Ability Of Trainees Research Articles

Communication and professionalism skills of a new graduate: the expectations and experiences of dental foundation trainers

The aim of this study was to investigate dental foundation year 1 (DF1) trainers' expectations of the dental graduate specifically in relation to non-clinical (professionalism and communication) skills and to explore whether these expectations were being met. In the UK, dental graduates undertake 1year of foundation training prior to being permitted to undertake NHS practice. An online survey was distributed to DF1 trainers via all 11 English deaneries and the Northern Ireland deanery. Demographic information and a general view of trainers' expectations of a new trainee were collected. Specific questions relating to six generic trainee problems were followed by 11 ability statements where trainers indicated their expectation of a trainee's ability to perform the skill on a 5-point scale (on own with confidence-unable to undertake). Statements were repeated and trainers were required to respond using the same scale in relation to experience of their current trainee. Five hundred and ten (53%) trainers completed the questionnaire with no missing data. Expectations were high with almost 50% of trainers expecting a new graduate to manage a full list of patients on their own. Experience of new graduates did not always match these expectations. Of concern was the ability to 'keep accurate patient records' and 'self-reflection and knowing when to seek help', where a small proportion of trainers experienced difficulties. Trainers' expectation and experience in relation to non-clinical skills of a new graduate were investigated. Although they had high expectations, the majority reported only minor problems overall. There were a few areas where concern was raised.

How do supervising physicians decide to entrust residents with unsupervised tasks? A qualitative analysis

Medical supervisors struggle to find meaningful ways to evaluate the preparedness of trainees to independently perform patient care tasks. The aim of this study was to describe the factors that influence how attending and resident physician perceptions of trust impact decision making. Internal medicine residents and attending physicians at a tertiary academic medical center were interviewed during a single academic year. Participants were asked to describe, using the critical incident technique, entrustment decisions made during their clinical rotations. A deductive qualitative analysis using the entrustable professional activities framework was used. The inter-rater reliability was calculated using a generalized kappa statistic. Eighty-four percent (46/50) of residents and 88% (44/50) of attending physicians participated. The analysis yielded 535 discrete mentions of entrusting factors that were mapped to the following domains deductively, with inductively derived subthemes: trainee factors (eg, confidence, specialty plans), supervisor factors (eg, approachability), task factors (eg, situational characteristics) and systems factors (eg, workload). The inter-rater kappa between the 2 raters was 0.84. Factors influencing trust in a trainee are related to the supervisor, trainee, their relationship, task, and the environment. Attending physicians note early interactions and language cues as markers of trustworthiness. Attending physicians reported using perceived confidence as a gauge of the trainee's true ability and comfort. Attendings noted trainee absences, even those that comply with regulation, negatively affected willingness to entrust. Future studies are needed to develop better assessment instruments to understand how entrustment decisions for independent practice are made.

The Role of Graduate Medical Education in Global Health: Proceedings From the 2013 Academic Emergency Medicine Consensus Conference

The past 40years have seen expanded development of emergency medicine (EM) postgraduate residency training programs worldwide. An important part of this educational experience is the ability of resident trainees to participate in experiences abroad. However, little is known about how these experiences shape trainees and the populations they serve. During the 2013 Academic Emergency Medicine consensus conference, a group of educators met to define and outline current trends in graduate medical education (GME) emergency care research. The authors discuss future research questions bridging the gap of GME and global health.

Challenging Authority During a Life-Threatening Crisis

Background Effective operating theatre (OT) communication is important for team function and patient safety. Status asymmetry between team members may contribute to communication breakdown and threaten patient safety. We investigated how hierarchy in the OT team influences an anaesthesia trainee's ability to challenge an unethical decision by a consultant anaesthetist in a simulated crisis scenario. Methods We prospectively randomized 49 postgraduate year (PGY) 2–5 anaesthesia trainees at two academic hospitals to participate in a videotaped simulated crisis scenario with a simulated OT team practicing either a hierarchical team structure (Group H) or a non-hierarchical team structure (Group NH). The scenario allowed trainees several opportunities to challenge their consultant anaesthetist when administering blood to a Jehovah's Witness. Three independent, blinded raters scored the performances using a modified advocacy–inquiry score (AIS). The primary outcome was the comparison of the best-response AIS between Groups H vs NH. Secondary outcomes included the comparison of best AIS by PGY and the percentage in each group that checked and administered blood. Results The AIS did not differ between the groups (P=0.832) but significantly improved from PGY2 to PGY5 (P=0.026). The rates of checking blood (92% vs 76%, P=0.082) and administering blood (62% vs 57%, P=0.721) were high in both groups but not significantly different between the groups. Conclusions This study did not show a significant effect of OT team hierarchical structure on trainee's ability to challenge authority; however, the results are concerning. The challenges were suboptimal in quality and there was an alarming high rate of blood checking and administration in both groups. This may reflect lack of training in appropriately and effectively challenging authority within the formal curriculum with implications for patient safety.

