Procedural Competence Research Articles

Exploring metacompetence in child welfare simulation training: toward a holistic model

ABSTRACT Holistic competence involves two distinct constructs: procedural competencies and metacompetencies A framework developed by Tufford and colleagues (2017), suggests four domains of metacompetence: skills in action, deepened perspectives on diversity, managing affective intensity in the moment, and openness to learning. This exploratory evaluation study was guided by the research question, in what ways does Illinois child welfare simulation training address the four domains of metacompetence? Findings indicted that relevant knowledge and skill development for each domain are supported in the training. More nuanced evaluation could better assess procedural and metacompetence and more fully operationalize holistic competence for child welfare professionals.

Bridging the procedures skill gap from medical school to residency: a simulation-based mastery learning curriculum.

The transition from medical student to intern is a recognized educational gap. To help address this, the Association of American Medical Colleges developed the Core Entrustable Professional Activities for entering residency. As these metrics outline expectations for all graduating students regardless of specialty, the described procedural expectations are appropriately basic. However, in procedure-heavy specialties such as emergency medicine, the ability to perform advanced procedures continues to contribute to the disconnect between undergraduate and graduate medical education. To prepare our graduating students for their internship in emergency medicine, we developed a simulation-based mastery learning curriculum housed within a specialty-specific program. Our overall goal was to develop the students' procedural competency for central venous catheter placement and endotracheal intubation before graduation from medical school. Twenty-five students participated in a simulation-based mastery learning procedures curriculum for ultrasound-guided internal jugular central venous catheter placement and endotracheal intubation. Students underwent baseline assessment, deliberate practice, and post-test assessments. Both the baseline and post-test assessments used the same internally developed checklists with pre-established minimum passing scores. Despite completing an emergency medicine rotation and a critical care rotation, none of the students met the competency standard during their baseline assessments. All twenty-five students demonstrated competency on both procedures by the end of the curriculum. A second post-test was required to demonstrate achievement of the central venous catheter and endotracheal intubation minimum passing scores by 16% and 28% of students, respectively. Students demonstrated procedural competency for central venous catheter placement and endotracheal intubation by engaging in simulation-based mastery learning procedures curriculum as they completed their medical school training. With three instructional hours, students were able to achieve basic procedural competence for two common, high-risk procedures they will need to perform during emergency medicine residency training.

Graduating Vascular Surgery Trainee Proficiency in Endovascular and Open Peripheral Revascularization Procedures

Endovascular interventions for peripheral artery disease have increased in prevalence over time given the inherent benefits of minimally invasive approaches. While it is essential that vascular surgery graduates are facile with endovascular techniques, the results of the BEST-CLI trial highlight the equivalent importance of ensuring trainee competence in open skills. Recent studies demonstrate increasing case volume of both endovascular and open procedures during vascular surgery training. Case volume is merely a surrogate marker for competence, however, and the objective competence attained by trainees at the time of graduation is unknown. We sought to investigate operative autonomy and competence of graduating vascular surgery trainees performing endovascular as compared to open peripheral vascular revascularization procedures. Operative performance and autonomy ratings for infrainguinal endovascular and open revascularizations from the Society for Improving Professional Learning Operative (SIMPL OR) application database were collected for all vascular surgery participating institutions from 2018-23. The distribution for autonomy and performance ratings were determined by training level for endovascular and open procedures, respectively. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and autonomy and performance assessment, adjusting for training level and case complexity. Subsequently, the estimated model was applied to predict the probability of a graduating trainee being rated as meaningfully autonomous or competent while performing endovascular and open procedures across various case complexities. Sixty-nine residents from 23 programs (12 fellowship, 11 residency) were assessed on 706 revascularization procedures (n=383 endovascular, 323 open). When controlling for training level and case complexity, there were no differences in autonomy (OR 1.11 [95% CI: 0.62-1.99]) or competency assessment (OR 0.86 [95% CI: 0.46-1.59]) for endovascular, as compared to open, peripheral revascularization procedures. For average complexity procedures, the predicted probability of a trainee being assessed as competent and autonomous at the time of graduation was high (competent: 88% endovascular, 86% open; autonomous: 96% endovascular, 97% open). Predicted probability of competence and autonomy for complex procedures was lower but remained similar between groups (competent:73% endovascular, 70% open; autonomous: 92% endovascular, 92% open). There is no difference in the graduating level of autonomy and competence of endovascular as compared to open peripheral revascularization procedures for vascular surgery trainees. These findings suggest vascular surgery trainees enter independent practice with adequate proficiency to utilize the full scope of techniques to care for patients requiring peripheral revascularization procedures.

