0001). Six-month retention scores were higher than pretest scores (P < .05) but lower than posttest scores (P < .05). On a scale of 1-6, with 1 representing strongly disagree and 6 strongly agree, residents strongly agreed that the conferences provided an excellent learning experience (mean score, 5.27). CONCLUSION: Resident-prepared conferences are effective for teaching residents chest radiology. Resident testing at 6 months demonstrated retention of knowledge above pretest levels but lower than posttest levels.

Resident conference at the viewbox: an experimental approach.

RATIONALE AND OBJECTIVES: To develop and test an experimental radiology resident conference format designed to incorporate more cases, improve visibility of cases, increase resident participation, decrease resident anxiety, and provide residents with feedback on their oral presentation skills. METHODS: Sixteen radiology residents were paired into eight teams. Each team was given an identical packet of eight chest radiograph cases, assigned a viewbox, and given 16 minutes to review the cases. Each case was then discussed in front of the group, by one resident from a team, such that all teams participated in oral presentation. The conference moderator provided a written handout, discussion of the findings, and diagnosis for each case. Residents anonymously evaluated each other's performance, the experimental conference format, and 15 traditional conferences. RESULTS: Residents subjectively found the experimental conference to be a statistically significant improvement over the traditional conferences in certain areas (P < .05). CONCLUSION: The experimental conference serves as a valuable alternative to the traditional "hot-seat" conference.

Longitudinal comparison of multimedia textbook instruction with a lecture in radiology education.

RATIONALE AND OBJECTIVES: The purpose of this prospective randomized study was to compare the long-term instructional effectiveness of a computer-based radiology multimedia textbook (MMTB) with that of a traditional lecture. METHODS: Volunteer faculty/fellows and residents were randomly assigned to either a computer-based MMTB group or to a lecture group. The course content for each instructional group was the same. Pretests, posttests, and 1-year long-term retention tests were administered to both groups. The same 10 questions were on all tests. The resulting data were analyzed using analysis of variance procedures available on the Statistical Analysis System. RESULTS: A comparison of the long-term instructional effectiveness of an MMTB versus a lecture showed that the MMTB computer instructional method was at least comparable in spite of the initial short-term appearance of lecture superiority. CONCLUSION: These results suggest a promising future for MMTB and other forms of computer-based education in radiologic instruction for medical students and radiologists.

Development of a radiology faculty appraisal instrument by using critical incident interviewing.

RATIONALE AND OBJECTIVES: To develop a valid and reliable radiology faculty appraisal instrument based on scientific methods. MATERIALS AND METHODS: Fifteen radiology residents participated in critical incident interviewing. During a 1-hour interview, a resident was asked to describe five incidents each of effective and ineffective faculty behavior. Two investigators independently listened to the tape-recorded interviews, and two different investigators sorted the incidents into broad categories. A faculty appraisal instrument was developed by listing similar incidents under broad categories. A five-point rating scale was applied to each item. Content validity was assessed by resident and faculty critique of the appraisal instrument. RESULTS: A total of 168 incidents of faculty behavior were generated. The frequency with which similar incidents were reported was recorded. The most common behaviors reported were related to staff expertise and teaching. Interjudge reliability was good, as determined by computing K indices of agreement (overall K = 0.59). There was good agreement regarding instrument content validity among residents but not among faculty. CONCLUSION: Residents supported the use of the new appraisal instrument, but further tests of validity and reliability and faculty acceptance of the instrument will determine its usefulness as a tool for monitoring faculty teaching performance and making decisions regarding faculty promotion.

Radiology faculty evaluation: bi-institutional implementation of an experimental appraisal instrument.

RATIONALE AND OBJECTIVES: The authors evaluated the reliability and validity of an experimental radiology faculty appraisal instrument. MATERIALS AND METHODS: Residents from the University of Wisconsin (UW) and Indiana University (IU) were asked to use a previously developed behaviorally based, 53-item experimental faculty appraisal instrument. Twenty UW residents evaluated 29 UW faculty members and 37 IU residents evaluated 31 IU faculty members by using the experimental instrument. Residents also evaluated faculty by using their institution's existing appraisal instrument. RESULTS: Correlations between existing and experimental forms were .69 and .87 for UW and IU, respectively. Existing form reliabilities were .89 and .94 and experimental form reliabilities were .98 and .98 for UW and IU, respectively. Experimental form length was reduced to 30 items by eliminating the questions that correlated the least with section scores. Reliabilities of scores on the shortened form were .97 and .98 and correlated .65 and .88 with scores on the longer form for UW and IU, respectively. CONCLUSION: Ratings obtained with the existing forms correlated substantially with the experimental form, attesting to the experimental form's validity. Shortening the experimental form had a minimal effect on the reliability and validity of the data obtained. The behavior-based form was used to rate behaviors that residents believed discriminated between effective and ineffective instructors, enabling an objective and relevant assessment to be made.