Multimodality Education for Airway Endoscopy Skill Development

Simulation-Based Mastery Learning With Virtual Coaching: Experience in Training Standardized Upper Endoscopy to Novice Endoscopists

Although virtual reality (VR) simulators can be used ability to objectively assess skills in endoscopy, the evaluation is solely quantitative. We have developed a novel method for the objective assessment of technical skills in lower gastrointestinal (GI) endoscopy that incorporates qualitative as well as quantitative measures. We developed a virtual endoscopy suite by deconstructing the VR simulator to enable a more realistic and ergonomic placement of the monitor. Trainee endoscopists with varying levels of experience performed the case 4 task of the simulator. Ten essential components of endoscopic performance were rated on a five-point Likert scale (global score) by three independent observers. These observers viewed two videos (one showing scope handling and the other showing the monitor image), which were synchronized and played simultaneously. The study population comprised six experts (group 1, > 200 procedures), seven subjects with intermediate experience (group 2, 20-80 procedures), and seven novices (group 3, 1-10 procedures). The global score was found to discriminate the level of skills across all three groups (p < 0.001). There were significant differences between groups 1 and 2 (p = 0.003) and groups 2 and 3 (p = 0.004). There was a significant correlation between the global score and the percentage of red-out (without vision) as recorded by the simulator (correlation coefficients = -0.61, p = 0.004). This novel method for the assessment of technical skills in lower GI endoscopy has construct validity and high interrater reliability.

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

In 1964, Dr. Barrows first introduced the standardized patients, who are individuals trained to imitate the pathological symptoms of the real patients, and involved them in teaching and clinical skills assessment for healthcare education. In recent decades, the application of the virtual patient has been rapidly grown and has been widely used in clinical or educational practice among residents, surgeons, or other medical professionals because the virtual patient is cost-effective and time-efficient [1]. The Food and Drug Administration (FDA) collaborated with the Foundation of Research on Information Technologies in Society (IT’IS Foundation, Zürich, Switzerland) to produce a virtual family, which is a set of anatomical computer-aided design (CAD) models of adults and children [2, 3], and those CAD models are used in electromagnetic, thermal, and computer fluid dynamics simulations. However, the meaning of virtual patients or models has varied across the recent years and more and more researchers tried to categorize the terminology of virtual patients. In general, virtual patients can be classified into seven major types including: case presentation, interactive patient scenarios, virtual patient game, high fidelity software simulation, human standardized patients, high fidelity manikins, and virtual standardized patients [4]. The virtual patients discussed in this study can be classified as interactive patient scenarios, whose application includes clinical reasoning, surgical planning, and disease diagnosis.

Context: Standardized patients are more prominently used to both teach and evaluate students' clinical skills and abilities. Objective: To investigate whether athletic training students perceived an encounter with a standardized patient (SP) as realistic and worthwhile and to determine their perceived comfort in future lower extremity evaluations with standardized and actual patients. Design and setting: Cross-sectional. Athletic Training Research and Education Laboratory, on-campus athletic training room, and Clinical Proficiency Evaluation Room. Subjects: Twenty-nine undergraduate athletic training students (17 female, 12 male) at a Midwestern CAATE-accredited institution who had completed a lower extremity orthopedic evaluation course in the past 12 months. Measurements: A Standardized Patient Encounter Feedback Form consisting of 5 Likert scale items (1 = strongly disagree; 5 = strongly agree) regarding the participants' perceptions of SP encounters with foot/ankle and knee orthopedic cases (eg, worthwhile, realistic, confidence with future SPs and actual patients). Data was analyzed using descriptive statistics. Written comments regarding the strengths and weaknesses of the encounters were analyzed inductively. Results: The participants indicated (90%–100% of the time) that: they agreed or strongly agreed that the encounters were worthwhile and realistic; the cases presented were appropriate; they were provided with adequate performance feedback by the SPs; and that their lower extremity evaluation skills were helped by the experiences. The participants indicated (86%–93% of the time) that they agreed or strongly agreed that the encounters made them feel more comfortable about future evaluations with standardized and actual patients. Conclusions: It appears that SPs provide realistic and worthwhile experiences for athletic training students. Thus, cases could be developed to evaluate athletic training clinical proficiencies in the future.

