Boot cAMP: educational outcomes after 4 successive years of preparatory simulation-based training at onset of internship.
Preparatory training for new trainees beginning residency has been used by a variety of programs across the country. To improve the clinical orientation process for our new postgraduate year (PGY)-1 residents, we developed an intensive preparatory training curriculum inclusive of cognitive and procedural skills, training activities considered essential for early PGY-1 clinical management. We define our surgical PGY-1 Boot Camp as preparatory simulation-based training implemented at the onset of internship for introduction of skills necessary for basic surgical patient problem assessment and management. This orientation process includes exposure to simulated patient care encounters and technical skills training essential to new resident education. We report educational results of 4 successive years of Boot Camp training. Results were analyzed to determine if performance evidenced at onset of training was predictive of later educational outcomes.
Learners were PGY-1 residents, in both categorical and preliminary positions, at our medium-sized surgical residency program. Over a 4-year period, from July 2007 to July 2010, all 30 PGY-1 residents starting surgical residency at our institution underwent specific preparatory didactic and skills training over a 9-week period. This consisted of mandatory weekly 1-hour and 3-hour sessions in the Simulation Center, representing a 4-fold increase in time in simulation laboratory training compared with the remainder of the year. Training occurred in 8 procedural skills areas (instrument use, knot-tying, suturing, laparoscopic skills, airway management, cardiopulmonary resuscitation, central venous catheter, and chest tube insertion) and in simulated patient care (shock, surgical emergencies, and respiratory, cardiac, and trauma management) using a variety of high- and low-tech simulation platforms. Faculty and senior residents served as instructors. All educational activities were structured to include preparatory materials, pretraining briefing sessions, and immediate in-training or post-training review and debriefing. Baseline cognitive skills were assessed with written tests on basic patient management. Post-Boot Camp tests similarly evaluated cognitive skills. Technical skills were assessed using a variety of task-specific instruments, and expressed as a mean score for all activities for each resident. All measurements were expressed as percent (%) best possible score. Cognitive and technical performance in Boot Camp was compared with subsequent clinical and core curriculum evaluations including weekly quiz scores, annual American Board of Surgery In-Training Examination (ABSITE) scores, program in-training evaluations (New Innovations, Uniontown, Ohio), and operative assessment instrument scores (OP-Rate, Baystate Medical Center, Springfield, Massachusetts) for the remainder of the PGY-1 year.
Performance data were available for 30 PGY-1 residents over 4 years. Baseline cognitive skills were lower for the first year of Boot Camp as compared with subsequent years (71 ± 13, 83 ± 9, 84 ± 11, and 86 ± 6, respectively; p = 0.028, analysis of variance; ANOVA). Performance improved between pretests and final testing (81 ± 11 vs 89 ± 7; p < 0.001 paired t test). There was statistically significant correlation between Boot Camp final cognitive test results and American Board of Surgery In-Training Examination scores (p = 0.01; n = 22), but not quite significant for weekly curriculum quiz scores (p = 0.055; n = 22) and New Innovations cognitive assessments (p = 0.09; n = 25). Statistically significant correlation was also noted between Boot Camp mean overall skills and New Innovations technical skills assessments (p = 0.002; n = 25) and OP-Rate assessments (p = 0.01; n = 12).
Individual simulation-based Boot Camp performance scores for cognitive and procedural skills assessments in PGY-1 residents correlate with subjective and objective clinical performance evaluations. This concurrent correlation with multiple traditional evaluation methods used to express competency in our residency program supports the use of Boot Camp performance measures as needs assessment tools as well as adjuncts to cumulative resident evaluation data.
Fernandez GL
，Page DW
，Coe NP
，Lee PC
，Patterson LA
，Skylizard L
，St Louis M
，Amaral MH
，Wait RB
，Seymour NE
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"How To" Videos Improve Residents Performance of Essential Perioperative Electronic Medical Records and Clinical Tasks.
The ability to use electronic medical records (EMR) is an essential skill for surgical residents. However, frustration and anxiety surrounding EMR tasks may detract from clinical performance. We created a series of brief, 1-3 minutes "how to" videos demonstrating 7 key perioperative EMR tasks: booking OR cases, placing preprocedure orders, ordering negative-pressure wound dressing supplies, updating day-of-surgery history and physical notes, writing brief operative notes, discharging patients from the postanesthesia care unit, and checking vital signs. Additionally, we used "Cutting Insights"-a locally developed responsive mobile application for surgical trainee education-as a platform for providing interns with easy access to these videos. We hypothesized that exposure to these videos would lead to increased resident efficiency and confidence in performing essential perioperative tasks, ultimately leading to improved clinical performance.
Eleven surgery interns participated in this initiative. Before watching the "how to" videos, each intern was timed performing the aforementioned 7 key perioperative EMR tasks. They also underwent a simulated perioperative emergency requiring the performance of 3 of these EMR tasks in conjunction with 5 other required interventions (including notifying the chief resident, the anesthesia team, and the OR coordinator; and ordering fluid boluses, appropriate laboratories, and blood products). These simulations were scored on a scale from 0 to 8. The interns were then directed to watch the videos. Two days later, their times for performing the 7 tasks and their scores for a similar perioperative emergency simulation were once again recorded. Before and after watching the videos, participants were surveyed to assess their confidence in performing each EMR task using a 5-point Likert scale. We also elicited their opinions of the videos and web-based mobile application using a 5-point scale. Statistical analyses to assess for statistical significance (p ≤ 0.05) were conducted using paired t-test for parametric variables and a Wilcoxon matched-pair test for nonparametric variables.