Scientific Production on Entrepreneurial Skills in Young Students: Bibliometric Analysis

Entrepreneurship is considered a key element for economic and social development, requiring cognitive, attitudinal, and procedural competencies for its realization. This study focuses on a documentary review aimed at answering the following questions: How is research on entrepreneurial capabilities approached in different countries? What is the volume of scientific production on this topic? In light of this, the present work is developed within the inclusion criteria: publications between 2012 and 2022, various types of documents, written in English, and included in the SCOPUS database. To conduct the analysis, a combination of tools such as VOSviewer, Biblioshiny, and Excel was used. These tools allowed for the identification of clusters, co-occurrence frequencies, and network nodes. Based on this, the behavior of authors, countries, journals, and the evolution of the topic over time were examined. The results reveal that the United States is the leading country in publishing research on entrepreneurship. There is an increase in scientific production related to this topic, with the majority of publications concentrated in a limited number of journals (53). Limited collaboration among authors and institutions is also evident. The co-authorship network is divided into 47 clusters, with weak grouping among them.

Introducing simulation-based education to Genitourinary Medicine specialty training in the North West of England: A quality improvement project exploring trainee perspectives and impact.

Simulation-based education (SBE) provides enactive experiences for learners. This project explores the utility of SBE in GUM training. Phase 1 was a qualitative survey of GUM trainees across the UK exploring their views on SBE. Phase 2 involved roll-out of SBE to new GUM trainees. Feedback was subsequently obtained. Twenty-three participants were surveyed in phase 1. When asked to rate the relevance of SBE to curriculum competencies on a scale of 1 to 5 (1 = not relevant, 5 = highly relevant), the highest ratings (score ≥4) were for proctoscopy (4.1), IUD insertion (4.1), SDI removal (4.1), SDI insertion (4.0), and punch biopsy (4.0). All curriculum items scored ≥3. Eighty-three percent (n = 19) felt SBE will improve clinician confidence and competence. Following introduction of SBE, participants fed back on the relevance of the session. All 5 respondents rated the session ≥4 for addressing their clinical and curriculum goals. All respondents rated the session ≥4 for improving clinician confidence and competence. The session received an overall rating of 5, and respondents similarly rated 5 for more sessions. Trainees recognise the value of simulated learning experiences and its role in improving procedural competence and addressing bespoke human factor skills relevant to GUM.

Tracheostomy tube changes by speech-language pathologists: a service review of an expanded scope of practice

