Objective Structured Clinical Evaluations Research Articles

A Pilot Study to Compare the Standardized Patient's Perception of Empathy Among the American Medical Graduates and International Medical Graduates Applying for Residency Training in the United States

Abstract:
 Background:
 Empathy is an essential ingredient of patient-centered care. Traditional neurology clerkship does not provide a structured way to teach, evaluate and inculcate the virtue of empathy among our medical students while dealing with various complex neurological conditions. We designed an innovative Objective Structured Clinical Evaluations (O.S.C.E.s) entitled as Empathetic Neurological Care (ENC) O.S.C.E.s as a part of clerkship evaluation to assess empathy among American Medical Graduates (A.M.G.s) and International Medical Graduates (I.M.G.s). We aim to illustrate the model of Empathetic Neurological Care (ENC) O.S.C.E. & to report the comparative analysis of empathy scores among the A.M.G.s and I.M.G.s.
 Methods:
 This is a pilot study comparing empathy among A.M.G.s and I.M.G.s, measured by the Standardized Patients (SPs) using the Jefferson Scale of Patient Perceptions of Physician Empathy (5-Point Likert Type Scale) during pre-designed ENC-OSCEs. The proposed curriculum included complex neurological cases involving breaking bad news (e.g., delivering the diagnosis of A.L.S.), opioid addiction counseling, disclosing medical error (stroke), and explaining the diagnosis of non-epileptic seizures.
 Conclusion: A.M.G.s scored higher empathy as compared to I.M.G.s by the S.P.s during ENC-OSCEs. We highlight the importance of focused empathy training with assessment during neurology clerkship rotations for A.M.G.s & the need of formal curricular training as a part of the orientation program at the beginning of residency training for I.M.G.s.

Adapting Medical Education Initiatives Through Team-Based e-Learning, Telemedicine Objective Structured Clinical Exams, and Student-Led Community Outreach During the COVID-19 Pandemic.

Although the COVID-19 pandemic has quickly prompted medical schools and students around the world to transition from their traditional classrooms to web-based learning, the global crisis has inspired the development of innovative e-learning solutions that use existing technology and other web-based tools to continue nurturing the education of medical students while ensuring the public health and safety of both students and faculty members alike. Through the perspective of medical students, we share how the COVID-19 pandemic has impacted and transformed small team–based learning in medical education; changed objective structured clinical exam evaluations and the practice of clinical skills through telemedicine; and nurtured nationwide, web-based, student-led initiatives for community outreach, telehealth, and medical services.

Geisinger Commonwealth School of Medicine.

Geisinger Commonwealth School of Medicine.

Objective structured teaching examination (OSTE): an underused tool developed to assess clinical teaching skills. A narrative review of the literature.

There are plenty of options for evaluating medical students and medical residents' clinical skills. Objective structured clinical evaluations (OSCEs) have emerged as a powerful and reliable tool for assessing multiple cognition domains of clinical expertise. In the same way as OSCEs have emerged to assess clinical skills, objective structured teaching evaluations (OSTEs) have come to light as promising and unbiased interventions for evaluating the act of clinical teaching. Narrative review developed at Universidade Federal de Uberlândia, Brazil. We searched the literature regarding OSTEs using the MEDLINE (via PubMed) and LILACS (viaBiblioteca Virtual em Saude) databases. The SciELO library was also searched for Brazilian papers. Systematic reviews, reviews and randomized controlled trials specifically assessing how OSTEs performed in relation to development of academic staff and medical residents were then selected. Our search retrieved 178 papers, of which 40 were considered eligible for intensive review. Most of the studies selected reported positive effects from OSTE activities. However, there was little quantitative data to gauge the impact of OSTEs on improvement of teaching skills. Considering that OSCEs have become a widely used tool for assessing medical students' and residents' clinical skills, it is high time to incorporate OSTEs for evaluating teaching skills in Brazil. Encouraging data to support implementation of this assessment tool in this country is available from abroad. The net benefit from this would possibly encompass medical students, residents and academic staff, through bringing awareness about the importance of excelling in teaching skills.

