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<\/a><\/p>\nBest article on using new learning and teaching styles<\/a><\/p>\n and<\/p>\n What we can learn from Cog Psych for Education in Medicine<\/a><\/p>\n find your learning style<\/p>\n http:\/\/www.metamath.com\/lsweb\/dvclearn.htm<\/a><\/p>\n Stress Inoculation Training is good <\/a><\/p>\n Chest had an entire supplement to what works in CME education (Chest 2009;135 supplement editorial p. 834 of main issue)<\/p>\n Best article on\u00a0debriefing with good judgment<\/a><\/p>\n Key elements of good CRM behaviour taught in CRM courses by Lighthall et al.12<\/a>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<\/p>\n <\/p>\n Simulator to teach CRM (Resuscitation 2007 Muller MP Six Steps from head to Hand)<\/p>\n <\/p>\n <\/p>\n Physicians are very bad at rating their competence compared to external ratings (JAMA 2006;296:1094-1102)<\/p>\n <\/p>\n <\/p>\n (NEJM Volume 355:2664-2669 December 21, 2006)<\/p>\n 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<\/p>\n Cognitive Stage<\/strong> 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 \u0097 how to hold the tie, how to place the throws, and how to move the hands.<\/p>\n Integrative stage<\/strong>\u00a0With 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.<\/p>\n Autonomous stage<\/strong>\u00a0In 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.<\/p>\n 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.<\/p>\n A review article from Klein (deliberate performance by Fadde and Klein<\/a>)<\/p>\n <\/p>\n <\/p>\n Applicants guide to EM Residencies (Annals EM 19:7, July 1990)<\/p>\n Global assessment of undergrads (Acad Emerg Med Sep 2002, 9:9, p.889)<\/p>\n Structured Scoring of EM Interviews (Acad Emerg Med\u00a0 January 2004, Vol. 11, No. 1)<\/p>\n An Educator’s Guide to Teaching Emergency Medicine to Medical Students (Academic Emergency Medicine Volume 11, Number 3 300-306)<\/p>\n Academic Emergency Medicine Volume 12, Number 6 559-561, Emergency Medicine Residency Selection: Factors Influencing Candidate Decisions<\/p>\n Residents having difficulties: consider non-clinical factors–Blues, birds\/blokes, banks, babies, booze, bilingual background. (MJA 2005;183(9):475)<\/p>\n <\/p>\n ACES curriculum Art, Chaos, Ethics and Science (Ann Emerg Med 2006;48:532)<\/p>\n <\/p>\n <\/p>\n ACGME core competencies. Numbers correspond to ACGME core competency bulleted descriptors in order as listed on the ACGME Web site at http:\/\/www.acgme.net\/outcome\/comp\/compfull.asp.<\/em><\/p>\n Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:<\/p>\n Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (eg, epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to:<\/p>\n Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:<\/p>\n Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families, and professional associates. Residents are expected to:<\/p>\n Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:<\/p>\n Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:<\/p>\n Article on integrating the core competencies into education (Acade Emerg Med 2007;14:80)<\/p>\n TABLE 1. Summary of Teaching and Assessment Tools for Each Competency<\/strong> Competency Teaching Assessment<\/p>\n Patient care Lectures, particularly those that are case based In-service exams \u00a0 Internet or CD learning CORD exams \u00a0 High-fidelity simulation Med-challenger\u0096based quizzes \u00a0 Procedure labs SDOT \u00a0 Critically appraised topics Simulation \u00a0 \u00a0 Home-based exams \u00a0 \u00a0 End-of-rotation evaluations \u00a0 \u00a0 OSCE or standardized patients \u00a0 Medical knowledge Lectures (traditional or case based) In-service exams \u00a0 Small-group instruction CORD online Question Bank \u00a0 Morning report case conference Homegrown examinations \u00a0 CD or online instruction \u00a0\u0095 Ultrasound interpretation \u00a0 Journal club \u00a0\u0095 ECG interpretation \u00a0 Assigned readings \u00a0\u0095 Core-content area \u00a0 Models and