Background/Aims Patients in acute care who have received a tracheotomy require efficient management to adequately progress through the acute care setting. This progression is predicated on efficient tracheostomy weaning through tracheostomy downsizing, capping and decannulation. The objective of this retrospective study was to review the outcomes of tracheostomy tube changes by speech-language pathologists. Methods A retrospective cohort analysis was performed of adult patients who received a tracheostomy tube change during their acute care hospitalisation by speech-language pathologists during a 6-month span in 2022. A total of 38 consecutive referrals undergoing an initial tracheostomy tube change had their electronic medical records reviewed. Success was defined as the placement of the tracheostomy tube into the tracheal lumen with confirmation of placement with no adverse events. Complications were recorded at the time of the tracheostomy tube change. Results Speech-language pathologists performed 38 (100%) initial tracheostomy tube changes successfully at the bedside without complications. The primary referral services were trauma and neurology. The primary diagnoses were polytrauma with a traumatic brain injury and multiple trauma without a traumatic brain injury or spinal cord injury. The mean Glasgow Coma Scale score and number of intubations were 12.4 and 1.4 respectively. A total of 34 (89%) tracheostomy tube changes resulted in the downsizing of the tracheostomy tube, while the remainder of tracheostomy tube changes (n=4; 11%) maintained the same size but were cuffless. All the tracheostomy tube changes were completed without complications, and all patients were noted as stable after 24 hours. Conclusions The procedural success corroborates the data reported by an earlier study in the literature and further validates the efficacy of a competent and experienced speech-language pathologists' ability to perform low-risk tracheostomy tube changes in the acute setting. This study demonstrates real world data from a single large trauma centre of tracheostomy tube changes performed by speech-language pathologists. Such data better defines the emerging role expansion of speech-language pathologists in the acute care setting. Implications for practice This study has the potential to expand the discussion around speech-language pathologists changing tracheostomy tubes in the acute care setting for a low-risk cohort. The authors have outlined the requisite training that may serve as a resource for speech-language pathologists to develop procedural competency.

Experiences and Outcomes of the Society of Genitourinary Reconstructive Surgeons Fellowship Training: Growth in Fellowships Mirrors the Evolution of the Discipline

ObjectiveTo describe experiences and outcomes of the Society of Genitourinary Reconstructive Surgeons (GURS) fellowship match. In 2012, GURS developed a centralized fellowship match which has grown from 13 to 30 programs. MethodsGURS match statistics and case logs were reviewed from 2013-2024. Additionally, a 37 question survey evaluating satisfaction, procedural competency, fellowship experience, and employment opportunities were sent to graduates. Linear regression was performed to examine trends over time. ResultsOver the study period, program match success remained stable (94.7%;p=0.50) while applicant success (63.3%) increased over time (p=0.04). North American and female applicants experienced higher match success (72.8% and 73.6%) compared to their international (35.5%;p<0.0001) and male counterparts (60.0%;p=0.02). On case log analysis, mean surgical volumes per year increased in urethral reconstruction (mean=88.1;p=0.02), male sexual health (n=32.7;p=0.03), genital reconstruction (mean=16.4;p<0.01) and abdominal reconstruction (mean=24.5;p=0.03). Male incontinence surgeries remained stable (mean=30.5;p=0.21) while female reconstruction declined (mean=23.2;p=0.01). With a survey response rate of 54.5% (97/178), training satisfaction was 95.9% which did not differ by gender (p=0.54) or year of training (p=0.22). 97.9% felt competent to enter unsupervised reconstructive practice, 94.8% reported an understanding of the relevant literature and 96.9% were satisfied with their job as a reconstructive urologist. 49.5% identified a different case mix in practice compared to fellowship, most commonly related to abdominal (44.9%) or genital reconstruction (16.3%). ConclusionGURS fellowships have grown organically over the last decade and mirror the growth and evolution of the discipline with sustained high-levels of graduate satisfaction, surgical experience, competence, scholarly inquiry and employment.

Direct Observation of Procedural Skills (DOPS) in Enhancing Clinical Competencies of Postgraduate Medical and Dental Education: A Scoping Review

Background: As postgraduate medical or dental education students, most of us will have come across Direct Observation of Procedural Skills or DOPS. DOPS promoted clinical effectiveness by evaluating practice-based skills in the authentic organizational context, and subsequently proactively feeding back the learning to learners. This scoping review sought to synthesize the work done in determining DOPS's effectiveness in enhancing clinical competencies in some fields of medicine and dentistry. Methods: The study was carried out by using the following search engines: PubMed, Medline, Google Scholar, Science Direct, SID, Medlib and Google searched unpublished sources (Gray literature) and selected references (reference of reference) by typing the following keywords: (DOPS), clinical competencies, postgraduate medical and dental education. Results: From 215 papers 40 were analyzed and together demonstrated the efficiency of the Direct Observation of Procedural Skills (DOPS) as an assessment tool for numerous medical and dental profiles. It was revealed that DOPS improved procedural confidence, procedural performance competence and general clinical skills, all over the world. In their views, learners and educators overestimated the usefulness of DOPS and acknowledged its function of enhancing clinical competencies and offering feedback. The participants encountered some difficulties such as time limitations, coordination problems, and curriculum mismatch Nevertheless, DOPS was much more effective than traditional approaches in increasing satisfaction and reliability of the assessments in various medical training settings. Conclusion: In the context of postgraduate medical and dental education and training, the DOPS assessment tool was found to be very effective in enhancing clinical competencies and procedural skills. However, the successful implementation has the points that need to be attended like the training of the assessors and standardization although there are benefits of the same. Further studies were encouraged to investigate ways of enhancing the use of DOPS and how best it could be incorporated into post-graduate training