The effectiveness of end-of-life care simulation in undergraduate nursing education: A randomized controlled trial

BackgroundNursing students have limited opportunities to experience end-of-life care, so it is difficult for them to learn how to deliver it empirically. The use of simulations with standardized patients may be a way to provide realistic experience of end-of-life care for nursing students. ObjectivesThe aim of this study was to evaluate the effectiveness of end-of-life care simulations with standardized patients in improving the knowledge, skill performance and self-confidence of undergraduate nursing students. DesignRandomized controlled study. SettingJapanese university nursing school. ParticipantsThirty-eight students in the third year of the Bachelor's degree in nursing (simulation group = 20, control group = 18). MethodsAfter randomization to a simulation or control group, participants in the simulation group participated in an end-of-life care simulation with standardized patients. The primary outcome of a change in the knowledge score was assessed using a knowledge questionnaire, skill performance by completing Objective Structured Clinical Evaluations, and self-confidence related to end-of-life care by self-reported questionnaires. ResultsThe simulation group improved significantly in knowledge, skill performance in physical assessment and psychological care, and self-confidence related to end-of-life care. The results of the two-way analysis of variance showed a significant interaction between groups and time (p = 0.000). Analysis of the simple main effect showed a significant difference (p = 0.000) between groups after the end-of-life care simulation and a significant difference (p = 0.000) over time in the simulation group. There were large effects on knowledge improvement (η2 = 0.372), physical assessment (η2 = 0.619), psychological care skill performance (η2 = 0.588), and self-confidence in both physical assessment (η2 = 0.410) and psychological care (η2 = 0.722). ConclusionsEnd-of-life care simulation with standardized patients would be an effective strategy to train nursing students, who have limited opportunities to experience end-of-life care.

Resuscitation skills after Helping Babies Breathe training: a comparison of varying practice frequency and impact on retention of skills in different types of providers.

Helping Babies Breathe (HBB), a basic neonatal resuscitation curriculum, improves early neonatal mortality in low-resource settings. Our goal was to determine retention of resuscitation skills by different cadres of providers using the approved HBB Spanish translation in a rural clinic and community hospital in Honduras. Twelve clinic and 37 hospital providers were trained in 1 d HBB workshops and followed from July 2012 to February 2014. Resuscitation skills were evaluated by objective structured clinical evaluations (OSCEs) at regular intervals. Clinic providers practiced monthly, whereas hospital providers were randomized to monthly practice for 6 months vs three consecutive practices at 3, 5 and 6 months. In the rural clinic, follow-up OSCE assessment showed rapid loss of skills by 1 month after HBB training. For all providers, repeated monthly testing resulted in improvements and maintenance of OSCE performance. In the community hospital, over all time points, the group with monthly OSCEs had 2.9 greater odds of passing compared with the group who practiced less frequently. Physicians were found to have 4.3 times greater odds of passing compared with nurses. Rapid loss of resuscitation skills occurs after an initial training. Repeated practice leads to retention of skills in all types of providers. Further investigation is warranted to determine the clinical correlation of neonatal outcomes after HBB training.

Conducting Objective Structured Clinical Exams in a Pediatric Nurse Practitioner Program Using Google Tools

Objective structured clinical evaluations have been used within the clinical teaching environment in physician and advanced practice registered nurse training programs for many years. This article highlights the value of using Google suite tools (including presentations, forms, and spreadsheets) to perform objective structured clinical evaluations within nurse practitioner training programs. These web-based tools enable faculty to evaluate a higher level of clinical acumen on Miller’s pyramid of clinical competence. Using the Google suite, faculty are now able to evaluate “shows how” in a more efficient manner.

Evaluation of an educational program for essential newborn care in resource-limited settings: Essential Care for Every Baby.

