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PubMed2002

Clinical performance assessment and interactive video teleconferencing: an iterative exploration.

BACKGROUND: The direct observation of students in authentic settings by faculty provides valuable feedback on performance and helps ensure mastery of clinical skills. DESCRIPTION: We explored the use of interactive video technology (IVT) as a way of involving community preceptors as raters on a clinical performance exam for 3rd-year students after their family medicine clerkship. Family medicine preceptors, from locations in their communities, observed students on campus conduct interviews and physical exams of standardized patients and then interacted with them during their case presentations. EVALUATION: We chose an action research approach to this project and conducted four independent trials. Interviews and observations were structured around three areas of concern: human, technical, and institutional. CONCLUSIONS: We feel confident in recommending IVT as a viable option for involving community preceptors in high-stakes testing and with other campus-based activities. We also report on the value of IVT in faculty development activities.

Behavior↗
PubMed1996

Clinical application of three-dimensional (3-D) vision systems and virtual reality helmets in video-assisted surgery.

Thoraco-Iaparoscopic surgery presents a series of technical difficulties linked mainly to the necessity of acquiring proper motor coordination and spatial reconstruction of an operative field that is seen from a distance on a two-dimensional video monitor, in the absence of any direct tactile feedback. In an effort to improve the motor coordination of the operating surgeon and of the surgical team, many apparatuses have recently become available on the market that allow the reproduction of a 3-Dimage on a video monitor. Such apparatuses have technical characteristics that are substantially diverse in technology and provide signifi- cantly different end results.

Journal Article↗
PubMed1992

[Modification of autoregulation of intrinsic physical processes in field-dependent subjects: a study of performance in heart rate biofeedback].

Witkin, the founder of the concept of "field dependence", assumed that there is a relationship between field dependence and body perception. However, this hypothesis was never investigated experimentally in a well-controlled study. Twenty healthy subjects learned to increase and decrease their heart rate dependent upon two discriminative stimuli. In order to increase and decrease their heart rate they received exteroceptive feedback (movements of a rocket-ship on a video screen). Each trial lasted 6 s. The distance of the rocket-ship from a certain point indicated the amount of the achieved increase or decrease. Field dependent subjects scoring higher in field dependency as measured by the Embedded Figures Test were poorer at heart rate control on feedback and transfer trials (test trials with feedback removed) than were subjects scoring low in field dependency. This result may be of therapeutic interest in the application of behavioral medicine to psychosomatic and psychiatric disorders.

Adult↗
PubMed2000

Effectiveness of supplemental grasp-force feedback in the presence of vision.

Previous studies have shown that supplemental grasp-force feedback can improve control for users of a hand prosthesis or neuroprosthesis under conditions where vision provides little force information. Visual cues of force are widely available in everyday use, however, and may obviate the utility of supplemental force information. The purpose of the present study was to use a video-based hand neuroprosthesis simulator to determine whether grasp-force feedback can improve control in the presence of realistic visual information. Seven able-bodied subjects used the simulator to complete a simple grasp-and-hold task while controlling and viewing pre-recorded, digitised video clips of a neuroprosthesis user's hand squeezing a compliant object. The task was performed with and without supplemental force feedback presented via electrocutaneous stimulation. Subjects had to achieve and maintain the (simulated) grasp force within a target window of variable size (+/- 10-40% of full scale). Force feedback improved the success rate significantly for all target window sizes (8-16%, on average), and improved the success rate at all window sizes for six of the seven subjects. Overall, the improvement was equivalent functionally to a 35% increase in the window size. Feedback also allowed subjects to identify the direction of grasp errors more accurately, on average by 10-15%. In some cases, feedback improved the failure identification rate even if success rates were unchanged. It is thus concluded that supplemental grasp-force feedback can improve grasp control even with access to rich visual information from the hand and object.

Adult↗
PubMed2003

Using three-channel video to evaluate the impact of the use of the computer on the patient-centredness of the general practice consultation.