Perceptions of Nurse Practitioners and Physician Assistants/Associates Toward the Concept of Developing an Advanced Practice Postgraduate Residency/Fellowship Program at a Large Academic Medical Center.

Introduction There have been exponential growth and increased interest in postgraduate residency/fellowship formalized training among nurse practitioners (NPs) and physician assistants/associates (PAs). Although not a requirement for state licensure and entry-level practice, postgraduate NP and PA residency/fellowship programs offer a structured pathway for new graduates and experienced PAs and NPs looking to transition into a new medical or surgical specialty/subspecialty. In this article, we examine the perceptions of employed NPs and PAs toward postgraduate training including the concept of developing a program at our institution. Methodology This was a cross-sectional single-large academic medical center (AMC) study, where an anonymous electronic survey was initially developed by the director of advanced practice providers (APPs). The survey was piloted by members of the Advanced Practice Council (APC) comprising NPs, PAs, and certified registered nurse anesthetists (CRNAs), and their collective feedback was used to finalize the survey prior to distribution. Descriptive statistics were used to describe and summarize the data. In addition, we assessed the association between respondents' characteristics and perceptions regarding NP and PA residency/fellowship programs using chi-squared tests of independence. Results The majority of the respondents (69.1%; 65/94) believed that starting an advanced practice residency/fellowship program at our AMC has many benefits such as increasing specialty-specific knowledge and training (79.8%; 75/94), improving medical decision-making (73.4%; 69/94), promoting professional development and clinical education (73.4%; 69/94), and improving procedural competency (60.6%; 57/94). Moreover, over half of the respondents (53.2%; 50/94) indicated that there is value in an APP residency/fellowship program obtaining optional accreditation. Additionally, over half of the respondents (56.4%; 53/94)indicated that they would be interested in participating as a clinical preceptor if an APP residency/fellowship program was developed at our AMC. Lastly, about one-third of the respondents felt strongly that APP residency/fellowship training programs should offer post-professional doctoral degree options such as Doctor of Nursing Practice (DNP), Doctor of Medical Science (DMSc), and Doctor of Health Science (DHSc). Conclusion Although most respondents have never completed a formalized postgraduate training program and were less familiar with the published literature regarding these programs, our findings suggest that the attitudes ofemployed NPs and PAs aregenerally positivetoward the concept of postgraduate specialty-specific training.

The Importance of a Champion in Leading Major Improvements in Residency Programs.

Residency programs are expected to meet many requirements in training their residents, including providing adequate numbers of pediatric visits and procedures opportunities. In the residency program studied here, these numbers were inadequate, despite the efforts of faculty members over the years. A self-designated faculty champion (with traits including vision, persuasiveness, proactivity, and tenacity) launched a series of clinical initiatives to combat these problems. The number of pediatric visits in the Family Medical Center (FMC) were tracked and compared from 2012, prior to the intervention led by the faculty champion, through 2023. The number of procedures performed in the FMC were tracked and compared from 2015, when the procedures-only clinic was launched by the faculty champion, through 2023. The number of pediatric visits in the FMC in 2012-2013 was a total of 12. By 2022-2023, that number had grown to 1,454. The number of procedures in the FMC was four in 2015-2016, but by 2022-2023 had grown to 470. The improved numbers support competency-based medical education, with increased faculty observation, teaching, and evaluation. For procedures training, the improved numbers support faculty members in using the Procedural Competency Assessment Tools to evaluate resident performance. A faculty champion who is interested, self-motivated, persistent, and focused on leading the project from beginning to end can bring about significant improvements in a residency program, despite the program's track record of difficulty in making such improvements.