BackgroundEssential Care for Every Baby (ECEB) is an evidence-based educational program designed to increase cognitive knowledge and develop skills of health care professionals in essential newborn care in low-resource areas. The course focuses on the immediate care of the newborn after birth and during the first day or until discharge from the health facility. This study assessed the overall design of the course; the ability of facilitators to teach the course; and the knowledge and skills acquired by the learners.MethodsTesting occurred at 2 global sites. Data from a facilitator evaluation survey, a learner satisfaction survey, a multiple choice question (MCQ) examination, performance on two objective structured clinical evaluations (OSCE), and pre- and post-course confidence assessments were analyzed using descriptive statistics. Pre-post course differences were examined. Comments on the evaluation form and post-course group discussions were analyzed to identify potential program improvements.ResultsUsing ECEB course material, master trainers taught 12 facilitators in India and 11 in Kenya who subsequently taught 62 providers of newborn care in India and 64 in Kenya. Facilitators and learners were satisfied with their ability to teach and learn from the program. Confidence (3.5 to 5) and MCQ scores (India: pre 19.4, post 24.8; Kenya: pre 20.8, post 25.0) improved (p < 0.001). Most participants demonstrated satisfactory skills on the OSCEs. Qualitative data suggested the course was effective, but also identified areas for course improvement. These included additional time for hands-on practice, including practice in a clinical setting, the addition of video learning aids and the adaptation of content to conform to locally recommended practices.ConclusionECEB program was highly acceptable, demonstrated improved confidence, improved knowledge and developed skills. ECEB may improve newborn care in low resource settings if it is part of an overall implementation plan that addresses local needs and serves to further strengthen health systems.Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-015-0382-z) contains supplementary material, which is available to authorized users.

Pre-hospital rapid sequence induction: Factual inaccuracies?

This distinction is of some importance when considering the educational background of those practicing RSI, as ECPs hold a four-year degree in emergency medical care (EMC). On page 633, and again on page 636, the authors describe RSI training as being a ‘two day university course’ and that they consider this to be insufficient. [1] I agree that two days of training on RSI is insufficient. However, this is not an accurate description of current RSI education at all institutions offering the EMC degree programme. The ‘two day university course’ was offered once in 2009 by one institution for those who already held an EMC degree, as a way of incorporating RSI (which was newly-approved at the time) into their clinical practice. The important point is that it was a ‘once-off ’ arrangement intended to update those who qualified with an EMC degree before RSI was approved for ECP scope of practice; it has not been the approach followed for undergraduate students since 2010. At the University of Johannesburg (UJ), RSI has been incorporated into an educational strategy on airway management which spans four years. Our approach in designing and implementing RSI education since 2010 has involved advice, input and involvement from specialists in both anaesthesiology and emergency medicine. Assessments include a mix of theory, objective structured clinical evaluations, simulations and assessments carried out in the emergency centre and pre-hospital environments. While we would like all of our students to have clinical experience in RSI before qualifying as independent practitioners, there is a very real problem of access to critical procedures. The healthcare system caters for a large number of students from a variety of fields and institutions. All compete for clinical experience in a small number of facilities that have suitable levels of clinical supervision. Given these constraints, we are currently implementing the approach outlined in the position statement referred to by the authors in their

Communication Interventions for the Management of Patients Who are Challenging or Resistant. Utilizing a Teaching for Understanding Framework

Abstract Purpose of study: Communication programmes have become a part of mainstream education at all levels of dental training. As part of the Behavioural Science Programme as applied to Dentistry UCC, the teaching for understanding framework (TfU) was adopted to teach dental students how in clinical practice to manage patients who are challenging, or resistant. The key TfU goals are to understand and identify the types of challenging patients; to understand and develop communication skills, a core component of which is empathic concern; and to develop interpersonal and intrapersonal awareness. Method In order to assess the application of the TfU goals, dental students are required to engage in Objective Structured Clinical Evaluations (OSCE's) so that their ability to communicate with patients with challenging behaviour can be assessed. This requires the student to remain patient- centred and to manage the clinical encounter by using a selection of clinical interventions to dissipate the patient's emotional response to the medical or clinical situation. Conclusion & Recommendations: If the interaction is managed effectively the student will address the patient's concerns, acknowledge the patient's affective state, and refocus the patient on the decision(s) to be made with regard to their dental treatment plan. The value of using the TfU framework is ultimately to bridge the gap between the theories learnt in class and their application in clinical practice.