Hospital of the University of Pennsylvania, Philadelphia, PA (a quaternary teaching hospital within the University of Pennsylvania Health System).
Eleven out of 15 interns (12 entered and 11 completed the study) from our categorical and preliminary general surgery residency programs during the 2016 academic year.
Before exposure to the brief "how to" videos, 6 of 11 interns were unable to complete all 7 EMR tasks; after exposure, all 11 interns were able to complete all 7 EMR tasks. Moreover, interns' times for each task improved following exposure. Interns self-reported improved confidence in booking an OR case (4 ± 0.9 vs. 4.7 ± 0.6, p = 0.05), ordering negative-pressure wound therapy supplies (3.1 ± 1.6 vs. 4.5 ± 0.7, p < 0.05), writing a brief operative note (3.7 ± 1.2 vs. 4.6 ± 0.7, p = 0.05), discharging patients from the postanesthesia care unit (3.3 ± 1.0 vs. 4.4 ± 0.8, p < 0.05), checking vital signs (2.5 ± 1.4 vs. 4.5 ± 0.8, p ≤ 0.01), and performing necessary EMR tasks during an emergency situation (2.4 ± 0.8 vs. 4.6 ± 0.7, p ≤ 0.0001). Participants also demonstrated a significant improvement in average clinical score on the emergency simulations (5.2 ± 1.7 vs. 6.6 ± 0.9, p < 0.05). Interns' opinions of the videos and the mobile phone application were favorable.
In our group of 11 surgery interns, exposure to a series of short "how to" videos led to increased confidence and shortened times in performing 7 essential EMR tasks. Additionally, during a simulated perioperative emergency, EMR tasks were performed significantly faster. Clinical performance also improved significantly following exposure to the videos. This just-in-time educational intervention could improve workflow efficiency and clinical performance, both of which may ultimately enhance perioperative patient safety.
Zoghbi V
，Caskey RC
，Dumon KR
，Soegaard Ballester JM
，Brooks AD
，Morris JB
，Dempsey DT
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Examination to assess the clinical examination and documentation of spine pathology among orthopedic residents.
The Accreditation Council for Graduate Medical Education (ACGME) guidelines requires residency programs to teach and evaluate residents in six overarching "core competencies" and document progress through educational milestones. To assess the progress of orthopedic interns' skills in performing a history, physical examination, and documentation of the encounter for a standardized patient with spinal stenosis, an objective structured clinical examination (OSCE) was conducted for 13 orthopedic intern residents, following a 1-month boot camp that included communications skills and curriculum in history and physical examination. Interns were objectively scored based on their performance of the physical examination, communication skills, completeness and accuracy of their electronic medical record (EMR), and their diagnostic conclusions gleaned from the patient encounter.
The purpose of this study was to meaningfully assess the clinical skills of orthopedic post-graduate year (PGY)-1 interns. The findings can be used to develop a standardized curriculum for documenting patient encounters and highlight common areas of weakness among orthopedic interns with regard to the spine history and physical examination and conducting complete and accurate clinical documentation.
A major orthopedic specialty hospital and academic medical center.
Thirteen PGY-1 orthopedic residents participated in the OSCE with the same standardized patient presenting with symptoms and radiographs consistent with spinal stenosis. Videos of the encounters were independently viewed and objectively evaluated by one investigator in the study. This evaluation focused on the completeness of the history and the performance and completion of the physical examination. The standardized patient evaluated the communication skills of each intern with a separate objective evaluation. Interns completed these same scoring guides to evaluate their own performance in history, physical examination, and communications skills. The interns' documentation in the EMR was then scored for completeness, internal consistency, and inaccuracies.
The independent review revealed objective deficits in both the orthopedic interns' history and the physical examination, as well as highlighted trends of inaccurate and incomplete documentation in the corresponding medical record. Communication skills with the patient did not meet expectations. Further, interns tended to overscore themselves, especially with regard to their performance on the physical examination (p<.0005). Inconsistencies, omissions, and inaccuracies were common in the corresponding medical notes when compared with the events of the patient encounter. Nine of the 13 interns (69.2%) documented at least one finding that was not assessed or tested in the clinical encounter, and four of the 13 interns (30.8%) included inaccuracies in the medical record, which contradicted the information collected at the time of the encounter.
The results of this study highlighted significant shortcomings in the completeness of the interns' spine history and physical examination, and the accuracy and completeness oftheir EMR note. The study provides a valuable exercise for evaluating residents in a multifaceted, multi-milestone manner that more accurately documents residents' clinical strengths and weaknesses. The study demonstrates that orthopedic residents require further instruction on the complexities of the spinal examination. It validates a need for increased systemic support for improving resident documentation through comprehensive education and evaluation modules.
Haglin JM
，Zeller JL
，Egol KA
，Phillips DP
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ResearchGate
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