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PubMed1987

An objective measure of clinical performance.

Studies repeatedly have shown the clinical performance of students and residents to be less than expected by faculty. Because evaluation methods substantially influence education, poor performance can be improved with better clinical evaluation methods. This study evaluated a standardized method to measure clinical performance in which trained actual and simulated patients were organized in a multiple-station format for efficient testing of examinees on 17 cases in less than four hours. Specific checklists completed by patients and predetermined scoring protocols yielded reliable data and reduced faculty time. Data from 204 students in three clerkships were consistent with previous research showing case specificity and substantial case-to-case variability. As a group however, the students' overall total scores were very similar. This suggests that clinical education is inconsistent and that a profile of an examinee's performance is more accurate than a single overall score. Validity of this standardized clinical examination was supported by significant but moderate correlations with faculty ratings of ward performance and the medicine subtest of the National Board of Medical Examiners test, part II. Direct per-student costs were $21.00. This standardized objective examination of clinical skills is feasible for use in training programs and will provide reliable and valid data on clinical performance not available through typical methods.

Clinical Competence↗

PubMed1998

New "horizontal" curriculum in family medicine residency.

PROBLEM ADDRESSED: Opportunities for residents in a family medicine program to experience continuity of care with a group of patients and to be immersed in the role of a family physician were thought by faculty to be insufficient. OBJECTIVES OF THE PROGRAM: To enhance residents' experience of continuity of care with a group of patients; to create a model for training that better simulates clinical practice; and to position core family medicine experiences as the central and continuing focus of the residency program. MAIN COMPONENTS OF THE PROGRAM: The new curriculum replaces block rotations in family medicine with "horizontal" experiences comprising 3 half-days of patient care and 1 half-day seminar each week for all residents through both years of the program. The remaining time in first year is spent on the major disciplines--medicine, pediatrics, emergency, and obstetrics--for which a horizontal family medicine-centred experience has also been introduced. The second-year curriculum is flexible and largely self-directed. Initial evaluations indicate improved continuity of care of family practice patients and broadened clinical exposure for residents. The program has been fully accredited by the College. CONCLUSIONS: A horizontal curriculum in family medicine, designed to address perceived deficiencies in the traditional block rotational model of training, can be developed and implemented in an urban teaching hospital.

Accreditation↗

PubMed2006

[The measurement of cutting forces in full crown preparation with three-dimensional transducer unit].

OBJECTIVE: To measure the cutting forces applied by clinicians during preparing full crown and to provide basic data for the training of dentistry in a virtual reality. METHODS: Each of six prosthodontists and six dental students prepared three extracted maxillary premolars. The cutting forces were measured with a three-dimensional transducer unit. Differences in cutting time and forces between groups were analyzed with independent-samples t-test. RESULTS: The cutting forces varied in the range from 0.10 N to 4.90 N. The average cutting force (1.71 N) of four axial surfaces was higher than that (0.45 N) of occlusal surface (including functional cusp inclines) (P < 0.01). The cutting time by prosthodontists was shorter than that by the students (P < 0.05). Moreover, the vertical component of the cutting force was higher than the horizontal one (P < 0.01). CONCLUSIONS: The magnitude of cutting forces could be greatly influenced by the motion direction and tendency of the handpiece. The data on cutting forces might serve as the foundation of cutting simulation algorithm for training in a virtual reality.

Adolescent↗

PubMed2003

Peer tutoring in patient-centred interviewing skills: experience of a project for first-year students.

Peer tutoring is a potentially valuable resource in higher education. There are few published accounts of the impact of peer tutoring in medical education. College-wide experience of peer tutoring together with difficulties recruiting medical teachers for a communication programme led to the development of a peer-tutoring project. This paper reports the impact on first-year medical students of peer tutoring in patient-centred interviewing. After attending a preparatory workshop, third-year medical students co-facilitated their first-year colleagues in a session:Interviewing a Simulated Patient. First-year students completed written evaluations immediately after the session and two months later randomly selected students were assessed in patient-centred interviews. The impact of the peer-tutoring experience was evaluated by comparing these outcomes for students in groups co-facilitated by peer tutors with those who worked in groups facilitated by medical teachers. The eight learning objectives were completely met by more than 56% of students. However, there were statistically significant differences for four objectives with more students in groups facilitated by medical teachers completely meeting these objectives. Although the seven educational techniques used in the session were rated favourably by all students, two were rated as more effective in achieving the learning objectives by students in groups facilitated by medical teachers. Free-text comments revealed no differences between groups. Two months after the session, there were no differences between students in terms of interviewing skills as rated by trained observers and simulated patients, whilst simulated patients were more satisfied with interviews from students facilitated by peer tutors (p <0.02). Peer tutors can support the acquisition of basic patient-centred interviewing skills in first-year medical students when contributing to one session of a structured programme. First-year students were receptive and willing to learn from their senior colleagues.