A Profession That Leads Together Makes a Difference Together: A definitive description of leadership in nutrition and dietetics is impossible, because examples and resulting actions are diverse, spanning and impacting all practice areas. Below, in response to questions I asked of some RDN leaders, I'm so happy to share more about our members exhibit effective leadership through their work and

Anesthesiologists and otolaryngologists are specialists who share overlapping patient considerations because of the proximity of the surgical field and airway. Although many surgical environments benefit from a collegial team dynamic, the interdisciplinary otolaryngologic environment mandates collaboration from anesthesiologists and otolaryngologists for optimal patient outcomes1. Patients undergoing head and neck surgery are at high risk of potentially devastating events if the airway anatomy is distorted secondary to pathologic conditions or previous surgeries. Although many ENT Anesthesia fellowship programs provide exposure to a wide array of clinical cases and development of airway technical skills, the current simulation literature suggests that training programs focus on improvement of procedural skills in silo2–4. However, this is not optimal for prevention or management of high stress situations where crises resource management (CRM) and interdisciplinary team dynamics can affect patient outcome. We would like to encourage every ENT Anesthesia and Surgical training program to consider introducing a comprehensive simulation-based educational component to ensure proficiency in CRM, communication skills, and leadership skills to better manage the rare and critical cases. The use of simulation for interdisciplinary training amongst anesthesiologists, surgeons, and nurses offers flexibility, preserves realism, and enhances patient safety, which makes it ideal for education and assessment of practitioners, regardless of level of training. A wide variety of simulation technology exists with differing degrees of complexity and fidelity that can be used to advance technical skills. Two major classes are part-task trainers and whole-task trainers. Part-task trainers include simple models designed for a specific task. They vary from animal models and mannequins, to more advanced screen-based computer interface. Examples of airway trainers such as the Laerdal adult airway mannequin are capable of mask ventilation, supraglottic airway placement, fiberoptic intubation, as well more invasive procedures of cricothyrotomy and tracheostomy. Slightly more advanced part-task trainers include bronchoscopy devices such as GI-BRONCH Mentor (3D Systems, Littleton, CO) which provide screen-based simulation coupled with tactical psychomotor mechanics. Part-task trainers are important for clinicians to build fundamental skills that can be translated into proficiency in clinical practice. For example, studies have shown a faster acquisition of direct laryngoscopy and improved psychomotor skills on fiberoptic intubations when practiced initially on part-task trainers5,6. In contrast, whole-task trainers (Laerdal SimMan 3G, CAE HPS) are full-scale patient simulators with advanced computer-driven technology and human-modeled physiology that can be altered for desired clinical scenarios. When whole-task trainers are combined with standardized patients and part-task trainers, a hybrid learning environment can be created to incorporate high-fidelity simulation scenarios involving technical as well as nontechnical skills. Team training in the form of interprofessional education (IPE) and interprofessional learning (IPL) is critical for patient safety in the operating room in general, but more so in head and neck cases due to the shared working environment between otolaryngologists and anesthesiologists1. IPE refers to 2 or more professions learning with, from and about each other to improve collaboration and the quality of care, whereas IPL is learning that arises from interaction between members of 2 or more professions7. Rare and potentially disastrous ENT scenarios can be created and implemented, requiring interdisciplinary teamwork and communication for proper patient care. For instance, an in situ simulation course (one that uses actual clinical resources and equipment) at Boston Children’s Hospital teaches teamwork, CRM, and decision-making of high-risk, low frequency airway emergencies to a team of otolaryngology residents, anesthesia trainees, and operating room nurses8. Scenarios such as foreign body aspiration, the bleeding airway, or airway obstruction requiring a surgical airway can be simulated using a hybrid approach with mannequins and standardized patients. These complex educational modules can enhance the learning process and joint coordination of care for both specialists9,10. A rarer emergency includes the airway fire scenario, which not only tests the nontechnical skills and treatment, but also introduces the “fire triad” (oxidizer, ignition source, and fuel), and creates heightened awareness of anesthetic and surgical management to avoid such a disaster11–13. In situ simulations can also be conducted before implementation of new protocols to assess efficiency, to identify disruptions to workflow, and to evaluate various aspects of patient care such as systems-based errors and integration errors. At Johns Hopkins, an interdisciplinary difficult airway response team was created to manage hospital wide airway emergencies and incorporation of in situ simulations proved to be an invaluable tool to probe the system and to identify defects in resources14. A comprehensive, high-fidelity simulation curriculum incorporated into the ENT anesthesia fellowship allows the refinement of psychomotor skills for advanced airway as well as development of nontechnical management skills. Furthermore, when deliberate stressors are added to a fully immersive simulation involving participants in anesthesiology, otolaryngology and nursing, an opportunity is provided to enhance IPE and to facilitate multidisciplinary collaboration. A study conducted on advanced cardiac life support skills showed that adding extreme emotional stressors to a simulated scenario demonstrated an increased retention of skills and knowledge, as well as better performance of advanced cardiac life support15. Another study revealed that a negative outcome to the patient during simulated independent practice led to better retention of clinical skills upon retesting as compared with those who performed in a simulated supervised practice (where a superior helped intervene to prevent the negative outcome)16. The debriefing period that follows allowed the participants to reflect on individual practice and teamwork to identify weak links and areas of improvement for patient safety and care. Simulation has been used successfully as an assessment tool for medical students, residents, nurse anesthetists and practicing anesthesiologists17–20, as well those deemed incompetent21,22 or those retraining to reestablish competence23. Simulation is an ideal technique for fellowship training, education, and assessment of technical and nontechnical skills, especially in the subspecialty of ENT Anesthesia where unfamiliarity of rare ENT emergencies and crisis situations can have catastrophic implications. We urge that every ENT Anesthesia fellowship consider developing and incorporating simulation as part of the fellowship curriculum. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report.

