Assessment of surgical competence at carotid endarterectomy under local anaesthesia in a simulated operating theatre.

BACKGROUND: Methods of surgical training that do not put patients at risk are desirable. A high-fidelity simulation of carotid endarterectomy under local anaesthesia was tested as a tool for assessment of vascular surgical competence, as an adjunct to training. METHODS: Sixty procedures were performed by 30 vascular surgeons (ten junior trainees, ten senior trainees and ten consultants) in a simulated operating theatre. Each performed in a non-crisis scenario followed by a crisis scenario. Performance was assessed live by means of rating scales for technical and non-technical skills. RESULTS: There was a significant difference in technical skills with ascending grade for both generic and procedure-specific technical skill scores in both scenarios (P < 0.001 for all comparisons). Similarly, there was also a significant difference in non-technical skill with ascending grade for both scenarios (P < 0.001). There was a highly significant correlation between technical and non-technical performance in both scenarios (non-crisis: r(s) = 0.80, P < 0.001; crisis: r(s) = 0.85, P < 0.001). Inter-rater reliability was high (alpha > or = 0.80 for all scales). CONCLUSION: High-fidelity simulation offers competency-based assessment for all grades and may provide a useful training environment for junior trainees and more experienced surgeons.

Skills training using multimedia and models.

All doctors need basic surgical skills. Learning and retaining such skills requires repeated practice. This article describes structured training provided by a multimedia computer program combined with practice on simulated tissue models.

Performance in the Duke-Elder ophthalmology undergraduate prize examination and future careers in ophthalmology.

AIMS: Cognitive factors (eg, academic achievement) have had a significant role in selecting postgraduate surgical trainees in the past. This project sought to determine the role of a national undergraduate ophthalmology prize examination (Duke-Elder examination) in the selection of postgraduate ophthalmology trainees. This would also serve as a quality assurance exercise for the assessment, in which the ultimate aim is to encourage trainees into ophthalmology. METHODS: A retrospective analysis of the top 20 ranked candidates in the Duke-Elder examination from 1989 to 2005 (except 1995) was carried out to determine which of them subsequently entered the ophthalmic training and General Medical Council Specialist Registers. RESULTS: Out of the top 20 candidates in the exam, 29.5% went into specialist training in ophthalmology. Some appeared in the top 20 more than once, with 56% of them going into ophthalmic training, but they had a similar median time to enter training as those who appeared in the top 20 once. There was no significant evidence to suggest that the overall median ranking scores between the UK medical schools differed (P=0.23; Kruskal-Wallis test). However, there was a marked difference in frequency of top 20 candidates from each medical school, which could not be explained by the size of the medical school alone. CONCLUSION: It is difficult to conclude from these findings the importance that the Duke-Elder examination has in the selection of trainees into ophthalmology. The role of cognitive factors in selection into postgraduate medical/surgical training is discussed, along with the potential academic criteria, which may influence interview scores.

Complexity, risk and simulation in learning procedural skills.

BACKGROUND: A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learner's evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualize a dynamic awareness of prevailing risk and the implications of moving between zones. THE IMPORTANCE OF CONTEXT: We argue that clinical exposure can be consolidated by simulation where appropriate, ensuring that each learner gains the skills for safe care within the increasingly limited time available for training. To be effective, however, such simulation must be realistic, patient-focused, structured and grounded in an authentic clinical context. Challenge comes not only from technical difficulty but also from the need for interpersonal skills and professionalism within clinical encounters. PATIENT FOCUSED SIMULATION: Many existing simulations focus on crises, so clinicians are in a heightened state of expectation that may not reflect their usual practice. We argue that simulation should also reflect commonly occurring non-crisis situations, allowing clinicians to develop an awareness of the complex events that underpin clinical encounters. We describe a patient-focused approach to simulation, using simulated patients and inanimate models within realistic scenarios, to ground experience in authentic clinical practice and bring together the complex elements that underpin clinical events. APPLICATIONS: Although our argument has evolved from surgical practice and operating theatre teams, we believe it can be widely applied to the increasing number of health care professionals who perform clinical interventions.

Innovative training for new surgical roles--the place of evaluation.

BACKGROUND: This paper describes the central role of 'external' evaluation, provided by an independent researcher, in developing an innovative curriculum for new professional roles with surgery. Workforce changes affecting the National Health Service provided an opportunity to develop 2 new roles and design training programmes to support them. The perioperative specialist practitioner (PSP) role was designed from scratch, while surgical care practitioner (SCP) training built on existing practice. Training programmes combined formal modules at Imperial College London (approximately 48 days over 10 months) with supervised clinical practice in each participant's base hospital. Programmes balanced factual knowledge, clinical and communication skills, professional issues and personal development and used a range of innovative techniques. EVALUATION METHODS: A qualitative approach based on a utilisation-focused model monitored the development and implementation of 4 pilot PSP and SCP training programmes. A total of 124 individual and 48 group interviews were conducted at intervals over 3 years, sampling course participants, the project team clinical supervisors and administrators. An independent researcher collected, analysed and presented data at key stages, feeding back findings to the project team as the programmes evolved. DISCUSSION: Effective training programmes for new roles can be developed, but the process is time-consuming and requires sensitivity. An independent evaluator offers great benefits, modulating the collaborative partnership between participants and project team. Positive responses (relating to content and teaching methods) from our study enabled us to refine a learner-centred programme. Negative responses often demanded immediate action to address important concerns, and evaluation provided early warning. External evaluation provides a vital perspective in the development of curricula supporting new roles.

Blurring the boundaries: scenario-based simulation in a clinical setting.

