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Surgery is an exceptionally complex domain where multi-dimensional expertise is developed over an extended period of time, and mastery is maintained only through ongoing engagement in surgical contexts. Expert surgeons integrate perceptual information through both conscious and subconscious awareness, and respond to the environment by leveraging their deep understanding of surgical constructs. However, their ability to utilize these deep knowledge structures can be complicated by continuous advances in technology, medical science, pharmacology, technique, materials, operative environments, etc. that must be routinely accommodated in professional practice. The demands on surgeons to perform perfectly in ever-changing contexts increases cognitive load, which could be reduced through judicious use of accurate and reliable artificial intelligence (AI) systems. AI has great potential to support human performance in complex environments such as surgery; however, the foundational requirements for the rules governing algorithmic development of performance requirements necessitate the active involvement of surgeons to precisely model the quantitative measures of performance along the continuum of expertise. Providing the AI development community with these data will help assure that accurate and reliable systems are designed to supplement human performance in applied surgical contexts. The Military Health System's Clinical Readiness Program is developing these types of metrics to support military medical readiness. [ABSTRACT FROM AUTHOR]

Ov er a 2-day course, participants under go hands-on training in a 1-to-1 f ashion conducted by 4 e xperienced trauma sur geons and selected subspecialists who pro vide real-time assessment a nd indi vidualized feedback. I NVITED E DIT ORIAL MILIT AR Y MEDICINE, 186, 5/6:152, 2021 Sustaining Clinical R eadiness f or Combat Casualty Car e K yle N. R emic k, MD F A CS; P amela B. Andr eat t a, EdD, PhD, MF A, FSSH, NPCT; Mar k W. Bo w yer, MD, F A CS, DMCC, FR CS(Glasg) W e read with interest the article of Richards et al. titled "Re vie w of a Role 2 in Afghanistan: Understanding the Data on Medical and Sur gical V olumes in a Deplo yed Setting. [Extracted from the article]

The article discusses the competency-based medical education (CBME) program for physicians in the U.S. It states that it is an attractive option for the residency program and the resident. It notes that the program requires demonstration of mastery in targeted domain supported by criterion-reference and objective performance-based analysis. It mentions that transitioning to the CBME program will take a number of years.

Mobile health technology, specifically Short Message Service (SMS), provides a low-cost medium to transmit data in real time. SMS has been used for data collection by highly literate and educated health care workers in low-resource countries; however, no previous studies have evaluated implementation of an SMS intervention by low-literacy providers. The Liberian Ministry of Health and Social Welfare identified a lack of accurate data on the number of pregnancies from rural areas. To capture these data from 11 rural communities in Liberia, 66 low-literate traditional midwives and 15 high-literate certified midwives were trained to report data via SMS. Data were reported via a 9-digit code sent from Java-based mobile phones. Study aims included determining the following components of SMS transmission: success rate, accuracy, predictors of successful transmission, and acceptance. Success rate of SMS transmission was significantly higher for certified midwives than for traditional midwives. The error rate was significantly higher for traditional midwives than for certified midwives. Years of education was the only predictor of successful SMS transmission. Traditional midwives and certified midwives accepted the intervention, although certified midwives found it easier to use. Certified midwives performed significantly better than did traditional midwives. SMS texting interventions should be targeted to health care workers with higher rates of literacy. [ABSTRACT FROM PUBLISHER]

Military and civilian first responders must be able to recognize and effectively manage mass disaster casualties. Clinical management of injuries resulting from nerve agents provides different challenges for first responders than those of conventional weapons. We evaluated the impact of a mixed-methods training program on competency acquisition in cholinergic crisis clinical management using multimedia with either live animal or patient actor examples, and hands-on practice using SimMan3G mannequin simulators. A purposively selected sample of 204 civilian and military first responders who had not previously completed nerve agent training were assessed pre- and post-training for knowledge, performance, self-efficacy, and affective state. We conducted analysis of variance with repeated measures; statistical significance p < 0.05. Both groups had significant performance improvement across all assessment dimensions: knowledge > 20%, performance > 50%, self-efficacy > 34%, and affective state > 15%. There were no significant differences between the live animal and patient actor groups. These findings could aid in the specification of training for first-responder personnel in military and civilian service. Although less comprehensive than U.S. Army Medical Research Institute of Chemical Defense courses, the training outcomes associated with this easily distributed program demonstrate its value in increasing the competency of first responders in recognizing and managing a mass casualty cholinergic event. [ABSTRACT FROM AUTHOR]