Helping Babies Breathe: Global neonatal resuscitation program development and formative educational evaluation

ObjectivesTo develop an educational program designed to train health care providers in resource limited settings to carry out neonatal resuscitation. We analyzed facilitator and learner perceptions about the course, examined skill performance, and assessed the quality of instruments used for learner evaluation as part of the formative evaluation of the educational program Helping Babies Breathe. MethodsMultiple stakeholders and a Delphi panel contributed to program development. Training of facilitators and learners occurred in global field test sites. Course evaluations and focus groups provided data on facilitator and learner perceptions. Knowledge and skill assessments included pre/post scores from multiple choice questions (MCQ) and post-training assessment of bag and mask skills, as well as 2 objective structured clinical evaluations (OSCE). ResultsTwo sites (Kenya and Pakistan) trained 31 facilitators and 102 learners. Participants expressed high satisfaction with the program and high self-efficacy with respect to neonatal resuscitation. Assessment of participant knowledge and skills pre/post-program demonstrated significant gains; however, the majority of participants could not demonstrate mastery of bag and mask ventilation on the post-training assessment without additional practice. ConclusionsParticipants in a program for neonatal resuscitation in resource-limited settings demonstrated high satisfaction, high self-efficacy and gains in knowledge and skills. Mastery of ventilation skills and integration of skills into case management may not be achievable in the classroom setting without additional practice, continued learning, and active mentoring in the workplace. These findings were used to revise program structure, materials and assessment tools.

International trauma training: teaching and evaluating physicians in a cross cultural setting

BackgroundTrauma is a leading cause of death and disability worldwide. Training and evaluation of physicians trauma skills and knowledge is more difficult in cross cultural settings due to language and...

Student Learning: Perception versus Reality

Pharmacy education has entered an era of focus on assessment of learning outcomes as an evidence-based approach to determine the effectiveness of instructional methods. Assessment of the learning outcomes is more important than the methods or the process of teaching. We know that what happens in the minds of our students is more important than what the instructor thinks about student learning. Journal authors now include much more information in their manuscripts to document student learning; nevertheless, many published reports in pharmacy education still do not provide adequate evidence of learning. A scan of papers that have appeared in the Journal over the past few years shows many examples of measures that directly assessed student learning and others that focused on students' “perception” of their learning. While students' perceptions of their learning may provide a type of assessment, they should not be used as the primary evidence that an instructional approach is effective. Perception may not be reality. When authors focus their assessment of learning on student perceptions, students are typically asked to rate on a survey instrument how well they believe they understood a topic, or how “confident” or “comfortable” they are regarding knowledge in an area. Student perceptions of their own knowledge may not accurately assess the higher-level knowledge they will need in practice. By the very act of participating in a course, students may perceive their learning has significantly improved. Instructor and student perceptions of learning are prone to multiple types of biases. Instructors attempting to demonstrate the effectiveness of their instruction should not rely on student perceptions as the primary evidence of learning. Student perceptions of their learning may provide one subset of information but should not be the primary assessment. Often, student perception data are not validated as a measure of achievement of competencies. Evidence for learning and achievement of competencies should include direct measures of learning, which could be traditional examinations that address course competencies, structured instructor evaluations, use of assessment rubrics, or other direct assessments such as objective structured clinical evaluations (OSCEs). Guidelines for the assessment of learning are provided in the IDEAS paper by Poirier and colleagues.1 This document serves as a framework for an evidence-based approach to fully describe a new course or instructional approach. Other papers in the Journal provide additional guidance on assessment measures.2-5 Authors should note that manuscripts are unlikely to be published in AJPE if the only measure of learning is student perceptions of their own learning. Editors may return manuscripts to authors who only include student perception data, and manuscript reviewers are instructed to expect validated direct measures of student learning for articles that describe new instructional approaches. The ultimate endpoint of interest to the pharmacy educator should be whether students achieve desired competencies that indicate the knowledge and skills that are needed to effectively practice pharmacy. Students' own perceptions of their knowledge and skills may not reflect reality or provide an accurate and thorough assessment, and should not serve as a primary measure of learning effectiveness. The quality of pharmacy education and education literature will be improved when standards for publication include the requirement for direct measures of student learning beyond student perceptions of their knowledge and skills.