Communication↗

PubMed1995

Prediction of protein folding class using global description of amino acid sequence.

We present a method for predicting protein folding class based on global protein chain description and a voting process. Selection of the best descriptors was achieved by a computer-simulated neural network trained on a data base consisting of 83 folding classes. Protein-chain descriptors include overall composition, transition, and distribution of amino acid attributes, such as relative hydrophobicity, predicted secondary structure, and predicted solvent exposure. Cross-validation testing was performed on 15 of the largest classes. The test shows that proteins were assigned to the correct class (correct positive prediction) with an average accuracy of 71.7%, whereas the inverse prediction of proteins as not belonging to a particular class (correct negative prediction) was 90-95% accurate. When tested on 254 structures used in this study, the top two predictions contained the correct class in 91% of the cases.

Amino Acid Sequence↗

PubMed1994

Physiology, morphology and detailed passive models of guinea-pig cerebellar Purkinje cells.

1. Purkinje cells (PCs) from guinea-pig cerebellar slices were physiologically characterized using intracellular techniques. Extracellular caesium ions were used to linearize the membrane properties of PCs near the resting potential. Under these conditions the average input resistance, RN, was 29 M omega, the average system time constant, tau 0, was 82 ms and the average cable length, LN, was 0.59. 2. Three PCs were fully reconstructed following physiological measurements and staining with horseradish peroxidase. Assuming that each spine has an area of 1 micron 2 and that the spine density over the spiny dendrites is ten spines per micrometre length, the total membrane area of each PC is approximately 150,000 microns 2, of which approximately 100,000 microns 2 is in the spines. 3. Detailed passive cable and compartmental models were built for each of the three reconstructed PCs. Computational methods were devised to incorporate globally the huge number of spines into these models. In all three cells the models predict that the specific membrane resistivity, Rm, of the soma is much lower than the dendritic Rm (approximately 500 and approximately 100,000 omega cm2 respectively). The specific membrane capacitance, Cm, is estimated to be 1.5-2 muF cm-2 and the specific cytoplasm resistivity, Ri, is 250 omega cm. 4. The average cable length of the dendrites according to the model is 0.13 lambda, suggesting that under caesium conditions PCs are electrically very compact. Brief somatic spikes, however, are expected to attenuate 30-fold when spreading passively into the dendritic terminals. A simulated 200 Hz train of fast, 90 mV somatic spikes produced a smooth 12 mV steady depolarization at the dendritic terminals. 5. A transient synaptic conductance increase, with a 1 nS peak at 0.5 ms and a driving force of 60 mV, is expected to produce approximately 20 mV peak depolarization at the spine head membrane. This EPSP then attenuates between 200- and 900-fold into the soma. Approximately 800 randomly distributed and synchronously activated spiny inputs are required to fire the soma. 6. The passive model of the PC predicts a poor resolution of the spatio-temporal pattern of the parallel fibre input. An equally sized, randomly distributed group of approximately 1% of the parallel fibres, activated within a time window of a few milliseconds, would result in approximately the same composite EPSP at the soma.

Animals↗

PubMed2005

Simulation for trauma and combat casualty care.

Training medical providers to care for traumatically injured patients is a difficult undertaking and currently used training strategies are often suboptimal. The further strains placed on trauma care in the military environment only add to the challenge. Simulation applications ranging from simple physical models to complex, computer-based virtual reality systems have either been developed or are being developed to help support and improve trauma care training. Several of these applications have been shown to be as good as or better than the standard training methods they are designed to replace. Simulators are available for training in the treatment of disorders of the airway, difficulty with breathing, and problems dealing with circulation as well as various non-life-threatening but disabling injuries. Some of these simulators have already drastically changed how the standard Advanced Trauma Life Support course is taught. Advances in both technology and application of simulators will continue to affect trauma skills training for the foreseeable future.