Does Aptitude Influence the Rate at which Proficiency Is Achieved for Laparoscopic Appendectomy?

The attainment of technical competence for surgical procedures is fundamental to a proficiency-based surgical training program. We hypothesized that aptitude may directly affect one's ability to successfully complete the learning curve for minimally invasive procedures. The aim was to assess whether aptitude has an impact on ability to achieve proficiency in completing a simulated minimally invasive surgical procedure. The index procedure chosen was a laparoscopic appendectomy. Two groups of medical students with disparate aptitude were selected. Aptitude (visual-spatial, depth perception, and psychomotor ability) was measured by previously validated tests. Indicators of technical proficiency for laparoscopic appendectomy were established by trained surgeons with an individual case volume of more than 150. All subjects were tested consecutively on the ProMIS III (Haptica) until they reached predefined proficiency in this procedure. Simulator metrics, critical error scores, and Objective Structured Assessment of Technical Skills (OSATS) scores were recorded. The mean numbers of attempts to achieve proficiency in performing a laparoscopic appendectomy for group A (high aptitude) and B (low aptitude) were 6 (range 4 to 7) and 14 (range 10 to 18), respectively (p < 0.0001). Significant differences were found between the 2 groups for path length (p = 0.014), error score (p = 0.021), and OSATS score (p < 0.0001) at the initial attempt. High aptitude is directly related to a rapid attainment of proficiency. These findings suggest that resource allocation for proficiency-based technical training in surgery may need to be tailored according to a trainee's natural ability.

Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy

Effective operating theatre (OT) communication is important for team function and patient safety. Status asymmetry between team members may contribute to communication breakdown and threaten patient safety. We investigated how hierarchy in the OT team influences an anaesthesia trainee's ability to challenge an unethical decision by a consultant anaesthetist in a simulated crisis scenario. We prospectively randomized 49 postgraduate year (PGY) 2-5 anaesthesia trainees at two academic hospitals to participate in a videotaped simulated crisis scenario with a simulated OT team practicing either a hierarchical team structure (Group H) or a non-hierarchical team structure (Group NH). The scenario allowed trainees several opportunities to challenge their consultant anaesthetist when administering blood to a Jehovah's Witness. Three independent, blinded raters scored the performances using a modified advocacy-inquiry score (AIS). The primary outcome was the comparison of the best-response AIS between Groups H vs NH. Secondary outcomes included the comparison of best AIS by PGY and the percentage in each group that checked and administered blood. The AIS did not differ between the groups (P=0.832) but significantly improved from PGY2 to PGY5 (P=0.026). The rates of checking blood (92% vs 76%, P=0.082) and administering blood (62% vs 57%, P=0.721) were high in both groups but not significantly different between the groups. This study did not show a significant effect of OT team hierarchical structure on trainee's ability to challenge authority; however, the results are concerning. The challenges were suboptimal in quality and there was an alarming high rate of blood checking and administration in both groups. This may reflect lack of training in appropriately and effectively challenging authority within the formal curriculum with implications for patient safety.

Efficacy of an Online Education Program for Ultrasound Diagnosis of Pneumothorax

Experienced ultrasonographers can rule out pneumothorax reliably. The authors hypothesized that with basic training, anesthesia residents and faculty can also reliably rule out pneumothorax when presented with an optimal ultrasound image of the chest. The study investigators created a library of 99 ultrasound video images of the chest with or without pneumothorax obtained from 53 patients undergoing elective thoracic surgery. After a 5-min tutorial, the physicians were invited to take a quiz based on 20 ultrasound videos randomly selected from the library. Sensitivity and specificity were calculated for overall performance, and a generalized estimating equations model was created to identify significant independent covariates affecting performance. To detect the retention rate for this skill, participants were asked to take the quiz again 6 months later. Seventy-nine anesthesia residents and faculty took part in the study. The sensitivity and specificity for ruling out pneumothorax was 86.6% and 85.6% respectively. On generalized estimating equation model, participants were significantly less likely to identify ultrasound features of pneumothorax if there was probe movement (P value = 0.002; OR 2.69; 95% CI 1.61-4.5) or heartbeat (P < 0.001; OR 3.54; 95% CI 2.27-5.51) on the ultrasound video. The median and interquartile ranges for scores (90%, and 80-95% respectively) did not change from the first to the second quiz. After viewing a 5-min online training video, physicians can reliably rule out pneumothorax on an optimal ultrasound image. They are also able to retain this skill for up to 6 months.