The aim of this study was to assess the feasibility of using three-channel video to explore the impact of the computer on general practitioner (GP) consultations. A previous study had highlighted the limitations of using single-channel video: firstly, there was a lack of information about exactly how the computer was being used, and secondly difficulty in interpreting the body language of the consulting clinician. More information was needed to understand the impact of the computer on the consultation, and in this pilot three-channel video was used to overcome these constraints. Four doctors consulted, with the patient's role played by an actor with a preset script and preloaded personal and family history record programmed into the computer. The output was analysed using the Roter Interaction Analysis System (RIAS) and observational methods were used to explore the effect of computers on aspects of verbal and non-verbal behaviour and the completeness of the computer data record. Three-channel video proved to be a feasible and valuable technique for the analysis of primary care GP consultations, with advantages over single-channel video. Interesting differences in non-verbal and verbal behaviour became apparent with different types of computer use during the consultation. Implications for the three-channel video technique for training, monitoring GP competence and providing feedback are discussed.

Attitude to Computers↗
PubMed2004

Localized Ras signaling at the leading edge regulates PI3K, cell polarity, and directional cell movement.

During chemotaxis, receptors and heterotrimeric G-protein subunits are distributed and activated almost uniformly along the cell membrane, whereas PI(3,4,5)P(3), the product of phosphatidylinositol 3-kinase (PI3K), accumulates locally at the leading edge. The key intermediate event that creates this strong PI(3,4,5)P(3) asymmetry remains unclear. Here, we show that Ras is rapidly and transiently activated in response to chemoattractant stimulation and regulates PI3K activity. Ras activation occurs at the leading edge of chemotaxing cells, and this local activation is independent of the F-actin cytoskeleton, whereas PI3K localization is dependent on F-actin polymerization. Inhibition of Ras results in severe defects in directional movement, indicating that Ras is an upstream component of the cell's compass. These results support a mechanism by which localized Ras activation mediates leading edge formation through activation of basal PI3K present on the plasma membrane and other Ras effectors required for chemotaxis. A feedback loop, mediated through localized F-actin polymerization, recruits cytosolic PI3K to the leading edge to amplify the signal.

Actins↗
PubMed2004

Voltage imaging from dendrites of mitral cells: EPSP attenuation and spike trigger zones.

To obtain a more complete description of individual neurons, it is necessary to complement the electrical patch pipette measurements with technologies that permit a massive parallel recording from many sites on neuronal processes. This can be achieved by using voltage imaging with intracellular dyes. With this approach, we investigated the functional structure of a mitral cell, the principal output neuron in the rat olfactory bulb. The most significant finding concerns the characteristics of EPSPs at the synaptic sites and surprisingly small attenuation along the trunk of the primary dendrite. Also, the experiments were performed to determine the number, location, and stability of spike trigger zones, the excitability of terminal dendritic branches, and the pattern and nature of spike initiation and propagation in the primary and secondary dendrites. The results show that optical data can be used to deduce the amplitude and shape of the EPSPs evoked by olfactory nerve stimulation at the site of origin (glomerular tuft) and to determine its attenuation along the entire length of the primary dendrite. This attenuation corresponds to an unusually large mean apparent "length constant" of the primary dendrite. Furthermore, the images of spike trigger zones showed that an action potential can be initiated in three different compartments of the mitral cell: the soma-axon region, the primary dendrite trunk, and the terminal dendritic tuft, which appears to be fully excitable. Finally, secondary dendrites clearly support the active propagation of action potentials.

Action Potentials↗
PubMed1995

Teaching communication skills: part of medical education?

Hypertension is generally a symptomless disease, but it needs lifelong treatment in most cases. This places enormous demands on individual doctors treating individual patients. Communication under these circumstances should be a skillful blend of patient education (for example about lifestyle, other risk factors, reasons for treatment) coupled with the development of a strong personal interest in, and relationship with, the patient in order to motivate that patient to follow advice and therapy. Communication skills in medicine are learnt slowly and often only by experience. Medical school deans are under enormous pressure to add extra items into an already crowded curriculum, and so education in communication tends to have a low priority. Before a school can take such interest in educating students in communication it first has to take an interest in the education of its teachers. Rather belatedly, medical schools are now taking such an interest. Previously academic promotion depended mainly on research publications and public profile and little on an assessment of an ability to teach. Increasingly both undergraduate and postgraduate teaching is now subject to assessment from those taught, and universities are now making formal assessments of their teachers' ability in communication. In Oxford all newly appointed teachers are asked to appear before a panel, give a short 10-15 min communication and to listen to criticism of their technique. Video filming of their performance is a valuable feedback in getting lecturers to see their own faults and to help improve their techniques. It is very important to begin such training not only at lecturer level but also at student level.(ABSTRACT TRUNCATED AT 250 WORDS)

Communication↗
PubMed2007

Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills.

