Introducing "I wish I knew then ...".
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Education, Professional↗
Biomedical subjects
Glenn Regehr
Publications and source records attributed to Glenn Regehr.
Research in medical education: balancing service and science.
Since the latter part of the 1990's, the English-speaking medical education community has been engaged in a debate concerning the types of research that should have priority. To shed light on this debate and to better understand its implications for the practice of research, 23 semi-structured interviews were conducted with "influential figures" from the community. The results were analyzed using the concept of "field" developed by the sociologist Pierre Bourdieu. The results reveal that a large majority of these influential figures believe that research in medical education continues to be of insufficient quality despite the progress that has taken place over the past 2 decades. According to this group, studies tend to be both redundant and opportunistic, and researchers tend to have limited understanding of both theory and methodological practice from the social sciences. Three factors were identified by the participants to explain the current problems in research: the working conditions of researchers, budgetary restraints in financing research in medical education, and the conception of research in the medical environment. Two principal means for improving research are presented: intensifying collaboration between PhD's and clinicians, and encouraging the diversification of perspectives brought to bear on research in medical education.
Curriculum↗
Variations in diagnostic criteria for carpal tunnel syndrome among Ontario specialists.
BACKGROUND: Variations in diagnostic criteria for carpal tunnel syndrome (CTS) may result in differing reports of disease prevalence, errors in diagnosis, and variable results of treatment. The objective of this study was to determine how consistent specialists are in their ratings of the importance of clinical criteria for the diagnosis of CTS. METHODS: Three hundred specialist physicians and surgeons received a questionnaire containing 57 clinical criteria for the diagnosis of CTS. A visual analog scale (VAS) was used to rate the importance of each criterion in the diagnosis of CTS. RESULTS: The overall consistency both across and within specialties was poor (intraclass correlation coefficient across specialties (ICC) = 0.28; ICC range within specialties 0.27-0.37). CONCLUSIONS: Specialists are relatively inconsistent in the importance they assign to clinical criteria for the diagnosis of CTS. This inconsistency may be an important source of variation in the reported prevalence and treatment of CTS.
Carpal Tunnel Syndrome↗
Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.
BACKGROUND: Calls abound for a culture change in health care to improve patient safety. However, effective change cannot proceed without a clear understanding of perceptions and beliefs about error. In this study, we describe and compare operative team members' and patients' perceptions of error, reporting of error, and disclosure of error. METHODS: Thirty-nine interviews of team members (9 surgeons, 9 nurses, 10 anesthesiologists) and patients (11) were conducted at 2 teaching hospitals using 4 scenarios as prompts. Transcribed responses to open questions were analyzed by 2 researchers for recurrent themes using the grounded-theory method. Yes/no answers were compared across groups using chi-square analyses. RESULTS: Team members and patients agreed on what constitutes an error. Deviation from standards and negative outcome were emphasized as definitive features. Patients and nurse professionals differed significantly in their perception of whether errors should be reported. Nurses were willing to report only events within their disciplinary scope of practice. Although most patients strongly advocated full disclosure of errors (what happened and how), team members preferred to disclose only what happened. When patients did support partial disclosure, their rationales varied from that of team members. CONCLUSIONS: Both operative teams and patients define error in terms of breaking the rules and the concept of "no harm no foul." These concepts pose challenges for treating errors as system failures. A strong culture of individualism pervades nurses' perception of error reporting, suggesting that interventions are needed to foster collective responsibility and a constructive approach to error identification.
Adult↗
What we don't know we are teaching: unveiling the hidden curriculum.
In addition to the intentional teaching of knowledge and skills by surgeons to their trainees and protégés is the unintended, often unrealized transmission of implicit beliefs, attitudes, and behaviors through a process called the hidden curriculum. The hidden curriculum is a function of implicit values held by the institution as a whole, and the individual surgical educators and allied health professionals working in the trainee's learning environment. It has been argued the hidden curriculum plays a central role in the development of professionalism, but it may also play an important role in inadvertently deterring good candidates from considering orthopaedic surgery as a career. We review the importance of attending to the messages we transmit to our trainees, protégés, and junior colleagues as we strive to develop professional competency and recruit the best into the field.
Attitude of Health Personnel↗
Self-assessment, self-direction, and the self-regulating professional.
