Search

BACKGROUND: Reflective practice is associated with improved accuracy of medical diagnosis and superior performance in complex situations. Systematic observation of trainees’ reflective capacities constitutes a basis for an effective support of reflective practice within the training paradigm. We set out to examine the reflective capacity among anesthesiology trainees in a tertiary referral hospital. METHODS: We invited 61 anesthesiology trainees in Cork University Hospitals, Ireland, to participate. Each trainee was invited to respond to 2 investigator-written vignettes prepared by the investigators and suitable for evaluation using the Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT) and to produce and then respond to a written vignette based on their own experience. All responses were assessed by 2 independent assessors who had undergone training in the application of the REFLECT rubric, which gives quantifiable scores. Interrater reliability was assessed by weighted kappa coefficient. Association between years of training in medicine and level of reflective capacity was examined using correlation and multiple regression analyses, controlling for age. RESULTS: Twenty-nine trainees agreed to participate, the overall REFLECT Level was 2.16 (SD 0.7), corresponding to “thoughtful action,” indicating low to moderate reflective ability. Cronbach’s alpha for the 5 items of the REFLECT scale was excellent (r = 0.92). Weighted kappa was very satisfactory (k = 0.81). A strong association was demonstrated between years in medicine and scores on REFLECT, controlling for age of participant (F = −2.57, Beta coefficient = −0.30). Respondents with less experience had greater mean REFLECT scores than respondents with more experience (F = 5.5, P = .02; post hoc mean difference = 0.7, P = .03 for ≤32 months vs ≥99 months). There was a significant effect for gender (t = −4.3, P = .001), with women’s responses receiving greater REFLECT scores than men’s responses (mean difference = 0.67, P = .001). CONCLUSIONS: Overall, participants demonstrated low to moderate reflective capacity, as assessed by the REFLECT rubric. Reflective capacity of the anesthesiology trainees appears to decrease as years of medical training progress. However, our respondents were not sampled over time to fully support this conclusion. Further research is needed on the psychometric properties of the REFLECT rubric and the generalizability of our findings.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Compassionate behavior in clinicians is described as seeking to understand patients’ psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery. Methods Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion. Results Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η2 = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not. Conclusions In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

BackgroundObtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment.MethodsSeven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail.ResultsInterrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room.ConclusionsSensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.

Objective: Simulation is a tool that has been used successfully in many high performance fields to permit training in rare and hazardous events. Our goal was to develop and evaluate a program to teach airway crisis management to otolaryngology trainees using medical simulation. Methods: A full-day curriculum in the management of airway emergencies was developed. The program consists of three airway emergency scenarios, developed in collaboration between attending otolaryngologists and faculty from the Center for Medical Simulation. Following each scenario, the participants are led in a structured, video-assisted debriefing by a trained debriefer. Didactic material on team leadership and crisis management is built into the debriefings. Pediatric otolaryngology fellows, residents, and medical students have participated in the four courses that have been held to date. Participants evaluated the program on a five-point Likert scale. Results: A total of 17 trainees participated in four pilot training courses. The survey data are as follows: overall program, 5.0 (SD, 0.00); course goals, 4.79 (SD, 0.43); realism, 4.36 (SD, 0.63); value of lecture, 4.71 (SD, 0.47); and quality of debriefings, 4.92 (SD, 0.28). Sample comments include: “This is a valuable tool for students and residents since true emergencies in ORL are often life-threatening and infrequent,” and “This is a great course—really all physicians should experience it.” Overall evaluation was extremely positive and both residents and fellows described the course as filling an important void in their education. Conclusion: Medical simulation can be an extremely effective method for teaching airway crisis management and teamwork skills to otolaryngology trainees at all levels.