BACKGROUND: Teaching of technical surgical skills to undergraduate medical students in a laboratory setting away from the patient is not common practice. Because of the large volume of students and shortage of available teaching faculty new methods of teaching must be developed for this group of trainees. In this study we examined the effectiveness of computer-based video training, different types of computer-based motion efficiency feedback (with and without expert criteria), and expert feedback on learning of a basic technical skill in medical students. METHODS: Forty-five junior medical students were randomized into 3 groups and learned suturing and knot-tying skills. Group A received computer-generated feedback about the economy of their movements. Group B received the same motion economy feedback, as well as expert reference values. Group C received verbal feedback from an expert. All groups were pre-tested, allowed 18 practice trials, and post-tested, and their skill retention was retested after 1 month. Performance was assessed by expert analysis using an objective structured analysis of technical skill and by computer analysis (Imperial College Surgical Assessment Device [ICSAD]). RESULTS: All groups showed improvement from pre-test to post-test. However, only group C showed retention of skill on delayed performance testing. CONCLUSIONS: Verbal feedback from an expert instructor led to lasting improvements in technical skills performance. Providing information about motion efficiency did not lead to similar improvements.

Biofeedback, Psychology↗
PubMed1998

Can GPs audit their ability to detect psychological distress? One approach and some unresolved issues.

BACKGROUND: General practitioners (GPs) should be able to detect psychological distress in their patients. However, there is much evidence of underperformance in this area. The principle of clinical audit is the identification of underperformance and amelioration of its causes, but there appear to be few evaluated models of audit in this area of clinical practice. AIM: To evaluate the feasibility of auditing GPs' performance as detectors of psychological distress. Specific objectives were to test a model of the audit cycle in the detection of psychological distress by GPs; to research GP perceptions of prior audit activity in this area and the validity of the instruments used to measure GP performance; and to research GP perceptions of the value of this specific approach to the audit of their performance and the particular value of different aspects of the model in terms of its impact on clinician behaviour. METHOD: Prospective controlled study of an audit cycle of GP detection of psychological distress. Nineteen GP principals used a self-directed educational intervention involving measurement of their performance, followed by data feedback and review of selected videotaped consultations. Qualitative data on GP views of audit in this area of clinical activity were collected before and after the quantitative data collection. RESULTS: The study shows that the GP cohort had not previously considered auditing their performance as detectors of psychological distress. They found the instruments of measurement and the model of audit acceptable. However, they also suggested modifications that might be educationally more effective and make the audit more practical. These included smaller patient numbers and more peer contact. The implications of the study for a definitive model of audit in this area are discussed. CONCLUSION: Effective audit of GP performance in detection of psychological distress is possible using validated instruments, and GP performance can be improved by educational intervention. GPs in this study appear more motivated by individual case studies and reflection through video analysis on undiagnosed patients than by quantitative data feedback on their performance. This study therefore supports other evidence that clinical audit has most impact when quantitative data is coupled with clinical examples derived from patient review.

Clinical Competence↗
PubMed2002

Changing an existing OSCE to a teaching tool: the making of a teaching OSCE.