Effectiveness of Simulator‐Based Echocardiography Training of Noncardiologists in Congenital Heart Diseases

Congenital heart diseases (CHD) are responsible for substantial morbidity and mortality in neonates. The preliminary diagnosis often is made by noncardiologists. For this reason, there is a huge demand of training in echocardiography of CHD. This is difficult to achieve due to limited resources of specialized centers. The goal of this study was to investigate the training effect of the echocardiography simulator EchoCom on trainee's ability to diagnose CHD. We enrolled 10 residents for simulator-based training in echocardiography of CHD. All participants were instructed on the simulator's basic handling and had one hour to scan the first 9 datasets information (ventricular septal defect, atrial septal defect, atrioventricular septal defect, Tetralogy of Fallot, transposition of great arteries, congenital corrected transposition of great arteries, common arterial trunk, hypoplastic left heart syndrome, normal anatomy) and establish a diagnosis. No help was given except for support regarding simulator related issues. Afterward, 2 rounds of structured simulator based echocardiography training focused on echocardiographic anatomy, spatial orientation, standard views, and echocardiographic anatomy of different CHD followed. All participants completed a standardized questionnaire containing 10 multiple-choice (MC) questions focusing on basic theoretical knowledge in echocardiographic anatomy and common CHD. Almost all of the residents invited from the affiliated children's hospital had little (20%) or no experience (80%) in echocardiography of CHD. Their Pretest and Posttest scores showed significant improvement for both, MC test and performance test, respectively. Our study showed that simulator-based training in echocardiography in CHD could be very effective and may assist with training outside the scope of CHD.

The motivation to teach as a registrar in general practice

The General Medical Council (GMC) states that teaching should be an integral part of the doctor's role and the Royal College of General Practitioners (RCGP) have incorporated teaching outcomes into the GP training curriculum. However, there are suggestions that the teaching role of a GP trainee declines as they move from hospital posts to the registrar community year. Using doctors in training as near-peer tutors offers multiple advantages. Trainees themselves benefit as teaching others is a strong driver of the tutor's own learning. In addition there are also practical incentives to mobilising this under-utilised pool of primary care clinical teachers given the continuing shift of focusing medical education in the community. This study forms part of a larger body of work exploring the attitudes and perceived learning needs of GP registrars with regards to developing a teaching role. A primary area of investigation was trainees' motivation to teach. This paper describes our attempts to establish: a) how strongly motivated are GP registrars to take on teaching roles? b) in consequence how strongly motivated are they to learn more about teaching? c) what are the factors which affect motivation to teach? Three themes emerged from the data. First, teaching was felt to be of low priority in comparison to competing clinical learning needs. Secondly, the clinical dominance to both formative and summative assessment during training further compounded this situation. Thirdly, registrars identified a number of practical barriers and incentives that influenced their teaching engagement. This included potential negative views from trainers as to their trainee's ability and requirement to be involved with teaching activities.<br>By understanding and addressing these issues, it is hoped that GP trainees' engagement with teaching activities can be better engendered with subsequent benefits for both the trainee and those they teach.

Development of Simulator Guidelines for Resident Assessment in Flexible Endoscopy

Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE EndoscopyVR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners' knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.

Exploring Factors Influencing the Transfer of Training using a Grounded Theory Study: Issues and Research Agenda

The aim of this study is to develop a final outcome in the form of a substantive theory on the transfer of training. The methods of initial data collection were: face-to-face interviews with the trainees, observations at the trainers’ workplace and on-line interview feedbacks. In accordance to the Grounded Theory requirements, the participants were selected using purposive sampling method taken from the list of trainees who have attended the training series which were held six months earlier prior to the first data collection tasks. The results revealed individual factors of trainees that influences the transfer of training can be classified and categorized into four main factors; the ability of trainees, trainees’ motivation, self-efficacy and attitudes and commitment of the trainees.