A primer on classical test theory and item response theory for assessments in medical education

A test score is a number which purportedly reflects a candidate's proficiency in some clearly defined knowledge or skill domain. A test theory model is necessary to help us better understand the relationship that exists between the observed (or actual) score on an examination and the underlying proficiency in the domain, which is generally unobserved. Common test theory models include classical test theory (CTT) and item response theory (IRT). The widespread use of IRT models over the past several decades attests to their importance in the development and analysis of assessments in medical education. Item response theory models are used for a host of purposes, including item analysis, test form assembly and equating. Although helpful in many circumstances, IRT models make fairly strong assumptions and are mathematically much more complex than CTT models. Consequently, there are instances in which it might be more appropriate to use CTT, especially when common assumptions of IRT cannot be readily met, or in more local settings, such as those that may characterise many medical school examinations. The objective of this paper is to provide an overview of both CTT and IRT to the practitioner involved in the development and scoring of medical education assessments. The tenets of CCT and IRT are initially described. Then, main uses of both models in test development and psychometric activities are illustrated via several practical examples. Finally, general recommendations pertaining to the use of each model in practice are outlined. Classical test theory and IRT are widely used to address measurement-related issues that arise from commonly used assessments in medical education, including multiple-choice examinations, objective structured clinical examinations, ward ratings and workplace evaluations. The present paper provides an introduction to these models and how they can be applied to answer common assessment questions.

Abstracts From the Proceedings of the 2005 Annual Meeting of the Association of Directors of Medical Student Educationin Psychiatry (ADMSEP)

The 31st Annual Meeting of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) was held from June 23 to June 25, 2005, at the Monterey Plaza Hotel and Spa in Monterey, California. Approximately 100 registrants from 60 medical schools in the United States and Canada were in attendance. Although the plenary sessions and workshops covered a wide range of educational topics, there was a focus on assessment of students' clinical skillsKeynote speeches were given by Richard Hawkins, deputy vice president, assessment programs, at the National Board of Medical Examiners and by Brian Hodges, director of the Wilson Center for Research in Education at the University of Toronto. Dr. Hawkins presented an overview of United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam with emphasis on the measures taken to ensure fairness and consistency. He also provided an update on examinee performance to date. Dr. Hodges discussed the development and spread of the use of Objective Structured Clinical Evaluations (OSCEs), along with current best practices with respect to simulation and the use of standardized patients, measuring student exam performance, and issues regarding the validity of the OSCE tool with respect to the novice, intermediate, and expert examinee. He also discussed particular features of the OSCE relevant to psychiatry.The abstracts presented in these proceedings were chosen for their general appeal to medical student educators and because they are representative of the type of educational research undertaken by ADMSEP members and colleagues. To appreciate the breadth of topics cover at the meeting, the reader is referred to the full program on the "Meetings" pages of the ADMSEP Web site, www.admsep.org.