Journal Article↗

PubMed2005

Human patient simulation is effective for teaching paramedic students endotracheal intubation.

OBJECTIVES: The primary purpose of this study was to determine whether the endotracheal intubation (ETI) success rate is different among paramedic students trained on a human patient simulator versus on human subjects in the operating room (OR). METHODS: Paramedic students (n = 36) with no prior ETI training received identical didactic and mannequin teaching. After randomization, students were trained for ten hours on a patient simulator (SIM) or with 15 intubations on human subjects in the OR. All students then underwent a formalized test of 15 intubations in the OR. The primary outcome was the rate of successful intubation. Secondary outcomes were the success rate at first attempt and the complication rate. The study was powered to detect a 10% difference for the overall success rate (alpha = 0.05, beta = 0.20). RESULTS: The overall intubation success rate was 87.8% in the SIM group and 84.8% in the OR group (difference of 3.0% [95% confidence interval {CI} = -4.2% to 10.1%; p = 0.42]). The success rate on the first attempt was 84.4% in the SIM group and 80.0% in the OR group (difference of 4.4% [95% CI = -3.4% to 12.3%; p = 0.27]). The complication rate was 6.3% in the SIM group and 4.4% in the OR group (difference of 1.9% [95% CI = -2.9% to 6.6%; p = 0.44]). CONCLUSIONS: When tested in the OR, paramedic students who were trained in ETI on a simulator are as effective as students who trained on human subjects. The results support using simulators to teach ETI.

Adolescent↗

PubMed1994

[Surgical hysteroscopy: complications, safety aspects, education and training].

Hysteroscopy has become an integral part of the overall gynaecological surgical concept. On the one hand the experience of our study group as well as a literature survey have demonstrated that results of hysteroscopic metroplasty, resection of submucous myoma and synechiolysis are at least comparable to those of conventional procedures, the advantages of minimal invasive surgery being evident. However, increasing complications, even with a lethal outcome, due to deficient technical equipment or insufficient training of the surgeon are reported. Yet, a survey of complications in literature and in our own series of hysteroscopies (n = 200), shows a median complication rate below 1%. Knowledge of possible complications, symptoms and management alternatives is, however, a first requirement for application of these minimal access procedures. The second major precondition being a well structured training program for surgeon and assisting team. With the recently developed in-vitro-simulation trainer, the HysteroTrainer, training of the entire spectrum of hysteroscopic procedures, including laser and high frequency electrosurgical applications, is now feasible. The simulator may also be employed for security checking of the complex hysteroscopic equipment.

Equipment Safety↗

PubMed1999

Evaluation of laparoscopic skills: a 2-year follow-up during residency training.

OBJECTIVE: To evaluate laparoscopic technical skill in surgical residents over a 2-year period. DESIGN: The laparoscopic technical skills of general surgical residents were evaluated using the MISTELS program. This provides an objective evaluation of laparoscopic skill, taking into account precision and speed. SETTING: Inanimate laparoscopic skills centre. PARTICIPANTS: Ten general surgical residents (5 PGY1, 3 PGY2 and 2 PGY3 residents) who were required to complete 3 structured laparoscopic tasks. OUTCOME MEASURES: A composite score incorporating precision and timing was assigned to each task. The paired t-test was used to compare performance of each resident at the 2 levels of their residency training for each task. Linear regression analysis was used to correlated level of training and total score (sum of all tasks). RESULTS: Linear regression analysis demonstrated a highly significant correlation between level of training and total score (r = 0.82, p < 0.01). There was a significant increase in scores in the cutting and suturing task over the 2-year period (p < 0.01). Transferring skills did not improve significantly (p = 0.11). CONCLUSIONS: Performance in the simulator improved over residency training and was correlated highly with postgraduate year. This simulator model is a valuable teaching tool for training and evaluation of basic laparoscopic tasks in laparoscopic surgery.

Canada↗

PubMedDate not supplied

The pattern of response of the inferior colliculus of the cat during the movement of a sound source.