A survey of the accuracy of interpretation of intraoperative cholangiograms

ObjectivesThere are few data in the literature regarding the ability of surgical trainees and surgeons to correctly interpret intraoperative cholangiograms (IOCs) during laparoscopic cholecystectomy (LC). The aim of this study was to determine the accuracy of surgeons' interpretations of IOCs. MethodsFifteen IOCs, depicting normal, variants of normal and abnormal anatomy, were sent electronically in random sequence to 20 surgical trainees and 20 consultant general surgeons. Information was also sought on the routine or selective use of IOC by respondents. ResultsThe accuracy of IOC interpretation was poor. Only nine surgeons and nine trainees correctly interpreted the cholangiograms showing normal anatomy. Six consultant surgeons and five trainees correctly identified variants of normal anatomy on cholangiograms. Abnormal anatomy on cholangiograms was identified correctly by 18 consultant surgeons and 19 trainees. Routine IOC was practised by seven consultants and six trainees. There was no significant difference between those who performed routine and selective IOC with respect to correct identification of normal, variant and abnormal anatomy. ConclusionsThe present study shows that the accuracy of detection of both normal and variants of normal anatomy was poor in all grades of surgeon irrespective of a policy of routine or selective IOC. Improving operators' understanding of biliary anatomy may help to increase the diagnostic accuracy of IOC interpretation.

Mentoring and Dental Foundation Training

This paper is based on an assignment written as part of the work required for the Faculty of General Dental Practice (UK)'s Certificate in Mentoring in Dentistry. Its author is currently a trainer for the first year of foundation training in a general dental practice in Kent. The paper commences by defining mentoring. It explores the relationship between postgraduate trainers and trainees and goes on to explain how it is the trainer's role to help trainees to use their strengths to overcome weaknesses. It details the person-centred approach, mentoring theories, helping models, the application of Kolb's learning cycle, the Inner Game theory, and the GROW model. It explores the role of foundation dental trainers as mentors to aid their trainee's ability to use reflective learning, and goes on to consider the implications of the changes that may result in the relationship between trainers and trainees as a consequence of the introduction of national recruitment. Finally, the author reflects on his experiences as a foundation dental trainer.

Effectiveness of a simulated clinical examination in the assessment of the clinical competencies of entry-level trainees in a family medicine residency programme

Clinical competence is a multidimensional concept and encompasses a variety of skills including procedural, problem-solving and clinical judgement. The initial stages of postgraduate medical training are believed to be a particularly important time for the development of clinical skill competencies. This study reports on an evaluation of a Simulated Clinical Examination (SCE) method as a means of assessing the clinical skill competencies of entry-level family medicine residents. Two entering cohorts of PGY1 family medicine residents (N = 35) participated in a SCE encompassing realistic clinical encounters with standardised patients (SPs). Residents were asked to complete pre- and post-evaluation surveys, and both faculty and residents were invited to participate in separate focus groups. The SCE was perceived as a useful method during the early phases of postgraduate training for assessing clinical skill competencies, providing constructive feedback to residents and enhancing self-awareness and confidence. The SCE also appeared to be useful in fostering confidence in interviewing and diagnostic reasoning, however self-reported confidence in the ability to perform clinical skill tasks related to history taking, physical examination and differential diagnosis was not associated with observed performance in these areas. The SCE was an effective technique for benchmarking skill performance, however further research is required to evaluate the effect of this on the self-assessment abilities of trainees over the course of postgraduate medical education.

Simulator Training to Automaticity Leads to Improved Skill Transfer Compared With Traditional Proficiency-Based Training

We hypothesized that novices will perform better in the operating room after simulator training to automaticity compared with traditional proficiency based training (current standard training paradigm). Simulator-acquired skill translates to the operating room, but the skill transfer is incomplete. Secondary task metrics reflect the ability of trainees to multitask (automaticity) and may improve performance assessment on simulators and skill transfer by indicating when learning is complete. Novices (N = 30) were enrolled in an IRB-approved, blinded, randomized, controlled trial. Participants were randomized into an intervention (n = 20) and a control (n = 10) group. The intervention group practiced on the FLS suturing task until they achieved expert levels of time and errors (proficiency), were tested on a live porcine fundoplication model, continued simulator training until they achieved expert levels on a visual spatial secondary task (automaticity) and were retested on the operating room (OR) model. The control group participated only during testing sessions. Performance scores were compared within and between groups during testing sessions. : Intervention group participants achieved proficiency after 54 ± 14 and automaticity after additional 109 ± 57 repetitions. Participants achieved better scores in the OR after automaticity training [345 (range, 0-537)] compared with after proficiency-based training [220 (range, 0-452; P < 0.001]. Simulator training to automaticity takes more time but is superior to proficiency-based training, as it leads to improved skill acquisition and transfer. Secondary task metrics that reflect trainee automaticity should be implemented during simulator training to improve learning and skill transfer.