Introduction Residency programs seek to match the best candidates with their positions. To avoid ethical conflicts in this process, the National Residency Matching Program (NRMP or Match) has rules regarding appropriate conduct, including guidelines on contact between candidates and programs. Our study examined communication between obstetrics and gynecology (Ob-Gyn) programs and residency candidates after interviewing and prior to ranking. Methods Ob-Gyn program directors in the United States were sent a self-administered survey via e-mail. Data were collected and analyzed using descriptive methods to examine communication practices of these programs. Results The response rate was 40%. The findings showed that respondents had variable interpretations of the NRMP rules and suggest that programs may be communicating their match intentions especially to favored candidates. Respondents' open text comments highlighted program directors' frustrations with current NRMP rules. Discussion NRMP communication rules are intended to minimize pressure on residency candidates. Our findings suggest they may be leading to unforeseen stresses on program directors and candidates. Conclusions As educational leaders in medicine, we must consider what professional communications are acceptable without increasing the pressure on candidates during the ranking and match process. [ABSTRACT FROM AUTHOR]

The article discusses simulation-based team training in obstetric emergencies for teaching, rehearsing and analyzing the interdisciplinary performance. Simulation training improves skills, communication and patient outcome. Institute of Medicine (IOM), the Joint Commission on Accreditation of Healthcare Organization (JCAHO) and the American Congress of Obstetricians and Gynecologists (ACOG) strongly support the simulation-based team training due to evidence showing reduced human errors.

The article discusses the advantages of simulation-based training on medical procedures at the task, clinical and environmental levels. It is asserted that simulation enables mastery prior to actual application and enables team members to practice together using various clinical scenarios. Tools may be inanimate or computer-driven and tasks that may be simulated include minimally invasive surgery, intravenous insertion and laparoscopic camera navigation. The need to adapt the leadership style and training approach to the type of team is also cited.

Abstract: Background: Computer-aided simulators may increase the safety and efficiency of training in laparoscopic surgery. Before implementation of the Immersion LapSim (Gaithersburg, MD) simulator in our training curriculum, we wished to determine its construct validity (ie, whether the simulator could differentiate laparoscopic novices from trainees with greater experience). Methods: Subjects were medical students (MS), residents (RES), and laparoscopic faculty (FAC). Subjects performed 10 repetitions of 6 LapSim tasks. The LapSim measured performance in 6 to 10 parameters per task, and performance was compared between groups. Post hoc t tests were used to make pair-wise comparisons among the 3 groups using the Bonferroni technique. Statistical significance was set at P < .05. Results: The degree of prior laparoscopic experience was reflected in performance on at least 1 parameter for each task. Several patterns of performance between MS, RES, and FAC were observed. Conclusions: The LapSim has performance parameters that reliably differentiate between subjects with varying laparoscopic experience. However, some performance parameters do not differentiate between groups. To accurately measure a trainee’s skill level, only parameters that sensitively measure the true level of performance should be used. [Copyright &y& Elsevier]