simulators Mock oral assessments \u00a0 \u00a0 Direct observation \u00a0 \u00a0 Standardized direct observation \u00a0 \u00a0 Models and simulators \u00a0 \u00a0 Portfolios \u00a0 Communication and interpersonal skills Resident portfolio Direct observations \u00a0 Resident retreats 360-degree evaluations \u00a0 Lectures on skills Global assessment \u00a0 Evaluation as teaching tool Curtain evaluations \u00a0 Faculty model behavior Consensus evaluation \u00a0 Simulated cases \u00a0 \u00a0 Professionalism Didactic curriculum Written examinations of knowledge, principles, and policies \u00a0 Case-based discussion Computer-based or oral exams with embedded ethical issues \u00a0 Clinical ED experiences encompassing patient management, with application of ethical principles to clinical situations OSCEs with standardized patients \u00a0 Visually based teaching tools (CD-ROMs, videotapes, Internet-based teaching educational programs) Modified essay questions \u00a0 Colloquial settings and retreats Direct observation and SDOT \u00a0 \u00a0 360-degree evaluation \u00a0 \u00a0 ACGME toolbox: self-administered rating forms and psychometric instruments \u00a0 System-based practice Administrative rotation Bedside evaluations \u00a0 Out-of-hospital care (EMS) rotations SDOT \u00a0 Departmental and hospital committees Resident portfolios \u00a0 Patient follow-up 360-degree evaluations (nursing, peer, ancillary staff) \u00a0 Case write-ups Standardized oral exams with issues involving consultants, interpreters, resources \u00a0 Practice-based learning Evidence-based medicine reviews of clinical questions Direct feedback on the conclusions drawn by the resident in a journal-club conference \u00a0 Journal clubs Feedback from the CAT conference \u00a0 Critically appraised topics Critical assessment of the resident’s periodic portfolio summaries \u00a0 Attending CQI meetings Critical assessment of the resident’s M&M conference summaries \u00a0 Self-assessment of portfolio \u00a0 \u00a0 Resident-led M&M conferences \u00a0 \u00a0 Mentoring by faculty<\/p>\n CD = compact disc; CORD = Council of Residency Directors; OSCE = objective structured clinical exams; ACGME = Accreditation Council for Graduate Medical Education; CAT = critically appraised topics; CQI = continuous quality improvement; M&M = morbidity and mortality; SDOT = standardized direct observation tool.<\/p>\n SBAR report to physician about a critical situation<\/p>\n S<\/p>\n Situation<\/p>\n I am calling about<\/p>\n <\/p>\n <\/strong><patient name and location>.<\/p>\n The patient’s code status is<\/p>\n <code status><\/p>\n The problem I am calling about is<\/p>\n ____________________________.<\/p>\n I am afraid the patient is going to arrest.<\/p>\n I have just assessed the patient personally:<\/p>\n Vital signs are<\/p>\n : Blood pressure _____\/_____, Pulse ______, Respiration_____ and temperature ______<\/p>\n I am concerned about the:<\/p>\n Blood pressure because it is over 200 or less than 100 or 30 mmHg below usual<\/p>\n Pulse because it is over 140 or less than 50<\/p>\n Respiration because it is less than 5 or over 40.<\/p>\n Temperature because it is less than 96 or over 104.<\/p>\n B<\/p>\n Background<\/p>\n The patient’s mental status is:<\/p>\n <\/p>\n Alert and oriented to person place and time.<\/p>\n Confused and cooperative or non-cooperative<\/p>\n Agitated or combative<\/p>\n Lethargic but conversant and able to swallow<\/p>\n Stuporous and not talking clearly and possibly not able to swallow<\/p>\n Comatose. Eyes closed. Not responding to stimulation.<\/p>\n The skin is:<\/p>\n Warm and dry<\/p>\n Pale<\/p>\n Mottled<\/p>\n Diaphoretic<\/p>\n Extremities are cold<\/p>\n Extremities are warm<\/p>\n The patient is not or is on oxygen.<\/p>\n The patient has been on ________ (l\/min) or (%) oxygen for ______ minutes (hours)<\/p>\n The oximeter is reading _______%<\/p>\n The oximeter does not detect a good pulse and is giving erratic readings.