Trauma advanced practice provider education: the current state of trauma advanced practice provider postgraduate education in the United States

BackgroundPostgraduate education for advanced practice providers (APPs) is a rapidly evolving field and includes residencies and fellowships designed to help narrow the gap between physicians and APPs. The current state...

Comparing Male and Female Resident Physicians in Central Venous Catheter Insertion Self-confidence and Competency: A Retrospective Cohort Study.

Female physicians often report lower self-confidence in their procedural and clinical competency compared to male physicians. There is limited data regarding self-reported confidence of female versus male trainees and any relation to objective competency in central venous catheter insertion. To analyze differences between male and female trainees in self-confidence and skill-based outcomes in placing central venous catheters. Using data from a central venous catheter simulation training program at a large tertiary medical center, we performed linear regressions to analyze confidence difference pre- and post-training, number of restarts, and number of cannulation attempts while controlling for baseline demographic characteristics of the sample. PGY-1 physician residents in all residency specialties who insert central venous catheters in the clinical setting at a tertiary academic center with a sample size of 281 residents. Confidence difference pre- and post-training measured on a Likert scale 1-5, number of restarts (novel global assessment variable), and number of cannulation attempts during the competency evaluation. Female trainees had both lower pre-program confidence (1.35 versus 1.74 out of 5, p < 0.001) and lower post-program confidence (3.77 versus 4.12 out of 5, p = 0.0021) as compared to male trainees. There was no statistically significant difference in number of restarts (95% CI - 0.073 to 0.368, p = 0.185) or cannulation attempts (95% CI - 0.039 to 0.342, p = 0.117) between sexes in linear regressions controlled for age, specialty designation, prior central venous catheter training, prior ultrasound guided vessel cannulation training, and pre-training confidence level. Female trainees rated their confidence significantly lower than their male counterparts both before and after the training program, despite no significant difference in skill-based outcomes. We discuss potential implications for trainees acquiring procedural skills during residency and for physician educators as they design training programs and delegate procedural opportunities.

Mental Practice to Maintain Procedural Competency of Faculty with Decreased Opportunities

Mental Practice to Maintain Procedural Competency of Faculty with Decreased Opportunities

Procedural skill maintenance: What it means to physicians, how it motivates them, and what stops them from doing so

Introduction: Maintenance of procedural skills is crucial for paediatric emergency medicine (PEM) physicians to provide high-quality care. A study by Lin-Martore et al. (2021) in the US identified key themes in conceptualising procedural skill maintenance (PSM), its motivations, and barriers to maintenance. However, the difference in culture brings into question the validity of their findings in other contexts. To determine its applicability specifically in an Asian context, this study aims to replicate the study at KK’s Women and Children Hospital (KKH), focusing on PEM physicians. While the findings are limited to a single hospital, they provide valuable insights into challenges encountered by PEM physicians. Methods: A general qualitative approach was used through semi-structured interviews. Participants were recruited through email. Interviews were conducted via Zoom and subsequently de-identified and transcribed. The data was coded manually through thematic analysis, identifying key themes. Results: Fifteen PEM physicians were interviewed. Participants conceptualised PSM through technical aspects and measured competence through objective and subjective measures. General motivation themes found the (1) desire to provide optimal patient care, (2) procedural competence as part of the identity of a PEM physician who teaches and performs procedures, and (3) desire for choice when alternatives are present. Barriers included limited time, support, and opportunities. Conclusion: The study found that the themes from the original study are applicable in KKH, featuring SDT concepts prominently. Practical recommendations for KKH were proposed. Future research can focus on the challenges and gaps in maintaining procedural skills and develop strategies to improve PSM in PEM physicians. Keywords: Procedural Skill Maintenance, Singapore, Emergency Medicine, Qualitative, Paediatric Medicine