OBJECTIVE: The teaching OSCE (objective structured clinical examination) was developed from existing OSCE materials to provide direct observation and feedback to students on their doctor-patient relationship skills, students' abilities to do a focused history and physical examination, and to familiarize students with this type of examination. DESCRIPTION: Existing OSCE cases were modified to ten minutes and to focus on case scenarios using standardized patients. Faculty facilitators were trained in giving feedback and oriented to the new OSCE format. Clerkship students are told in advance the general topics of the Teaching OSCE stations, so they can prepare. Students are divided in three groups of six to eight students and each group is assigned a faculty facilitator. Each student performs a ten-minute OSCE station and is observed directly by the faculty facilitator and the remaining students in the group using a video monitor. The faculty facilitator then leads a 12-minute feedback session on focused history-taking skills, physical examination skills, and the doctor-patient relationship skills. Students selected at random by the faculty facilitator also give feedback to their peer. Teaching OSCEs take three hours and are held twice during the clerkship such that each student is actively observed twice and watches a total of ten to 14 additional interactions. Facilitators grade students on attendance, participation, and evidence of preparation. The actual interaction with the standardized patient is used entirely for formative purposes and is not graded. DISCUSSION: Our department has used OSCEs for six years to evaluate students at the end of the third-year family medicine clerkship. Even after continuous improvement, our OSCE did not meet higher standards of reliability and would need at least three hours of testing per student to meet those standards. The low number of students in the rotation and limited resources to increase the duration of the OSCE made it very difficult to construct a more reliable examination. At the same time, both faculty and students wanted more direct observation and feedback on performance with clinical scenarios. Using existing OSCE resources to change the OSCE to a teaching tool proved to be an efficient use of teaching resources while increasing our educational impact. Students report that they appreciate the opportunity to have constructive discussions of their strengths and weaknesses in clinical encounters, observe a variety of doctor-patient interaction styles, and practice for future OSCE-type examinations. Faculty members enjoy this active teaching format and find the process of students giving feedback to their peers educationally useful. The teaching OSCE has been extremely well rated in the end-of-rotation evaluations and will be continued in future clerkships.

Education, Medical, Undergraduate↗
PubMed2001

Understanding and optimizing laparoscopic videosystems.

As tactile feedback and degree of freedom for instrument movement are restricted in laparoscopic surgery, the video image plays the most crucial role in giving the surgeon information about the performance of the operation. The development of small, reliable, high-resolution imaging systems is essential for the surgeon's acquisition detailed information about the tissues being manipulated. Image quality depends on each component of the laparoscopic imaging unit. In this context, it is crucial for the surgeon to have an understanding of how the video signal is formed, transmitted, and displayed. Moreover, the surgeon also needs to have an idea about the basic principles and specifications of the surgical video systems (i.e. charge-coupled device (CCD) camera, monitors, and digitizers). This knowledge is essential for choosing pieces of equipment and knowing how to assemble them into a functional operating suite. The aim of this review is to provide the surgeon with the basics of video signaling, and to familiarize him or her with the technical principles of the surgical video systems. An insight into the future of laparoscopic video systems also is made, and practical tips for improving image quality and troubleshooting are given throughout the article.

Calibration↗
PubMed2002

Temporal capacity of short-term visuomotor memory in continuous force production.

The focus of this article is on the temporal capacity of short-term visuomotor memory as reflected by changes in the time and frequency patterns of force output. In experiment 1, subjects produced continuous force output (isometric index finger flexion) to a target force level (from 5 to 75% of maximum voluntary contraction, MVC) displayed on a video monitor for 20 s. In the full visual feedback condition, visual feedback was displayed throughout each trial, while, for the visual feedback-withdrawal condition, visual feedback was occluded for the final 12 s of each trial. With visual feedback present, subjects matched their force output to the target force level for 20 s. When visual feedback was removed, participants continued to match the target force level for approximately 0.5-1.5 s; thereafter force output decayed exponentially. In line with this decay, short time-frequency analysis revealed a decrease in force intensity in the 0- to 5-Hz band. Force level did not influence the time before decay; however, greater forces led to larger decay. Experiment 2 assessed whether the force decay in experiment 1 was a property of visual or motor short-term memory by having participants set their own target force levels with no visual information provided throughout. In agreement with the findings of experiment 1, force output decayed, emphasizing the importance of a motor memory source. It is concluded that the 0.5- to 1.5-s time period represents a limit on the temporal capacity that precise visuomotor information is held in short-term memory.

Adult↗
PubMedDate not supplied

Randomized trial of a tailored nutrition education CD-ROM program for women receiving food assistance.