The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review

The aim of this systematic review is to describe the use of cadavers in postgraduate surgical training, to determine the effect of cadaveric training sessions on surgical trainees' technical skills performance and to determine how trainees perceive the use of cadaveric workshops as a training tool. An electronic literature search was performed, restricted to the English language, of MEDLINE(®), Embase™, the Cumulative Index to Nursing and Allied Health Literature (CINAHL(®)), Centre for Agricultural Bioscience (CAB) Abstracts, the Educational Resources Information Center (ERIC™) database, the British Education Index, the Australian Education Index, the Cochrane Library and the Best Evidence in Medical Education website. Studies that were eligible for review included primary studies evaluating the use of human cadaveric surgical workshops for surgical skills training in postgraduate surgical trainees and those that included a formal assessment of skills performance or trainee satisfaction after the training session. Eight studies were identified as satisfying the eligibility criteria. One study showed a benefit from cadaveric workshop training with regard to the ability of trainees to perform relatively simple emergency procedures and one showed weak evidence of a benefit in performing more complex surgical procedures. Three studies showed that trainees valued the experience of cadaveric training. Evidence for the effectiveness of cadaveric workshops in surgical training is currently limited. In particular, there is little research into how these workshops improve the performance of surgical trainees during subsequent live surgery. However, both trainees and assessors hold them in high regard and feel they help to improve operative skills. Further research into the role of cadaveric workshops is required.

EWTD: Incompatible with subspecialty training?

AimsHistorically, the RCPCH College Specialty Advisory Committee (CSAC) recommends that trainees in Paediatric Gastroenterology, Hepatology and Nutrition (PGHAN) spend at least 70% of working hours in that subspecialty. Since changes...

EWTD: incompatible with subspecialty training?

IntroductionHistorically, the RCPCH College Specialty Advisory Committee (CSAC) recommends that trainees in Paediatric Gastroenterology, Hepatology and Nutrition (PGHAN) spend at least 70% of working hours in that subspecialty. Since changes...

Accuracy of Cardiac Auscultation in Asymptomatic Neonates with Heart Murmurs: Comparison Between Pediatric Trainees and Neonatologists

The aim of this study was to assess whether cardiac auscultation performed by pediatric trainees and neonatologists can reliably distinguish innocent from pathologic heart murmurs in asymptomatic neonates. From January 2008 to April 2009 the pediatric trainees of our institution were requested to refer all asymptomatic neonates with a murmur and classify the murmurs as "innocent," "pathologic," or "possibly pathologic." Prior to echocardiography, each neonate was evaluated by two experienced neonatologists. The echocardiographic studies of 169 neonates were analyzed. Abnormal cardiac anatomy was found in 55 neonates (32.6%). The overall ability of pediatric trainees in identifying congenital heart disease (CHD) was moderate [area under the curve (AUC) = 0.855] and significantly lower compared to neonatologists (AUC = 0.919, p = 0.007). However, at "lower" levels of clinical confidence (i.e., clinical diagnosis of possibly pathologic murmurs), pediatric trainees had good ability in excluding CHD (sensitivity 94.6%; negative likelihood ratio = 0.09). The ability of cardiac auscultation for diagnosing CHD in asymptomatic neonates is limited and dependent on the physician's experience and level of clinical confidence. Echocardiography should remain an option for all neonates with a possibly pathologic murmur.

Assessing Fundamental 2-Dimensional Understanding of Basic Soft Tissue Techniques

To develop a written practical examination and scoring system for assessing trainee skills in basic soft-tissue techniques. A brief written practical examination was developed to assess the ability of trainees to sketch preoperative plans and postoperative results for common soft-tissue techniques: simple-excision, M-plasty, geometric broken line closure, Z-plasty, V-to-Y flap, and rhombic flap. A scoring system was developed to assign 0 to 5 points to each of 10 items on the examination for a total score of 0-50. The 15-minute examination was administered as a pretest, posttest, and 3-month posttest assessment as part of a soft-tissue course at our institution. University of Minnesota, Otolaryngology Department. Three raters reviewed all examination answer sheets independently. The pretest scores of examinees correlated strongly with their level of training; the average pretest for junior residents (PGY 1-2) compared with senior residents (PGY 4-5) was 17.3 (of 50) versus 26.0 (p < 0.01). The scoring system showed a high intrarater reliability and high interrater reliability with correlation coefficients of r = 0.99 and r = 0.95, respectively and agreement coefficients of κ = 0.82 and κ = 0.77, respectively. This written practical examination and scoring system may be used to assess the skills of trainees accurately in basic soft tissue techniques and to expose areas of deficiency that can be addressed in future training sessions.