During the application of a train of clicks simulating the movement of a sound source, evoked potentials (EP) of the inferior colliculus gradually changed their amplitude and form ("the movement effect") in 82% of the instances tested. The expression of the ipsilateral movement effect was on the average 1.5 times greater than the contralateral. The movement effect was observed over a wide range of velocities; but, in 65% of the instances, the effect was observed at movement velocities not less than 3.5 rad/sec. Velocities higher than 6.8 rad/sec were most effective in 78% of the instances. Differences in responses were discovered in 26% of the instances involving opposite directions of sound source movement. The movement effect depended substantially upon the site of the EP sampling.

Animals↗

PubMedDate not supplied

Systemic responses in man exposed to different heating and cooling treatment in a sauna.

Finnish saunas are popular for alleviating psycho-emotional and physical stress. Regular visits to a sauna may promote three adaptive effects: a simulation of the training generally associated with sports activities, the building up of resistance to the effects of extreme exposures, and the regulation of autonomic functions. However, the effect that the sauna has on the physiological mechanisms of humans--particularly, the effect of contrast-cooling following thermal exposure--is still obscure. An example of contrast-cooling following thermal exposure is that caused by swimming after using a sauna; such contrast-cooling may be a risk factor for people with unstable blood pressure, and gradual cooling-off after using a sauna may be preferable. In this series, various autonomic functions under different heating and cooling treatment in a sauna were studied. The authors have concluded that the mode of exposures to heating and cooling under control of Heart Rate (HR) changes has, to a certain extent, a relaxing effect, and thus can be recommended for alleviating psycho-emotional stress.

Adult↗

PubMed2000

Skills evaluation in minimally invasive surgery using force/torque signatures.

BACKGROUND: One of the more difficult tasks in surgical education is to teach the optimal application of instrument forces and torques necessary to facilitate the conduct of an operation. For laparoscopic surgery, this type of training has traditionally taken place in the operating room, reducing operating room efficiency and potentially affecting the safe conduct of the operation. The objective of the current study was to measure and compare forces and torques (F/T) applied at the tool/hand interface generated during laparoscopic surgery by novice (NS) and experienced (ES) surgeons using an instrumented laparoscopic grasper and to use this data for evaluating the skill level. METHODS: Ten surgeons (five-NS, five-ES) performed a cholecystectomy and Nissen fundoplication in a porcine model. An instrumented laparoscopic grasper with interchangeable standard surgical tips equipped with a three-axis F/T sensor located at the proximal end of the grasper tube was used to measure the F/T at the hand/tool interface. In addition, one axis force sensor located at the grasper's handle was used to measure the grasping force. F/T data synchronized with visual view of the tool operative maneuvers were collected simultaneously via a novel graphic user interface incorporated picture-in-picture video technology. Subsequent frame-by-frame video analysis of the operation allowed a definition of states associated with different tool/tissue interactions within each step of the operation. F/T measured within each state were further analyzed using vector quantization (VQ). The VQ analysis defines characteristic sets of F/T in the database that were defined as F/T signature. RESULTS: The magnitude of F/T applied by NS and ES were significantly different (p < 0.05) and varied based on the task being performed. Higher F/T magnitudes were applied by NS than by ES when performing tissue manipulation, whereas lower F/T magnitudes were applied by NS than by ES during tissue dissection. Furthermore, the time to complete the surgical procedure was longer for NS by a factor of 1.5-4.8 when compared to the time for ES. State analysis suggests that most of this time is consumed in an [idle] state, in which movements of the surgeon make no tissue contact. CONCLUSIONS: Preliminary data suggest that F/T magnitudes associated with the tool/tissue interactions provide an objective means of distinguishing novices from skilled surgeons. Clinical F/T analysis using the proposed technology and methodology may be helpful in training, developing surgical simulators, and measuring technical proficiency during laparoscopic surgery.

Cholecystectomy, Laparoscopic↗

PubMed1977

Initial pelvic examination instruction: the effectiveness of three contemporary approaches.

