Update in Education

Jul 30, 2018

Melanie J. Donnelly, MD, MPH; Lloyd R. Turbitt, MB, BCh, BAO, FRCA, MSc; Steven L. Orebaugh, MD; Rafael Nascimento, MD; Michael O'Rourke, MS; Adam K. Jacob, MD

As lifelong learners, we know that some of the most informative research is published in sources other than our own specialty-based literature. However, the breadth of published literature and our limited free time may not allow us the opportunity to search those alternative information sources. In this new ASRA News feature, members of the Education in Regional Anesthesia SIG have identified, vetted, and summarized five articles from peer-reviewed education literature as sources that might offer broadbased insight to fellow teachers and learners of regional anesthesia and pain medicine. Enjoy!

Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents

Martinelli SM, Chen F, DiLorenzo AN, et al. J Grad Med Ed. 2017;9(4):485–490.

The “flipped classroom” approach reverses the traditional learning environment by expecting learners to review instructional content prior to class and then spend class time on interactive activities involving that information to further reinforce the concepts. The goal is to emphasize learner-centered, active learning instead of a passive, teacher-centered approach.

“The flipped classroom ‘active learner-centered’ model of learning may hold some benefit for anesthesia resident education compared to the ‘passive teacher-centered' approach.”

The authors of this article sought to determine whether using a flipped classroom with anesthesia residents for a 4-week course resulted in enhanced content learning and experience. The participants consisted of 182 postgraduate year-two residents from eight different institutions who were studied during a 2-year period while preparing for the American Board of Anesthesiology (ABA) Basic Examination, specifically focusing on the pharmacology portion of the ABA Basic Content Outline. Standardized educational content was delivered via a flipped classroom or traditional method in four consecutive sessions. Knowledge-based pre- and posttests were administered, followed by a retention test held 4 months after the sessions. The authors found a slight advantage in knowledge retention in the flipped classroom model but not on the immediate posttest. Participants also noted more positive learning experiences with the flipped classroom model. The greatest limitation was a lack of generalizability beyond a single specialty or subject.

Final thought: The flipped classroom “learner-centered active learning” model of learning may hold some benefit for anesthesia resident education compared to the “passive teacher-centered” approach.

Residents’ Procedural Experience Does Not Ensure Competence: A Research Synthesis

Barsuk JH, Cohen ER, Feinglass J, et al. J Grad Med Ed. 2017; 9(2):201–208.

The commonly held belief that increased clinical experience invariably results in improved performance, especially with procedures, is not well supported by available evidence. Performance deficiencies may be better addressed with simulation, in which learners demonstrate mastery of techniques by achieving a required passing score, based on optimally performing standardized tasks, regardless of the actual number of attempts made.

Authors sought to compare resident clinical experience (that is, number of prior procedures performed) with the ability to achieve a minimum passing score on four different procedures performed in a simulation setting. Residents from several different types of training programs, representing a cross section of different hospitals, provided the number of prior procedures of each type that they had performed, based on their resident case logs.

During the simulation training, residents performed central venous catheter insertion, lumbar puncture, paracentesis, and thoracentesis (based on the type of training program). A baseline score was collected before the training was initiated, followed by didactics and deliberate practice until a learner attained the minimum passing score (MPS). Only 10% of residents achieved the MPS at baseline, and the number of prior procedures performed in the clinical setting was significantly associated with achieving a passing score in the simulation exercises.

The authors cited literature demonstrating that neither prior numbers of procedures or time-in-training correlates well with Accreditation Council for Graduate Medical Education definitions of competence. Conversely, simulation-based training with deliberate practice offers standardization, feedback from trained educators, translation of outcomes to improvements in actual clinical care, and ongoing, formative evaluation so that learners demonstrate a requited degree of mastery of a particular skill.

Limitations included self-reporting by the residents, the limited number of hospitals/trainees involved in the study (all from one city), and the potential discrepancy between what local experts determined as minimal standards for success in the study and the requirements of educators for learning the same procedures at the residents' actual training sites.

Final thought: Although performance of invasive procedures did improve with more clinical experience, the rate of attainment of passing scores compared to an established baseline of required behaviors was low before deliberate practice in a simulation setting.