Introduction: Objective Structured Teaching Exercises (OSTEs) provide a systematic framework for evaluating educational competencies through direct observation. This study aimed to train and validate medical students as standardized students (SSs) and psychology students as standardized patients (SPs), assessing their effectiveness in enhancing the communication skills of clinical instructors. Methods: This developmental research was conducted from February to October 2019, encompassing three phases: preparation, training, and validation. In the preparation phase, an expert committee established clinical cases based on literature regarding depressive disorders and created assessment checklists. The training phase included workshops for both SSs and SPs, where participants engaged in scenario practice and received constructive feedback. The validation phase involved evaluating the performance of SSs and SPs using a 12-item evaluation scale to ensure reliability, with the Kappa coefficient employed to assess the agreement among evaluators. Results: A total of 16 participants were involved in each group (SSs and SPs). Both groups exhibited high validity in their portrayals, exceeding 90%, with mean scores of 2.87 for SSs and 2.83 for SPs. Reliability assessments yielded high coefficients of 0.986 for SSs and 0.977 for SPs, indicating consistent performance. The Kappa coefficients for checklist completion were robust: SSs scored 0.872, while SPs achieved 0.710, with the Gold Teacher attaining a perfect Kappa score of 1.000. Conclusion: These findings demonstrate the effectiveness of both SSs and SPs in facilitating the development of communication skills among clinical educators through structured feedback in the OSTE format. Both SSs and SPs displayed exceptional validity and reliability in their roles, establishing them as effective tools for evaluating and enhancing the communication skills of clinical educators. These findings emphasized the potential of integrating standardized roles in medical education to enhance pedagogical effectiveness and improve patient care.