CONTEXT: The ability to perform clinical procedures safely is a key skill for health care professionals. Performing such procedures on conscious patients is challenging and requires a combination of technical and communication skills. We have developed quasi-clinical scenarios, where inanimate models attached to simulated patients provide a convincing learning environment. Procedures are rated by expert observers and by the 'patient' and recorded for subsequent review. This study explores the potential of locating such scenarios within a real clinical setting, allowing participants to experience the challenges of the workplace while ensuring patient safety. An innovative portable digital recording device (the 'Virtual Chaperone') is evaluated for use in clinical settings. METHODS: A qualitative design (observation and interview studies) investigated volunteer medical students undertaking 2 procedure scenarios (insertion of urinary catheter and wound closure with sutures) within the accident unit of a large London hospital. All procedures were observed in real time and recorded digitally (using the Virtual Chaperone). A protocol was used for structured feedback. Observational and interview data was analysed using standard qualitative techniques. RESULTS: Seven sessions with 22 undergraduate medical students took place over 9 months within 1 centre. Data confirmed the feasibility of using a moveable, self-contained training scenario within an authentic clinical setting. Overall, the response from participants was positive. CONCLUSION: Scenario-based teaching within an authentic clinical environment is feasible and perceived by participants to be educationally useful. This approach blurs traditional boundaries between skills laboratory teaching and clinical practice and may offer considerable advantages in training for clinical procedures.

Twelve tips on teaching basic surgical skills using simulation and multimedia.

SUMMARY All doctors need a core of basic surgical skills, whether or not they eventually specialize as surgeons. Mastering any skill requires sustained deliberate practice, usually over several years. Ideally this should start early in undergraduate training and be reinforced at intervals. Simulation is well established in medical education and is ideal for learning surgical techniques. Realistic simulated tissue models allow initial training to be detached from the stresses of clinical practice. Small-group workshops run by experienced tutors provide learner-centred teaching. Computer-aided learning encourages regular practice, in preparation for supervised clinical experience when the basics have been mastered. This article describes a five-stage approach to learning surgical procedures using the author's multimedia CD-ROM in combination with simulated tissue: (1) watching an animated graphic; (2) watching a clinical video; (3) watching a demonstration on a simulated tissue model; (4) doing the procedure on a model; (5) doing the procedure on a patient, under supervision.

Cancer of the oesophagus in Soweto.

Oesophageal cancer is remarkably common in Transkei, a rural part of South Africa, but has not been thought to affect urban blacks nearly as often. The incidence of oesophageal cancer in Soweto, South Africa's largest urban black community, is assessed. The age-standardized incidence is 125/100 000 in men and 37/100 000 in women. Oesophageal cancer is now a disease as much of urban as of rural blacks, a fact which may be epidemiologically significant. The prognosis for oesophageal cancer in blacks is widely believed to be almost hopeless, regardless of treatment. The results of treatment in 265 patients over 3 years are presented - in 21% the disease was confined to the oesophagus and these patients were treated by oesophagectomy (30% 3-year survival rate); 23% had local spread and were treated by extra-oesophageal bypass (11% 1-year and 2% 2-year survival rate); and 51% had advanced disease (1% 1-year survival rate, no survivors at 2 years). Five per cent of the patients died before any treatment could be given.

Simulation and clinical practice: strengthening the relationship.

INTRODUCTION: This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life. BACKGROUND: Evidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of 'learning by doing' in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's 'zone of proximal development' is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of 'legitimate peripheral participation' in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice. CONCLUSIONS: Simulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be used alongside clinical practice and linked closely with it.

Dermatofibrosarcoma protuberans in black patients.

Twelve cases of dermatofibrosarcoma protuberans in Black patients admitted to Baragwanath Hospital, Johannesburg, between 1979 and 1983 are reviewed. The cause of this slow-growing, low-grade malignant fibrous histiocytoma is unknown, but there is some evidence that trauma may be a predisposing factor. The clinical and histological features of dermatofibrosarcoma protuberans are described, and treatment by wide tridimensional excision with local reconstruction is recommended.

Amyloid goitre. A case report.

A case of primary amyloidosis presenting as a goitre is reported. The clinical features of amyloid goitre are described and the difficulties in making a pre-operative diagnosis are discussed. A plan of management for this rare thyroid condition is suggested.

Learning the skills of flexible sigmoidoscopy - the wider perspective.

BACKGROUND: Nurse-led gastrointestinal endoscopy is a priority clinical area in the UK. Endoscopic procedures are challenging to learn, requiring a combination of technical competence (manipulating a flexible endoscope and interpreting the findings) and interpersonal skills (engaging effectively with a conscious patient who is frequently apprehensive). This paper explores the potential of an innovative, scenario-based approach which links a simulated patient with a computer-driven virtual reality (VR) training device for flexible sigmoidoscopy. Within this safe yet realistic quasi-clinical environment, learners carry out the procedure while interacting with the 'patient'. Communication skills are assessed by simulated patients, while quantitative performance data relating to the procedure is generated automatically by the VR simulator. METHODS: This pilot study took place within a nurse practitioner endoscopy course. A mixed methodology combined qualitative and quantitative data (observation and interview studies, communication rating scales and a range of computer-generated output measures from the VR simulator) in a multifaceted evaluation. RESULTS: Seven nurses took part in the study. Participants found the scenarios to be a convincing and powerful learning experience. All experienced high levels of anxiety. Simulated patients identified strengths in participants' communication skills, together with areas for development. Simulator-based practice led to an improvement in objective performance measures. DISCUSSION: Scenario-based training provides a powerful learning experience, allowing participants to build their technical expertise and apply it within a holistic clinical context without the risk of causing harm. We used this pilot study as a springboard for discussions over wider implications of procedure-based skills training, locating it within the literature on expertise and situated learning.