One of the cornerstones of autonomy for any profession is the claim to self-regulation. To be effectively self-regulating, the profession generally depends on the individual practitioner to self-regulate his own maintenance of competence activities. This model of individual self-regulation, in turn, depends on the practitioner's ability to self-assess gaps in competence and willingness to seek out opportunities to redress these gaps when identified. The literature relevant to these processes, however, would suggest this model of individual self-regulation is overly optimistic. We review the literature and describe several difficulties associated with the traditionally held model of individual self-regulation. In particular, research demonstrates repeatedly that 1) self-assessment is not an effective mechanism to identify areas of personal weakness and that 2) even when areas of weakness are obvious to the adult learner, we often avoid engaging in learning in these areas because such learning often takes more energy and commitment than we are willing to expend. Implications of these difficulties for the current model of self-regulation are explored.
Adult↗
Factors in optimizing the learning environment for surgical training.
Today's surgeon is required to demonstrate a variety of professional competencies in an increasingly complex environment. Recently, the time available to train this surgeon has started to erode due to external pressures on administrators and faculty. This growing crisis has led to questions about how to optimize learning in the surgical environment. Clearly, to adequately train a competent surgeon in all the required aspects, multiple environments will be required. We must, therefore, look carefully at each environment to maximize its educational potential for each of the competencies. At the same time, however, we must ensure these educational environments and opportunities integrate into a coherent and systematic program of training that is flexible and adaptable to the individual needs of the trainees. This paper describes two broad areas that must be at the forefront of the community's thinking as we strive toward this goal: the irreplaceable value of a mentor and maximizing the potential of optimal challenge points in learning.
Humans↗
To blind or not to blind? What authors and reviewers prefer.
In order to inform discussions about possible changes to Medical Education's blinding policy, members of the journal's editorial board were interested in discovering reviewers' and authors' preferences with regard to the current double-blind policy and various alternatives. In September 2005, an 8-question, web-based survey was sent to all authors and reviewers who had submitted or reviewed a manuscript for Medical Education in 2003 and 2004 (n = 2632). The questions asked about authorship and reviewing experiences and preferences regarding 5 types of blinding procedure, from double-blinding to fully unblinded, open reviews. Following 2 electronic mailings, 838 surveys were completed. There was a range of experience among respondents, with a high proportion of experienced authors (49% with over 20 publications) and reviewers (41% with over 20 reviews). Overall, 68% of respondents preferred a review process that concealed author names and 72% preferred a process that allowed for concealment of reviewer names. Less experienced authors and reviewers were significantly more likely to prefer concealing author names, but even the most experienced respondents had a 54% preference for author concealment. Reasons for concealing identities included facilitating fairness and honesty in reviews and acknowledging the need to avoid personal conflicts or rivalries. Reasons for revealing identities included facilitating greater transparency and accountability, and a better understanding of the author's and reviewer's contexts and credentials. The Medical Education authors and reviewers who chose to respond to the survey voted strongly in favour of continuing the double-blinding procedure of concealing both author and reviewer identities during the review process.
Attitude↗
The persistent myth of stability. On the chronic underestimation of the role of context in behavior.
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Behavior↗
A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability.
BACKGROUND: Breakdown in communication among members of the healthcare team threatens the effective delivery of health services, and raises the risk of errors and adverse events. AIM: To describe the process of developing an authentic, theory-based evaluation instrument that measures communication among members of the operating room team by documenting communication failures. METHODS: 25 procedures were viewed by 3 observers observing in pairs, and records of events on each communication failure observed were independently completed by each observer. Each record included the type and outcome of the failure (both selected from a checklist of options), as well as the time of occurrence and a description of the event. For each observer, records of events were compiled to create a profile for the procedure. RESULTS: At the level of identifying events in the procedure, mean inter-rater agreement was low (mean agreement across pairs 47.3%). However, inter-rater reliability regarding the total number of communication failures per procedure was reasonable (mean ICC across pairs 0.72). When observers recorded the same event, a strong concordance about the type of communication failure represented by the event was found. DISCUSSION: Reasonable inter-rater reliability was shown by the instrument in assessing the relative rate of communication failures displayed per procedure. The difficulties in identifying and interpreting individual communication events reflect the delicate balance between increased subtlety and increased error. Complex team communication does not readily reduce to mere observation of events; some level of interpretation is required to meaningfully account for communicative exchanges. Although such observer interpretation improves the subtlety and validity of the instrument, it necessarily introduces error, reducing reliability. Although we continue to work towards increasing the instrument's sensitivity at the level of individual categories, this study suggests that the instrument could be used to measure the effect of team communication intervention on overall failure rates at the level of procedure.
