Cog Approaches to Training
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http://www.metamath.com/lsweb/dvclearn.htm
Chest had an entire supplement to what works in CME education (Chest 2009;135 supplement editorial p. 834 of main issue)
Crew Resource Management
Key elements of good CRM behaviour taught in CRM courses by Lighthall et al.12 Know your team and environment Anticipate and plan Allocate attention wisely Use all available information and cross-check it Use cognitive aids (e.g., checklists, reference materials) Take a leadership role Call for help early Communicate effectively Distribute the workload Mobilise and use all available resources Go to source: ScienceDirect – Resuscitation : Six steps from head to hand: A simulator based transfer oriented psychological training to improve patient safety
Simulator to teach CRM (Resuscitation 2007 Muller MP Six Steps from head to Hand)
Physicians are very bad at rating their competence compared to external ratings (JAMA 2006;296:1094-1102)
Motor Skills
nejm Volume 355:2664-2669 December 21, 2006 teaching procedural skills These new training techniques are based on established theories of the ways in which motor skills are acquired and expertise is developed. Fitts and Posner’s three-stage theory of motor skill acquisition is widely accepted in both the motor skills literature and the surgical literature ( Table 1). 11, 12 In the cognitive stage, the learner intellectualizes the task; performance is erratic, and the procedure is carried out in distinct steps. For example, with a surgical skill as simple as tying a knot, in the cognitive stage the learner must understand the mechanics of the skill how to hold the tie, how to place the throws, and how to move the hands. With practice and feedback, the learner reaches the integrative stage, in which knowledge is translated into appropriate motor behavior. The learner is still thinking about how to move the hands and hold the tie but is able to execute the task more fluidly, with fewer interruptions. In the autonomous stage, practice gradually results in smooth performance. The learner no longer needs to think about how to execute this particular task and can concentrate on other aspects of the procedure. Ericsson has helped to elucidate the acquisition of expertise. 13, 14 Expert performance represents the highest level of skill acquisition and the final result of a gradual improvement in performance through extended experience in a given domain. According to Ericsson, most professionals reach a stable, average level of performance and maintain this status for the rest of their careers. In surgery, “experts” have been defined by Ericsson as experienced surgeons with consistently better outcomes than nonexperts. An extensive literature on the relationship of operative volume to clinical outcomes supports the hypothesis that practice is an important determinant of outcome 15; the literature also provides support for Ericsson’s contention that many professionals probably do not attain true expertise. However, volume alone does not account for the skill level among practitioners, since variations in performance have been shown among surgeons with high and very high volumes. Deliberate practice is a critical process for the development of mastery or expertise. Ericsson argues that the number of hours spent in deliberate practice, rather than just hours spent in surgery, is an important determinant of the level of expertise. 13 Deliberate practice calls for the individual to focus on a defined task, typically identified by a teacher, to improve particular aspects of performance; it involves repeated practice along with coaching and immediate feedback on performance. The attained level of expertise has been shown to be closely related to time devoted to deliberate practice in the performance of expert musicians, chess players, and athletes. In the current model of surgical training, based primarily on apprenticeship, the opportunities for deliberate practice are rare. Operations are complex, and it is difficult to focus on one small component of the procedure. In our opinion, in order to better plan instruction and assess the efficacy of curricular interventions, valid and reliable assessments of technical skills are needed. Evaluating performance in the operating room is difficult, 16 and most efforts have focused on techniques that standardize the assessment process outside the operating room. One such method is the Objective Structured Assessment of Technical Skills (OSATS), 17, 18 in which candidates perform a series of standardized surgical tasks on inanimate models under the direct observation of an expert. Examiners score candidates using two methods. The first is a task-specific checklist consisting of 10 to 30 specific surgical maneuvers that have been deemed essential elements of the procedure. The second is a global rating form, which includes five to eight surgical behaviors, such as respect for tissues, economy of motion, and appropriate use of assistants. The validity and reliability of the OSATS are similar to those of the more traditional Objective Structured Clinical Examination (OSCE) and are acceptable for summative high-stakes evaluation purposes. 19, 20,21 To date, we have created more than 40 OSATS stations; some examples are shown in Figure 1.
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