Online classrooms enhance clerkship small group teaching

Context and setting The pressures of the modern health care environment have negatively impacted the teaching forums of traditional clinical clerkships, including small group teaching seminars. Why the idea was necessary Faculty pressured by market forces and increasing regulation have less time to meet face-to-face with students in small groups and are less likely to encounter their students in the clinical realm, damaging the faculty−student relationship and faculty members' ability to appropriately evaluate students. Students also have less opportunity in the clinical environment to observe the continuity of patient care, use of evidence-based medicine and clinical decision making by faculty. Online classrooms that supplement small group teaching sessions have the potential to not only offset these deficiencies but to enhance clinical reasoning and sophistication by creating a forum where students can work collaboratively with faculty facilitation in addressing an issue or working through a patient case. What was done We developed a web-based cyber classroom that hosts classrooms for individual tutorial groups. Students discuss 1 case each week in the classroom. Each student is assigned to serve as the discussion leader for 1 week of the classroom, providing an opportunity to build leadership skills. Faculty facilitators talk offline with discussion leaders at the start of the week to determine the case and review the discussion leader's responsibilities. Students work collaboratively in the classroom to assess the patient and develop a differential diagnosis, thus building the teamwork skills needed in clinical practice. Faculty members act as facilitators to guide, rather than lead, discussion. Cases presented in the cyber classroom are in addition to the standard tutorial curriculum reviewed in weekly face-to-face meetings. Each classroom is analysed to assess the pattern of the conversation. The quality of students' posts is also assessed on a 4-point scale, based on the sophistication of students' reasoning, use of evidence-based medicine, integration of material learned in different clinical scenarios or educational environments, and discussion of non-biomedical issues, such as ethical or cultural issues. Evaluations of the cyber classroom are correlated with other quantitative and qualitative assessments of the students, such as their performance on objective structured clinical examinations (OSCEs), shelf examinations and faculty evaluations. Evaluation of results and impact We analysed 8 classrooms, 4 each from 2 8-week clinical clerkships, including 70 students and 8 faculty facilitators with 8−9 students per classroom. We sampled weeks 3 and 6 of each classroom, analysing the differences in quality and discussion patterns between weeks 3 and 6 of each classroom and across classrooms. Based on this small sample, we expect to see a measurable increase in quality and a progression from faculty-centred to student-centred discussions from weeks 3–6 across the academic year's 6 rotations. In addition, faculty report an improved ability to differentiate among students and to assess students' knowledge and reasoning skills.

Virtual patients get real

and sophistication by creating a forum where students can work collaboratively with faculty facilitation in addressing an issue or working through a patient case. What was done We developed a web-based cyber classroom that hosts classrooms for individual tutorial groups. Students discuss 1 case each week in the classroom. Each student is assigned to serve as the discussion leader for 1 week of the classroom, providing an opportunity to build leadership skills. Faculty facilitators talk offline with discussion leaders at the start of the week to determine the case and review the discussion leader’s responsibilities. Students work collaboratively in the classroom to assess the patient and develop a differential diagnosis, thus building the teamwork skills needed in clinical practice. Faculty members act as facilitators to guide, rather than lead, discussion. Cases presented in the cyber classroom are in addition to the standard tutorial curriculum reviewed in weekly face-to-face meetings. Each classroom is analysed to assess the pattern of the conversation. The quality of students’ posts is also assessed on a 4-point scale, based on the sophistication of students’ reasoning, use of evidence-based medicine, integration of material learned in different clinical scenarios or educational environments, and discussion of non-biomedical issues, such as ethical or cultural issues. Evaluations of the cyber classroom are correlated with other quantitative and qualitative assessments of the students, such as their performance on objective structured clinical examinations (OSCEs), shelf examinations and faculty evaluations. Evaluation of results and impact We analysed 8 classrooms, 4 each from 2 8-week clinical clerkships, including 70 students and 8 faculty facilitators with 8)9 students per classroom. We sampled weeks 3 and 6 of each classroom, analysing the differences in quality and discussion patterns between weeks 3 and 6 of each classroom and across classrooms. Based on this small sample, we expect to see a measurable increase in quality and a progression from facultycentred to student-centred discussions from weeks 3–6 across the academic year’s 6 rotations. In addition, faculty report an improved ability to differentiate among students and to assess students’ knowledge and reasoning skills.