Introduction The uses of on-demand, interactive tablet-based surgical training environments are of interest as potential resources for both the acquisition and maintenance of rarely performed, critical procedures for expeditionary surgical care. This study examined the effectiveness of a tablet-based augmented reality (AR) procedural training environment for lower leg fasciotomy with a cohort of novice surgical trainees in (1) procedural knowledge, (2) tablet-based procedural skills, (3) tablet-based procedural time, and (4) procedural performance on a cadaver. We hypothesized that engaging with the AR procedural training would increase procedural knowledge and tablet-based skills and procedural time. We hypothesized that the tablet-based AR training environment would be insufficient to acquire the ability to perform lower leg fasciotomy on a cadaver. Materials and Methods This study was approved as exempt by the Institutional Review Board at USU. Surgical interns, sub-interns, and independent duty corpsman (n  = 30) with no prior lower leg fasciotomy experience voluntarily participated. Tablet-based training activities included pre-training assessment, engagement with instruction, interactive procedural practice, and post-training assessment. Tablet-based knowledge assessment included 17 multiple choice questions covering concepts, reasoning, and judgment associated with the procedure. Tablet-based procedural completion and time were assessed within the training environment. Within 1 week of completing the tablet activities, participants were assessed by fellowship-trained trauma surgeons while performing cadaver-based lower leg fasciotomy. Statistical analysis included paired t -tests and effect size (Cohen's d). Statistical significance was set at P  < .05. Results Tablet-based AR procedural training significantly improved procedural knowledge (P  < .001), tablet-based procedural skills (P  < .001), and reduced tablet-based procedural time (P  < .002). Effect sizes were very large for tablet-based procedural knowledge (d  = 1.75) and skills (d  = 3.2) and small (d  = 0.42) for procedural time. There were no significant effects of procedural knowledge, tablet-based procedural skills, or time on cadaver-based performance. No participant was able to accurately and independently complete lower leg fasciotomy procedure on a cadaver. Conclusions Tablet-based AR procedural training improved procedural knowledge and tablet-based skills; however, those gains did not transfer to the ability to perform the procedure on a cadaver. The tablet's limited AR interface did not support the acquisition of requisite surgical technique, tissue handling, and decision-making in novice surgical trainees. Experienced surgeons may have different outcomes because their mature understanding of surgical constructs would allow extrapolation of abilities to other procedural contexts. Further investigation of the tablet-based training environments for surgical care is necessary before distributing such resources to support clinical readiness. [ABSTRACT FROM AUTHOR]

Introduction: Preservation of life, preservation of limb, and preservation of eyesight are the priorities for military medical personnel when attending to casualties. The incidences of eye injuries in modern warfare have increased significantly, despite personal eye equipment for service members. Serious eye injuries are often overlooked or discovered in a delayed fashion because they accompany other life- and limb-threatening injuries, which are assigned a higher priority. Prehospital military ocular trauma care is to shield the eye and evacuate the casualty to definitive ophthalmic care as soon as possible, with exceptions for treatment of ocular chemical injury and orbital compartment syndrome. Retrospective analysis of eye injuries in recent conflicts identified gaps in clinical capabilities with up to 96% of ocular injuries being suboptimally managed. Ocular compartment syndrome (OCS) is a complication associated with orbital hemorrhage, where significant morbidity occurs as a result of increasing intracompartment pressure. The ischemic tolerance of the retina and optic nerve is approximately 90 minutes, so OCS must be rapidly diagnosed and aggressively treated through lateral canthotomy/cantholysis (LC/C) to prevent permanent vision loss. LC/C procedures consist of using hemostats to crush the lateral canthal fold and cutting the lateral canthal tendon from the inferior crus to relieve increasing intracompartment pressure. The purpose of this study was to examine the baseline capabilities of military physicians and surgeons to accurately and independently perform the LC/C procedures and identify performance gaps that could be closed through focused professional development activities.Materials and Methods: This study received institutional review board approval at our institution. A total of 60 subjects voluntarily participated in the study from emergency medicine (15), general surgery (28), and ophthalmology (17). All procedural assessments were performed 1:1 by expert faculty ocular trauma specialists using a high-reliability eye trauma simulator (Sonalysts, Inc.). The competency standard was set at independent and accurate completion of all procedural components and all critical procedural components. Analyses were performed using descriptive statistics and analysis of variance to examine between-group differences (P < 0.05).Results: There was a significant difference between the total score performance and the critical score performance for the three groups (P < 0.001). Outcomes indicate a significant linear relationship between the expertise level of the clinical provider and the procedural performance of LC/C. Outcomes demonstrate the baseline surgical capabilities of the general surgeons transferred to LC/C performance; however, they were unfamiliar with the anatomy and the procedural techniques and requirements. The group of emergency medicine participants demonstrated performance gaps not only in the same areas as the general surgeons but also in their baseline surgical abilities. This suggests that different professional development activities are necessary for surgeons and physicians tasked with performing LC/V procedures.Conclusions: We identified significant performance gaps among emergency medicine physicians, general surgeons, and ophthalmologists in their abilities to recognize and treat OCS through LC/C procedures. These sight-saving procedures are a critical competency for forward-situated clinicians in expeditionary contexts. We identified the need for targeted approaches to professional development for closing the performance gaps for both emergency medicine physicians and general surgeons. [ABSTRACT FROM AUTHOR]