Background: Valid methods are needed to identify anesthesia resident performance gaps early in training. However, many assessment tools in medicine have not been properly validated. The authors designed and tested use of a behaviorally anchored scale, as part of a multiscenario simulation-based assessment system, to identify high- and low-performing residents with regard to domains of greatest concern to expert anesthesiology faculty. Methods: An expert faculty panel derived five key behavioral domains of interest by using a Delphi process (1) Synthesizes information to formulate a clear anesthetic plan; (2) Implements a plan based on changing conditions; (3) Demonstrates effective interpersonal and communication skills with patients and staff; (4) Identifies ways to improve performance; and (5) Recognizes own limits. Seven simulation scenarios spanning pre-to-postoperative encounters were used to assess performances of 22 first-year residents and 8 fellows from two institutions. Two of 10 trained faculty raters blinded to trainee program and training level scored each performance independently by using a behaviorally anchored rating scale. Residents, fellows, facilitators, and raters completed surveys. Results: Evidence supporting the reliability and validity of the assessment scores was procured, including a high generalizability coefficient (ρ2 = 0.81) and expected performance differences between first-year resident and fellow participants. A majority of trainees, facilitators, and raters judged the assessment to be useful, realistic, and representative of critical skills required for safe practice. Conclusion: The study provides initial evidence to support the validity of a simulation-based performance assessment system for identifying critical gaps in safe anesthesia resident performance early in training.

Although former preterm birth infants are at risk for postoperative apnea after surgery, it is unclear whether the same is true of full-term birth infants. We evaluated the incidence of apnea in 60 full-term neonates and infants undergoing pyloromyotomy both before and after anesthesia. All subjects were randomized to a remifentanil- or halothane-based anesthetic. Apnea was defined by the presence of prolonged apnea (>15 s) or frequent brief apnea, as observed on the pneumocardiogram. Apnea occurred before surgery in 27% of subjects and after surgery in 16% of subjects, with no significant difference between subjects randomized to remifentanil or halothane anesthesia. This apnea was primarily central in origin, occurred throughout the recording epochs, and was associated with severe desaturation in some instances. Of the subjects with normal preoperative pneumocardiograms, new onset postoperative apnea occurred in 3 (23%) of 13 subjects who received halothane-based anesthetics versus 0 (0%) of 22 subjects who received remifentanil-based anesthetics (P = 0.04). Thus, postoperative apnea can follow anesthesia in otherwise healthy full-term infants after pyloromyotomy and is occasionally severe with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic.

Pyloric stenosis is sometimes associated with hemodynamic instability and postoperative apnea. In this multicenter study we examined the hemodynamic response and recovery profile of remifentanil and compared it with that of halothane in infants undergoing pyloromyotomy. After atropine, propofol, and succinylcholine administration and tracheal intubation, patients were randomized (2:1 ratio) to receive either remifentanil with nitrous oxide and oxygen or halothane with nitrous oxide and oxygen as the maintenance anesthetic. Pre- and postoperative pneumograms were done and evaluated by an observer blinded to the study. Intraoperative hemodynamic data and postanesthesia care unit (PACU) discharge times, PACU recovery scores, pain medications, and adverse events (vomiting, bradycardia, dysrhythmia, and hypoxemia) were recorded by the study's research nurse. There were no significant differences in patient age or weight between the two groups. There were no significant differences in hemodynamic values between the two groups at the various intraoperative stress points. The extubation times, PACU discharge times, pain medications, and adverse events were similar for both groups. No patient anesthetized with remifentanil who had a normal preoperative pneumogram had an abnormal postoperative pneumogram, whereas three patients with a normal preoperative pneumogram who were anesthetized with halothane had abnormal pneumograms after.The use of ultra-short-acting opioids may be an appropriate technique for infants less than 2 mo old when tracheal extubation after surgery is anticipated.