Assessing Residents' Competency in Care Management: Report of a Consensus Conference

Background: Residency programs must prepare physicians to practice in the current health care environment. This mandate is reflected in 3 of the 6 competency domains now required by the Accreditation Council for Graduate Medical Education: systems-based practice, interpersonal skills and communication, and practice-based learning and improvement. Summary: An invitational conference was convened, with experts in clinical practice, managed care administration, and education to identify and recommend optimal and promising assessment methods for 4 target areas: physician-patient communication, ethics, teamwork and collaboration, and practice management. Working in small groups, participants considered a range of resident assessment methods and identified current or future methods for each area, based on reliability, validity, use of behaviorally oriented outcomes, feasibility, and cost. Preferred methods of assessment varied by domain and include written examinations, computer-based patient management problems, standardized patients, objective structured clinical examinations, portfolios, 360-degree evaluations, and patient satisfaction surveys. Conclusions: The use of several practical, scientifically sound, and specific methods for assessing residents' competency in care management are recommended. Assessment instruments will need to be flexible enough to adapt to the rapid changes in the health care delivery system and terminology.

A clinical performance exercise for medicine--pediatrics residents emphasizing complex psychosocial skills.

To assess the skills of internal medicine-pediatrics (med-peds) residents in evaluating and counseling patients with complex psychosocial problems using a clinical performance exercise (CPE). The authors designed a 13-station CPE [nine standardized-patient (SP) stations and four non-SP stations]. Eight of the SP stations focused on counseling or assessing complex psychosocial needs, and three were videotaped and analyzed for specific verbal and nonverbal communication skills. Residents completed a written task for each station and SPs completed a checklist on interviewing and communication skills and a 52-item patient's-satisfaction survey. All first- and third-year residents (n = 25) from two academic years participated. The range of the average scores on the nine SP stations was 43-75%. The residents performed better with common problems (newborn hospital discharge instructions and cardiac risk-factor counseling) than with more complex problems that are less often encountered in the institution (HIV counseling), or problems less often recognized (adult survivor of childhood sexual abuse). As expected, third-year residents scored better than did first-year residents on the written "plan" part of the SP stations and on the non-SP stations. Third-year and first-year residents had similar scores, however, on measures of verbal and nonverbal communication and patient's satisfaction, and for gathering data and providing information. This is the first performance-based evaluation of residents in a combined med-peds residency program. The stations addressed more complex clinical skills than those reported for objective structured clinical evaluations of residents.

Helping Babies Survive Training Programs: Evaluating a Teaching Cascade in Ethiopia.

2.6 million neonates die annually; the vast majority of deaths occur in low- and middle-income countries (LMICs). The Helping Babies Survive (HBS) programs are commonly used in LMICs to reduce neonatal mortality through education. They are typically disseminated using a train-the-trainer cascade. However, there is little published literature on the extent and cost of dissemination. In 2015, the Ethiopian Ministry of Health and partner organizations implemented a countrywide HBS training cascade for midwives in 169 hospitals. We quantified the extent of HBS dissemination, and characterized barriers that impeded successful hospital-based training by surveying a representative from each of the 169 participant hospitals. This occurred from September 2017 to April 2018. We also assessed the cost of the training cascade. To assess acquisition of knowledge and skill in the training cascade, multiple-choice question examinations (MCQE) and objective structured clinical evaluations (OSCE) were conducted. Hospital-based training occurred in 132 participant hospitals (78%). 1,146 midwives, 69% of those employed by participant hospitals, received hospital-based training. Barriers included lack of preparation of hospital-based educators and limited logistical support. The cascade cost an average of 2,105 USD per facility or 197 USD per trainee. Knowledge improved and skills were adequate for regional workshop attendees based on MCQE and OSCE performance. The train-the-trainer strategy is an effective and affordable strategy for widespread dissemination of the HBS programs in LMICs. Future studies should assess knowledge and skill acquisition following the variety of pragmatic training approaches that may be employed at the facility-level.