Context Emergency and immediate care skills are often difficult to practice in real time during clinical education. One immediate care skill requiring advanced training that may not be implemented during clinical education is wound closure via suturing. Simple laceration management with sutures can be advantageous skill for athletic training students to learn and practice; however, deliberate practice with feedback in a realistic manner is necessitated. Objective To describe the use of hybrid simulation to practice suturing in professional and postprofessional athletic training programs. Background The practice of immediate and emergency skills is predominately classroom based and removes the patient experience. Simulation-based learning has provided athletic training educators an opportunity for skill practice with patient simulators and standardized patients to fill the gap. Description The hybrid simulation incorporates the use of a standardized live patient actor with an attached part-task–training simulated arm for suturing in a safe and realistic manner. Clinical Advantage(s) Incorporating a hybrid simulation encounter for practice of suturing skills requires multitasking and delivery of patient-centered care and promotes proper skill execution while receiving questions and direct feedback from the standardized patient. Conclusion(s) Suturing should be taught and assessed in a tiered format using part-task trainers such as pig skin and artificial skin pads. After skill development, a hybrid simulation as a summative assessment allows for the educator to evaluate the learners' interpersonal communication and technical skills in a safe manner.

Developing a Complex Simulation Experience to Prepare Students for Emergent Clinical Situations

University of Missouri—Kansas City School of Medicine

As one of the key measures of clinical skills assessment, the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE) is used to rate candidates' performance of osteopathic manipulative treatment (OMT). To evaluate the frequency of specific OMT modalities used by COMLEX-USA Level 2-PE candidates and to report frequent use on the basis of clinical presentation. With enhanced scoring procedures in place, OMT physician-examiners identified and documented specific OMT techniques that were performed by candidates at the 28 colleges of osteopathic medicine and branch campuses that had eligible students at that time. A frequency analysis for OMT techniques, according to clinical content axis, was applied to all candidates (N=4757) for the 2010-2011 testing cycle. Students used a wide range of specific OMT techniques. Candidates performed 24,202 instances of specific OMT techniques, including 10,471 myofascial/soft tissue (43.3%), 3942 muscle energy (16.3%), 1676 sinus drainage (6.9%), 1476 inhibition (6.1%), 1221 fascial release (5.0%), 1171 rib raising (4.8%), 918 lymphatic (3.8%), and 866 counterstrain (3.6%). A few students (<0.01%) used high-velocity, low-amplitude (HVLA), a technique that is prohibited from use on the COMLEX-USA Level 2-PE because of the potential hazard of repeatedly treating a standardized patient with thrust technique to the same segment in a given day. Additional techniques included functional, facilitated positional release, balanced ligamentous tension, and visceral. Use of techniques also varied according to the clinical presentation of the standardized patient (ie, cardiovascular, respiratory, neuromusculoskeletal, gastrointestinal, or other) and chronicity (ie, acute or chronic). Findings contributed to a better understanding of the types of OMT techniques being used by candidates taking COMLEX-USA Level 2-PE. Frequency of use of specific OMT modalities varied according to clinical case presentation.

Introduction: Interprofessional education (IPE) has emerged as an essential component of training for students in the health and social care professions. Standardised patients (SPs) have also been developed as an important simulation-based learning modality in health and social care curricula due to the authenticity and realism of the patient or client encounter that may be replicated. Reports evaluating the use of SPs across an IPE curriculum in the health and social care professions are limited. Methods: This evaluation study used a causal-comparative research design to examine the effect of SPs as an instructional method in an IPE curriculum. Evaluative outcomes of the educational experiences of students attending 37 IPE learning modules offered between Autumn 2006 and Winter 2012 were analysed. Results: A total of 6,561 students from seven health and social care professions rated the usefulness of the instructional methods used in each module through post- module surveys. Students consistently rated SPs as significantly more useful than other instructional methods, and overall mean satisfaction scores were significantly higher for IPE modules that incorporated SPs. Conclusions: This study’s findings demonstrate the positive effect that SPs can have on the learning experiences of health and social care students. By Using SPs in IPE curricula, the authenticity of classroom-based interprofessional learning experiences can be enhanced and lead to more positive IPE learning outcomes.

The development of affective skills in school-aged children

Introduction: Simulation tasks teams were conducted with each team consisting of a medical doctor, a nurse, an emergency life saving technician, and an ambulance crew certified for rescuer tasks. Methods: The scenarios were competitive using high-fidelity manikins and standardized actor patients on-site and at stations, called Rallye Medicina. Results: The current study aimed to evaluate tasks in a Japanese medical rally in 2019 for effectiveness. Conclusion: Multiple attribute utility technology was used, as the task was intended to achieve multiple goals.