Academic Medical Centers↗
Using a comprehensive examination to assess multiple competencies in surgical residents: does the oral examination still have a role?
BACKGROUND: While specialty-level evaluations evolve from traditional examinations to objective structured clinical examination-like assessments, a broader range of competencies are tested; consequently, examiners are forced to integrate results when making a determination of competency. The aim of this study was to describe how experts weigh relative performances on specific components of a comprehensive examination to make decisions of overall competency. STUDY DESIGN: The Patient Assessment and Management Examination is a standardized patient-based assessment of general surgery in which each 25-minute station encompasses four components: history and physical examination, investigation interpretation, diagnosis and treatment discussion with the patient, and a structured oral examination (SOE). A six-station Patient Assessment and Management Examination was administered to 21 senior surgery residents. Surgeons marked each station with global rating scales and, in addition, provided an end-of-station overall global assessment of performance. A "gold-standard" examination pass-or-fail decision was determined through videotape review of each candidate's performance across six stations by two blinded surgeons. Multiple linear regression analysis was used to determine which components were associated with the end-of-station overall global assessments. Multivariable logistic regression was used to determine which components were associated with the final "gold-standard" pass-or-fail assessment. RESULTS: The only component notably (p < 0.005) associated with end-of-station global assessment for all six stations was the SOE. Mean SOE score was the only notable independent variable associated with the gold-standard pass-or-fail decision (R(2) = 0.63, p < 0.001). CONCLUSIONS: Performance on the SOE section of a multicompetency examination is markedly associated with the final determination of competency. These results have implications for the design and implementation of comprehensive specialty-level assessments.
Clinical Competence↗
Self-assessment in the health professions: a reformulation and research agenda.
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Health Personnel↗
Perceptions of operating room tension across professions: building generalizable evidence and educational resources.
BACKGROUND: Effective team communication is critical in health care, yet no curriculum exists to teach it. Naturalistic research has revealed systematic patterns of tension and profession-specific interpretation of operating room team communication. Replication of these naturalistic findings in a controlled, video-based format could provide a basis for formal curricula. METHOD: Seventy-two surgeons, nurses, and anesthesiologists independently rated three video-based scenarios for the three professions' level of tension, responsibility for creating tension and responsibility for resolution. Data were analyzed using three-way, mixed-design analyses of variance. RESULTS: The three professions rated tension levels of the various scenarios similarly (F=1.19, ns), but rated each profession's responsibility for creating (F=2.86, p<.05) and resolving (F=1.91, p<.01) tension differently, often rating their profession as having relatively less responsibility than the others. CONCLUSIONS: These results provide an evidence base for team communications training about tension patterns, disparity of professional perspectives, and implications for team function.
Anesthesiology↗
Failure to fail: the perspectives of clinical supervisors.
BACKGROUND: Clinical supervisors often do not fail students and residents even though they have judged their performance to be unsatisfactory. This study explored the factors identified by supervisors that affect their willingness to report poor clinical performance when completing In-Training Evaluation Reports (ITERs). METHOD: Semistructured interviews with 21 clinical supervisors at the University of Ottawa were conducted and qualitatively analyzed. RESULTS: Participants identified four major areas of the evaluation process that act as barriers to reporting a trainee who has performed poorly: (1) lack of documentation, (2) lack of knowledge of what to specifically document, (3) anticipating an appeal process and (4) lack of remediation options. CONCLUSIONS: The study provides insight as to why supervisors fail to fail the poorly performing student and resident. It also offers suggestions of how to support supervisors, increasing the likelihood that they will provide a valid ITER when faced with an underachieving trainee.
Canada↗
Progressive independence in clinical training: a tradition worth defending?