Procedures Group Chat: A Resident-Driven Approach to Increase Procedural Competency

Introduction: In 2007, the American Board of Internal Medicine (ABIM) shifted away from requiring completion of procedures during residency training and towards emphasizing common procedural indications, contraindications, and complications. As a result, many procedures are now referred to consulting services such as critical care and interventional radiology (IR). Our aim was to address this training gap through a resident-driven initiative that provided daily opportunities to collaborate on procedures in a supervised clinical setting. Methodology: In January 2023, we created a secure group chat and invited Internal Medicine (IM) residents to voluntarily join if they were interested in learning or teaching bedside procedures such as thoracenteses, paracenteses, lumbar punctures, and line placement. Residents who identified a need for a non-emergent bedside procedure would reach out in the group chat to see if a resident certified to perform and supervise that procedure would be available and could subsequently coordinate availability. A two-question survey was sent to the entire residency program asking residents whether they were a part of the group chat and whether they found the chat helpful in advancing their medical knowledge. The impact of the initiative was measured through procedures logged in to New Innovations, a website used by graduate medical education to log completed procedures. We chose five procedures (paracenteses, thoracenteses, central lines, arterial lines, and lumbar punctures) to compare changes in procedure volume performed by IM residents one year before and after the group chat was set up. Results: 64 out of 108 residents responded to the survey (59% response rate). 90% of respondents stated that they were part of the group chat and 76.6% responded they “agree/strongly agree” that the procedures group chat has been helpful. Objective measures of the group chat’s impact revealed a 93% increase in the number of procedures performed by residents. IM Residents logged 122 procedures in 2022, the year prior to the initiation of the group chat, compared to 235 procedures logged in 2023, the year after. There was a 96% increase in paracentesis and 387% change in thoracenteses completed after the group chat was established. Conclusions: The procedures group chat nearly doubled the number of procedures completed and logged by residents. This group chat has fostered enthusiasm for patient care by helping us overcome some of the barriers and delays in health care due to factors out of our control, such as limited resources or staffing. Due to the inexpensive nature of this initiative, it can be easily replicated at other IM programs across the country, especially those without resources such as simulation centers. Future goals include creating formal teaching sessions including cadaver lab simulations and a proceduralist elective for procedures to be taught and supervised by certified residents, attendings, and subspeciality services for a multidisciplinary education.

SIMPLE procedures: Survey of Internal Medicine Providers' Limitations and Experiences with procedures and medical procedure services.

In response to a decline in bedside procedures performed by hospitalists, some hospital medicine groups have created medical procedure services (MPSs) concentrating procedures under the expertise of trained hospitalist-proceduralists. To characterize the structure, breadth, and heterogeneity of academic medical center MPSs, as well as compare the procedural landscape for groups with and without an MPS. The Survey of Internal Medicine Providers' Limitations and Experienceswith Procedures and MPSs, is a cross-sectional study, conducted in the United States and Canada through a web-based survey administered from October 2022 to March 2023. We used convenience and snowball sampling to identify eligible study participants. The survey explored presence of MPS, procedure volumes, patient safety, and educational practices. For MPSs, we explored onboarding, staffing, skill maintenancy, funding, and barriers to growth. Forty institutions (response rate 97.5%), represented by members of the Procedural Research and Innovation for Medical Educators (PRIME) consortium participated in the survey. MPSs were found in 75% of the surveyed institutions. Most MPSs (97%) involved trainees and were staffed by internists (100%) who often had additional clinical duties (70%). The majority (83%) of MPSs used checklists and procedural safety guidelines, but only 53% had a standardized process for tracking complications. There was significant variability in determining procedural competency and supervising trainees. Groups with an MPS reported higher procedure volume compared to those without. MPSs were highly prevalent among the participating institutions, offered a broad array of bedside procedures, and often included trainees. There was a high variability in funding models, procedure volumes, patient safety practices, and skill maintenance requirements.

Bridging the gap: assessing the integration of robotic-assisted surgery into Canadian surgical training programs.