OBJECTIVE: This article describes the development and randomized evaluation of a tailored nutrition education CD-ROM program for participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in North Carolina. DESIGN: After randomization to intervention or control groups, participants completed a baseline survey and were resurveyed immediately after program use and 1 to 2 months postintervention. SETTING: Two WIC clinics in central North Carolina. PARTICIPANTS: A total of 307 respondents to the follow-up survey (response rate 74.8%) comprised the study sample. Participants were female (96%), 20% were pregnant, and 50% were minorities (African American and other). INTERVENTION: The interactive CD-ROM consisted of a targeted video soap opera, dietary assessment, and individually tailored dietary feedback and strategies for change. MAIN OUTCOME MEASURES: Measures included total fat and fruit and vegetable intake, knowledge of low-fat and infant feeding choices, self-efficacy, and stages of change. ANALYSIS: Descriptive statistics assessed baseline comparability of study groups; analysis of covariance and F tests were used to assess program effects at follow-up. RESULTS: INTERVENTION group members increased self-efficacy (P <.01) and scored significantly higher (P <.05) on both low-fat and infant feeding knowledge compared with controls. No differential effect was observed for dietary intake variables. CONCLUSIONS AND IMPLICATIONS: The findings suggest that one dose of an interactive CD-ROM program can impact mediators of dietary change but may be insufficient to change behavior.

Adult↗
PubMed1989

Reducing spasticity to control muscle contracture of children with cerebral palsy.

A biofeedback training technique to control spasticity, previously successful with adults with cerebral palsy, was adapted for three children with spastic diplegia at risk for contractures. Visual feedback of muscle stretch reflex sensitivity is provided by video games, which are played by reducing reflex sensitivity. After a 10-week training period two of the three children had significantly reduced spasticity in the gastrocnemius muscle. The technique can be used with children as young as four years, is inexpensive, and can be carried out by parents with supervision by a physiotherapist.

Biofeedback, Psychology↗
PubMed2005

Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home.

OBJECTIVE: Quality improvement (QI) processes in nursing homes are highly variable and often ineffective. This study evaluated an innovative QI process to reduce pressure ulcers (PUs) in a nursing home with a high rate of PUs. DESIGN: This was a 48-week, longitudinal study comparing the incidence of PUs during 12-week baseline and intervention and post-intervention periods. SETTING: Not-for-profit, 136-bed nursing home in urban Western Pennsylvania. PATIENTS OR OTHER PARTICIPANTS: All residents and all staff at the nursing home participated in this study. INTERVENTIONS: The intervention consisted of 3 components: Ability enhancement, incentivization, and management feedback. To enhance ability, all staff members completed a computer-based interactive video education program on PU prevention and were mandated to use penlights to promote early detection. Incentivization included $75 for each staff member if the desired reduction in PU incidence was achieved. Management feedback provided real-time information of staff"s adherence to the mandated training. MAIN OUTCOME MEASURES: Outcome measures consisted of staff's adherence to mandated training and the incidence of new PUs during the baseline period compared to the intervention and post-intervention periods. RESULTS: Management responded to noncompliance with training with both rewards and stepped discipline. Adherence to protocol, as measured by training compliance, was 100%. There was a significant reduction (P < .05) in the incidence of stage 2 or worse PUs during the intervention period. During the post-intervention periods, the effect was lost. CONCLUSION: An innovative QI initiative resulted in a significant decrease in PUs in 1 facility. This intervention was not sustainable when the 3 components of the QI intervention were no longer actively maintained.

Aged↗
PubMed2005

Incorporating problem-based learning and video technology in teaching group process in an occupational therapy curriculum.

This paper describes an innovative, cost-effective method for teaching group dynamics in an occupational therapy curriculum. The revised "Models of Group Dynamics" course incorporated problem-based learning (PBL) sessions and video technology. In this single-semester course, the class of 24 students was divided into small groups of five to seven students. Each group participated in six hours of PBL sessions and six hours of observation. PBL; effectively served as the instructional methodology to stimulate group dynamics because it demands that the students engage in the group process by creating an open structure for discussion, negotiating goals, and building team consensus in the group. The PBL experience facilitated the integration of the various content areas of the curriculum by expecting the student to apply previous learning to the construction of a therapeutic treatment plan. Through the use of a closed-circuit video monitor, students in the observation group analyzed group process skills in real time without interruption. This format provided the opportunity for students to generate feedback responses about group process with faculty guidance. The use of a closed-circuit video monitor was a low-cost, effective tool that facilitated the learning process. Measures of student learning indicated that the new course design was effective in meeting course objectives. Measures of the effectiveness of the new course design included focus groups conducted in two time periods: after completion of the course and after completion of fieldwork. The results demonstrated that the course had continuing impact on group skills carried into the fieldwork experience.

Attitude of Health Personnel↗