Initial pelvic examination skills were taught to 38 second-year medical students who were assigned to one of three study groups. The cognitive posttest scores of all groups were nearly identical, but the students who had received training from professional simulated patients rated significantly better in psychomotor and interpersonal skills than did those who received simulated outpatient instruction by a gynecologist. Thirty-five per cent of the psychomotor and interpersonal ratings attained by the latter and 5 per cent of those attained by the former were marginal or inadequate. It was concluded that a program involving professional simulated patients is an effective method of teaching pelvic examination skills to beginning students.

Adult↗

PubMed1985

Evaluation of neuronal connectivity: sensitivity of cross-correlation.

Cross-correlation analysis of separable multi-unit activity is one of the most commonly used methods to investigate connectivity in neural networks. In the course of development of new analysis techniques which go beyond the study of pairs or triplets of neurons, the need arose for a simple yet versatile simulator to generate spike trains from networks of specified structure. The present paper describes such a simulator and presents some examples of its performance as analyzed by cross-correlation. We noted a distinct asymmetry in the sensitivity of cross-correlation for the presence of excitatory vs inhibitory connections. A theoretical analysis is given from which quantitative criteria for detectability were derived. It appears that indeed the sensitivity of cross-correlation for excitation is larger to an order of magnitude than it is for inhibition. Possible consequences of this finding are indicated, and the relation to commonly used methods to measure strength of interaction are discussed.

Action Potentials↗

PubMed1996

Computerized approach to active and objective quality control of patient care.

The paper describes a quality control program based on the principles of clinical methodology and indicators defined by physicians and hospital administrators according to general as well as local needs. The program is supported by a knowledge-based system which can be used in two ways: with on-line helps and hints to ensure effective and efficient medical decisions on a simulated patient for training purposes; and without facilities supporting the user to be used on an on-line setting for performance evaluation. The quality control program includes the evaluation of effectiveness and efficiency of patient care with respect to the overall process, single hypotheses and individual decisions: the evaluation regards the number and reliability of activated hypotheses, costs, time spent, number and appropriateness of investigations. The overall process is recursive, in that the results of each cycle are used by physicians to define new goals and indicants for the next cycle; quality control is active because physicians under evaluation are directly involved in the definition of goals and indicants and in the evaluation of results; evaluation is objective because indicants are predefined, and evaluation criteria are transparent.

Artificial Intelligence↗

PubMed1996

Information theoretic analysis of action potential trains. II. Analysis of correlation among n neurons to deduce connection structure.

We propose a cross-correlational method based on information theory, which produces a network connection structure to account for observed patterns of action potential activity in multi-unit recordings. Firing probabilities and conditional probabilities are estimated from the action potential trains of n neurons. Two-point mutual information (2pMI) and joint conditional mutual information (JCMI) are calculated by using the estimated probabilities, and then the n-point mutual information (npMI) is calculated. A significant peak of npMI indicates that each neuron is connected to all other neurons at specified time differences, either directly or indirectly. To distinguish between direct and indirect connection, the two-point m-joint conditional mutual information (2pJCMI) is calculated over the peak region for each pair of neurons. A minimum effective connection structure among the n neurons can be deduced in this manner. The procedure for deducing the connection structure for three- and n-neuron networks is described. We apply this method to action potential trains produced by simulated neural networks. Some limitations of the method are also discussed.

Action Potentials↗

PubMed1992

Dealing with verbal abuse: evaluation of the efficacy of a workshop for student nurses.

Verbal abuse is a problem that can confront all health care professionals in their day to day practice. Studies into abuse of professionals have emphasised the stressful effects of non-physical violence and have shown that it is often the most inexperienced members of various professions who are in the 'front line' of such attacks. The group of staff particularly at risk are student nurses (HSC 1987). This paper presents an evaluative study of a workshop devised to help student nurses to deal with verbal abuse (Wondrak 1989). Psychiatric nursing students were studied from two intakes into a training course. A simulated situation of an interview with a verbally abusive patient was video taped and assessment was made by independent raters of each subjects ability to deal with the situation. 14 of the subjects then attended a verbal abuse workshop and when re-tested, their ability to deal with abuse was compared with those 15 student nurses who did not attend a workshop. The findings are encouraging, indicating that there is a significant change in the experimental group on a number of variables, related to both practical and emotional aspects of dealing with abuse. Thus the efficacy of the short workshop in improving ability to deal with verbal abuse was demonstrated.

Adaptation, Psychological↗