SummaryThe adoption of robotic surgery has surged globally across multiple surgical specialties, but uptake in Canada has unfolded at a slower pace. Surgical educators and trainees in Canada face potential challenges related to sufficient exposure, experience, and competence in robotic surgical procedures. We conducted a cross-sectional national survey to gain insight into the perspectives of program directors overseeing general surgery residency and fellowship programs on the integration of robotic surgery into Canadian surgical training programs. Despite the presence of robotic surgery platforms at most academic and academic-affiliated hospitals, few trainees have exposure to any robotic surgery. Furthermore, a gap exists between the training provided in robotic surgery and its anticipated relevance to trainees upon graduation. Increased focus on the integration of robotic surgery within general surgical training in Canada is required to equip trainees for their careers.

Participation of the Prosecutor in the Civil Cases Dealt with by the Courts of Controlling Authority

In the paper, the author concludes that it is inappropriate to regulate the procedural and legal competence of various officials of the prosecutor’s office to initiate a review of judicial acts by the courts of controlling authority. The author examines the issue of the possibility of allocating the prosecutor’s participation in the consideration of civil cases by the courts of controlling authority into an independent, third form of the prosecutor’s participation in civil (arbitrazh) proceedings in the light of both the legislative expansion of the prosecutor’s procedural powers and trends in judicial practice. The author draws attention to the need to clarify in the law the legal form by which the prosecutor’s initiative aimed at reviewing judicial acts is implemented. As a result of the analysis of judicial practice where the courts and the prosecutor assessed the need for the prosecutor’s participation in specific cases in different ways, the author concluded that the correctness of resolving the issue of involving (not involving) the prosecutor to participate in the consideration of a civil case is predetermined by an essential rather than a formal approach to the legal qualification by the court of the substantive requirements under consideration.

Shifting the Curve: Mastery Learning to Teach Nerve Conduction Studies in Physical Medicine and Rehabilitation Residency.

Nerve conduction studies are a commonly performed procedure and a core competency for physical medicine and rehabilitation residents. Nerve conduction studies are complex to learn and no standardized training protocols exist across physical medicine and rehabilitation programs. The aims of this study are to standardize training and assessment of resident proficiency in nerve conduction studies skills and to evaluate the impact of an educational intervention on skills development. This was a repeated measures design wherein 36 physical medicine and rehabilitation residents underwent a pretest, followed by a mastery learning-based intervention, including deliberate practice. Residents were then expected to meet or exceed a minimum passing score at posttest. Performance improved from a median score of 4.5/66 on the pretest to a median score of 63/66 on the posttest. Thirty-three of 36 residents achieved the minimum passing score on the first attempt; three residents required additional deliberate practice and met the minimum passing score on the second attempt. A curriculum featuring deliberate practice dramatically increased checklist scores of residents performing nerve conduction studies. This mastery learning program shows a reliable and reproducible method to achieve procedural competency within a physical medicine and rehabilitation residency program and can shift the curve to allow residents to immediately start performing nerve conduction studies at the start of their clinical experience.

Putting the ready in readiness: A post hoc analysis of surgeon performance during a military mass casualty situation in Afghanistan.

All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient mass-casualty situation (MASCAL). The sample included orthopedic (four) and general surgeons (eight) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan, on August 26, 2021. One orthopedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1, expeditionary knowledge (examination score); 2, procedural skills competencies (performance assessment score); and 3, clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases was reviewed and rated (performance score) by the Joint Trauma System's Performance Improvement Branch, a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each predeployment measure and MASCAL surgical care. Predeployment knowledge and clinical activity measures met program benchmarks. Baseline predeployment procedural skills competency scores did not meet program benchmarks; however, those gaps were closed through retraining, ensuring all surgeons met or exceeded the program benchmarks predeployment. There were very large effect sizes (Cohen's d ) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons. The prescribed program measures ensured that all surgeons achieved predeployment performance benchmarks and provided high-quality trauma care to our nation's service members. Prognostic and Epidemiological; Level IV.