<\/p>\n A<\/p>\n Assessment<\/p>\n This is what I think the problem is:<\/p>\n <\/p>\n <\/strong> <say what you think is the problem> <\/strong><\/p>\n The problem seems to be cardiac infection neurologic respiratory _____<\/p>\n I am not sure what the problem is but the patient is deteriorating.<\/p>\n The patient seems to be unstable and may get worse, we need to do something.<\/p>\n R<\/p>\n Recommendation<\/p>\n I suggest or request that you<\/p>\n <\/p>\n <\/strong><say what you would like to see done>.<\/p>\n transfer the patient to critical care<\/p>\n come to see the patient at this time.<\/p>\n Talk to the patient or family about code status.<\/p>\n Ask the on-call family practice resident to see the patient now.<\/p>\n Ask for a consultant to see the patient now.<\/p>\n Are any tests needed:<\/p>\n Do you need any tests like CXR, ABG, EKG, CBC, or BMP?<\/p>\n Others?<\/p>\n If a change in treatment is ordered then ask:<\/p>\n How often do you want vital signs?<\/p>\n How long to you expect this problem will last?<\/p>\n If the patient does not get better when would you want us to call again?<\/p>\n http:\/\/www.ihi.org\/NR\/rdonlyres\/CE050347-B6B9-4782-AB72-4643FB315418\/0\/Whittington_SBAR_JtCommJ_Mar06.pdf <\/p>\n The elements of a safe and effective written signout are included in the mnemonic “ANTICipate”: A<\/strong>dministrative, N<\/strong>ew information (clinical update), T<\/strong>asks, I<\/strong>llness, and C<\/strong>ontingency plans. Accurate administrative<\/em> information, such as patient name and location, is one of the most important components of a written signout according to surveys of internal medicine night-floats at UCSF (Unpublished data from October 2004 evaluation interviews of cross-coverage internal medicine residents at UCSF). New information<\/em> includes a brief history and diagnosis, updated medications and problem list, current baseline status (eg, cardiac status), and recent procedures and significant events. Tasks<\/em> are the “to-do” list, or the things that need to be completed during cross-coverage. Listing the tasks in “if, then” statements reduces the need for conjecture on the part of the cross-coverage practitioner. For example, in this case, the written signout would include: “Check CXR which was taken at 4:00 PM. If clear, call nurse to communicate results; if PTX, call thoracic surgery.” “Illness<\/em>” is the primary provider’s subjective assessment of the severity of illness, and contingency planning includes statements that assist the cross-coverage in managing anticipated problems. It is also important to report what therapeutic interventions have been successful in the past\u0096thus giving the cross-coverage provider important historical background to assist in decision making. Given our case, an appropriate contingency plan could be: “If patient is short of breath, try an albuterol inhaler (given history of COPD), but consider pneumothorax since he recently had a subclavian line placed.”<\/p>\n <\/p>\n At UCSF, the transformation to a system-wide structure of written and verbal signout was facilitated by a conceptual framework to manage the change, using Kotter’s 8-step approach.(23<\/a>)<\/p>\n<\/span>Debriefing<\/span><\/h2>\n
<\/span>Crew Resource Management<\/span><\/h2>\n
<\/a><\/p>\n<\/span>Motor Skills<\/span><\/h2>\n
<\/a><\/p>\n<\/span>teaching procedural skills<\/span><\/h3>\n
<\/span>Deliberate Performance vs. Deliberate Practice<\/span><\/h2>\n
<\/span>Team Stepps<\/span><\/h2>\n
<\/span>Resident and Medical Student Development<\/span><\/h2>\n
<\/a><\/p>\n<\/a><\/p>\n<\/span>Core Competencies<\/span><\/h2>\n
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<\/span>Interpersonal and communication skills<\/span><\/h3>\n
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<\/span>Systems-based practice<\/span><\/h3>\n
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\n<\/span>SBAR (Situation, Background, Assessment, Recommendation)<\/span><\/h2>\n
<\/a><\/p>\n<\/span>Signouts<\/span><\/h2>\n
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