BACKGROUND: Progressive independence is a traditional premise of clinical training. Recently, issues such as managed care, work hours limitation, and patient safety have begun to impact the degree of autonomy afforded to clinical trainees. This article reviews empirical evidence and theory pertaining to the role of progressive autonomy in clinical learning. METHOD: A computerized literature search was performed using Medline, PsycINFO, Social Sciences Citation Index, and Educational Resources Information Center. This article presents a synthetic review of relevant empirical and theoretical concepts from the domains of medicine, psychology, education, kinesiology, and sociology. RESULTS: The clinical psychology and medical education literatures provide evidence that clinical trainees act more independently as their training progresses, but have not yet evaluated the educational efficacy of providing progressive independence, or the consequences of failing to do so. The expertise and motor learning literatures provide some theoretical evidence (as yet untested in complex clinical environments) that the provision of too much guidance or feedback to trainees could be educationally detrimental in the long term. The sociology literature provides insight into the cultural values underlying the behavior of clinical teachers and trainees relating to issues of supervision and independence. CONCLUSIONS: There is limited empirical support for the current model of progressive independence in clinical learning; however, diverse theoretical perspectives raise concern about the potential educational consequences of eroding progressive independence. These perspectives could inform future research programs that would create a creative and effective response to the social and economic forces impacting clinical education.
Counseling↗
Assessment of critical appraisal skills.
BACKGROUND: Studies have provided little evidence that critical appraisal skills improve with focused courses. However, outcome measures in these studies have been questionable. The goal of this study was to develop a feasible, reliable, and valid assessment of critical appraisal skills. METHODS: Forty-four surgery residents read three articles and then responded to short answer questions and provided 7-point ratings regarding various methodological aspects of each article. Reliability and validity of the examination were assessed. RESULTS: The mean score was 52.4% (SD 8.6%). Internal consistency of the 55-question examination was 0.77. Interrater reliability of clinician markers was 0.91. Mean score for residents with more intensive critical appraisal training was significantly higher than for those with little or no training (56.6% versus 49.3%, t(35) = 2.31, P = 0.02), suggesting construct validity. CONCLUSIONS: This examination has promising psychometric properties, and may be useful in evaluating critical appraisal curricula.
Clinical Competence↗
The effectiveness of video feedback in the acquisition of orthopedic technical skills.
BACKGROUND: The addition of video feedback to bench model training offers residents the opportunity to see themselves perform a surgical task. Videotaped feedback therefore promotes self-evaluation, a critical learning skill, and also has the potential to influence how a resident executes a skill once they have had the opportunity to see themselves perform the task. METHODS: Twenty-nine surgical residents were video recorded while performing three technical skills. They then were randomly assigned to receive either no feedback, video feedback alone, or video feedback with the help of an expert, an orthopedic surgeon. The surgical task was then repeated. Orthopedic surgeons evaluated the videotapes using the global rating scale and technical checklist form. RESULTS: One-way between-subject analysis of variance comparing the pretest and post-test difference scores on three different measures for each of the three tasks revealed no statistically significant differences. After controlling for rater variance, the global rating scores across the three surgical tasks did not reveal any statistically significant differences. CONCLUSIONS: This study failed to demonstrate an improvement in technical skills based on utilization of video feedback.
Analysis of Variance↗
Teaching practicing surgeons critical appraisal skills with an Internet-based journal club: A randomized, controlled trial.
BACKGROUND: The effectiveness of interventions for developing critical appraisal skills in practicing physicians has not been studied, despite the documented importance of reading the literature in caring for patients and in continuing professional development. The objective of this study was to evaluate whether an Internet-based intervention would lead to enhanced critical appraisal skills in practicing surgeons. METHODS: General surgeons who agreed to participate were randomized into 2 groups. The intervention was a curriculum in critical appraisal skills that included a clinical and methodologic article, a listserve discussion, and clinical and methodologic critiques. The control group received only the clinical articles. The primary outcome measure was a previously validated 2-hour test of critical appraisal. RESULTS: Of the 55 surgeons who completed the examination, subjects in the intervention group performed better on the test of critical appraisal skills than those in the control group (mean score: intervention group, 58% +/- 8 vs control group, 50% +/- 8), with a large effect size of 1.06 standard deviation units (t+3.92, P <.0001). Training conditions accounted for 22% of the variance in total scores. CONCLUSIONS: A multifaceted, Internet-based intervention resulted in improved critical appraisal skills of practicing general surgeons.
Adult↗