Challenges in Health Care Simulation: Are We Learning Anything New?

Henriksen K, Rodrick D, Grace EN, et al. Acad Med. 2018;93(5):705–708.

Health care simulation in medical training institutions has established methodology for skills improvement and practicing clinical management, yet educators debate whether we are actually learning anything new about optimal use of health care simulation, particularly with respect to improving patient safety and quality of care. Many studies simply re-evaluate already demonstrated knowledge.

The authors posited that to learn something new, the question needs to shift from “Is simulation effective?” to “How can it be more effective?” The answer involves different tasks, targets, and fields. Identifying relevant educational issues is more useful, such as outcome measurement and the best ways to structure deliberate practice and assess performance.

More must be learned about how simulation training skills transfer to the clinical setting as well as improved quality and safety for patients. Research in this area will also need to be diversified, depending on the questions asked. As the author suggested, an open and purposeful pursuit of questions in patient safety and nontechnical skills such as teamwork, situation awareness, and decision-making are important. As we learn how to optimize the use of simulation, patient safety will improve.

Final thought: In our complex health care system, patient safety remains a multifaceted challenge that requires multifaceted approaches.

Association Between Teaching Status and Mortality in U.S. Hospitals

Burke LG, Frakt AB, Khullar D, et al. JAMA. 2017;317(20):2105– 2113.

Does admission to a teaching hospital versus a nonteaching hospital impact overall mortality rate? Study authors found that among approximately 21 million hospitalizations of Medicare beneficiaries, adjusted 30-day mortality rates were significantly lower at 250 major teaching hospitals compared with 894 minor teaching and 3,339 nonteaching hospitals (8.3% vs 9.2% and 9.5%, respectively). Significantly lower 30-day mortality was also observed in major teaching versus nonteaching hospitals in 11 of 15 medical conditions and two of six surgical procedures evaluated. In addition, sensitivity analysis revealed significantly lower 7-day and 90-day mortality in teaching versus nonteaching hospitals.

The differences in mortality by teaching status may be related to greater experience treating particular conditions or earlier adoption of new technology. However, accounting for hospital volume did not substantially explain the observed mortality differences.

The study findings were limited only to mortality; therefore, other hospital quality metrics were excluded. Because the study included only Medicare patients, results may not be generalizable to nonelderly populations. In addition, it did not account for patient preferences in end-of-life care. Variations in palliative care practice across teaching and nonteaching hospitals may confound mortality rates.

Final thought: Admission to a major teaching hospital was associated with lower overall 30-day mortality compared with admissions to a nonteaching hospital; however, the study had several confounding factors and must be interpreted with caution.

Adapting Feedback to Individual Residents: An Examination of Preceptor Challenges and Approaches

des Ordons AR, Cheng A, Gaudet J, et al. J Grad Med Educ. 2018;10(2):168–175.

Feedback is important for resident development, but nuances of providing feedback to trainees with various personality traits or skill levels may be challenging. In this single-center qualitative study, 18 preceptors participated in feedback simulations of resident– patient interactions. Each preceptor watched four separate recorded interactions of a resident (portrayed by a professional actor) discussing goals of care with a patient. In each recording, the resident possessed a unique trait: (1) highly performing resident, (2) resident with insight gaps, (3) overly confident resident, and (4) emotionally distressed resident. After observing the interactions, the preceptor had 8–10 minutes to provide feedback to the resident (actor), which was followed by an 8- to 10-minute debrief with a study facilitator regarding the feedback.

Analysis of recorded feedback sessions demonstrated that preceptors adapted their feedback to the different scenarios but identified unique challenges in each context. Unique approaches to providing feedback could be considered, including coaching a high-performing resident (eg, framing feedback as a conversation, encouraging the resident to identify strengths and challenges), directing a resident with insight gaps because self-assessment is ineffective in achieving insight, mediating an overly confident resident (eg, encouraging reflection on patient experience, eliciting ideas for implementing teaching points from the resident), and mentoring an emotionally distressed resident (eg, exploring source of distress, asking permission to defer feedback, identifying support for the resident, sharing own strategies).

Final thought: Understanding the challenges educators encounter and approaches taken to adapt feedback to individual trainees may help faculty meet the challenges of competency-based medical education.

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