This report describes how realistic patient simulation can be used with video teleconferencing to conduct long-distance clinical case discussions with realistic re-enactments of critical events. By observing what appears to be a real procedure unfolding in real time, it is intended that audience members will better learn and appreciate the lessons from conferences. A commercially available mannequin simulator and video teleconferencing technology were used in nine sessions between a free-standing simulation center and different conference sites throughout the U.S. Transmission was via high-speed telephone lines. In each conference, a clinical scenario was simulated on a screen. Audience members asked questions of a live simulated "patient" and family and later advised the care team on routine treatments and management of urgent clinical problems that arose during management of the mannequin simulator in a highly realistic clinical setting. Ninety-eight percent of respondents from one audience of 150 (response rate 60%) judged the quality of the presentation as "very good or excellent." In response to the statement that "the educational value of the presentation was much greater than that of a standard case conference," 95% scored 4 or 5 on a five-point Likert scale (where 5 is highest agreement). While all conferences were conducted successfully, there were instances of technical challenge in using teleconferencing technology. Technical information about the teleconferencing system and scenario preparation, contingency planning for failures, and other details of using this new teaching modality are described. Although audiences were enthusiastic in their response to this approach to clinical case conferences, further study is needed to assess the added value of interactive simulation for education compared to standard conference formats.

BACKGROUND: Safety climate is often measured via surveys to identify appropriate patient safety interventions. The introduction of an insurance premium incentive for simulation-based anesthesia crisis resource management (CRM) training motivated our naturalistic experiment to compare the safety climates of several departments and to assess the impact of the training. METHODS: We administered a 59-item survey to anesthesia providers in six academic anesthesia programs (Phase 1). Faculty in four of the programs subsequently participated in a CRM program using simulation. The survey was readministered 3 yr later (Phase 2). Factor analysis was used to create scales regarding common safety themes. Positive safety climate (% of respondents with positive safety attitudes) was computed for the scales to indicate the safety climate levels. RESULTS: The usable response rate was 44% (309/708) and 38% (293/772) in Phases 1 and 2 respectively. There was wide variation in response rates among hospitals and providers. Eight scales were identified. There were significantly different climate scores among hospitals but no difference between the trained and untrained cohorts. The positive safety climate scores varied from 6% to 94% on specific survey questions. Faculty and residents had significantly different perceptions of the degree to which residents are debriefed about their difficult clinical situations. CONCLUSIONS: Safety climate indicators can vary substantially among anesthesia practice groups. Scale scores and responses to specific questions can suggest practices for improvement. Overall safety climate is probably not a good criterion for assessing the impact of simulation-based CRM training. Training alone was insufficient to alter engrained behaviors in the absence of further reinforcing actions.

The difficulty of assessing the effects of mind- altering drugs on human behavior, especially conduct in real-life situations, is discussed. Problems in classification of drugs are also noted; it is emphasized that assumed drug effects are, at best, statements of probability. In considering crimes associated with drug use, it is necessary to distinguish between crimes based on drug use itself, which include all offenses for illicit acquisition, possession, and use of dangerous drugs and narcotics, and dangerous behavior resulting from use. The evidence is clearest for alcohol, revealing a distinct relationship between alcohol use and health hazard, suicide, accidents, and violence. The evidence is less clear for heroin, since most users are delinquent prior to being identified as "addicts" so that continued criminality after heroin use cannot be "caused" by narcotics. That the kind of criminality engaged in is influenced by drug use does seem a reasonable conclusion. Evidence about the degree of risk for the use of other drugs (sedatives, stimulants, hallucinogens, volatile intoxicants, and the like) and crime is absent. Generally, it appears that most Americans use drugs without major ill- effects—including occasional illicit use. Those likely to be engaged in drug use and in crime are likely to be urban slum- dwelling males, with an overrepresentation of minority groups. Such behavior is apt to be part of a life pattern of deficit and disorder.

Mexiletine and tocainide were administered to 79 patients to determine whether the response to one of these drugs would predict the effect of the other. In 57 patients, the two agents were evaluated noninvasively with monitoring and exercise testing, and efficacy was judged by the suppression of spontaneous ventricular arrhythmia. In the remaining 22 patients, electrophysiologic testing was performed and efficacy was defined as the inability to induce more than two repetitive ventricular premature beats. An equal number of patients responded to mexiletine and tocainide (38 versus 39%). However, in only 42 patients (53%) were the results concordant. There was no difference in concordance when the results were analyzed by method of drug evaluation, left ventricular ejection fraction or etiology of presenting arrhythmia. It is concluded that mexiletine and tocainide have different clinical effects and must be evaluated individually.