Faizal Haji

Needs assessment for simulation training in neuroendoscopy: a Canadian national survey

OBJECT In recent years, dramatic changes in surgical education have increased interest in simulation-based training for complex surgical skills. This is particularly true for endoscopic third ventriculostomy (ETV), given the potential for serious intraoperative errors arising from surgical inexperience. However, prior to simulator development, a thorough assessment of training needs is essential to ensure development of educationally relevant platforms. The purpose of this study was to conduct a national needs assessment addressing specific goals of instruction, to guide development of simulation platforms, training curricula, and assessment metrics for ETV. METHODS Canadian neurosurgeons performing ETV were invited to participate in a structured online questionnaire regarding the procedural steps for ETV, the frequency and significance of intraoperative errors committed while learning the technique, and simulation training modules of greatest potential educational benefit. Descriptive data analysis was completed for both quantitative and qualitative responses. RESULTS Thirty-two (55.2%) of 58 surgeons completed the survey. All believed that virtual reality simulation training for ETV would be a valuable addition to clinical training. Selection of ventriculostomy site, navigation within the ventricles, and performance of the ventriculostomy ranked as the most important steps to simulate. Technically inadequate ventriculostomy and inappropriate fenestration site selection were ranked as the most frequent/significant errors. A standard ETV module was thought to be most beneficial for resident training. CONCLUSIONS To inform the development of a simulation-based training program for ETV, the authors have conducted a national needs assessment. The results provide valuable insight to inform key design elements necessary to construct an educationally relevant device and educational program.

What we call what we do affects how we do it: a new nomenclature for simulation research in medical education

Rapid technological advances and concern for patient safety have increased the focus on simulation as a pedagogical tool for educating health care providers. To date, simulation research scholarship has focused on two areas; evaluating instructional designs of simulation programs, and the integration of simulation into a broader educational context. However, these two categories of research currently exist under a single label—Simulation-Based Medical Education. In this paper we argue that introducing a more refined nomenclature within which to frame simulation research is necessary for researchers, to appropriately design research studies and describe their findings, and for end-point users (such as program directors and educators), to more appropriately understand and utilize this evidence.

Surgical activity of first-year canadian neurosurgical residents

INTRODUCTION Surgical activity is probably the most important component of surgical training. During the first year of surgical residency, there is an early opportunity for the development of surgical skills, before disparities between the skill sets of residents increase in future years. It is likely that surgical skill is related to operative volumes. There are no published guidelines that quantify the number of surgical cases required to achieve surgical competency. The aim of this study was to describe the current trends in surgical activity in a recent cohort of first-year Canadian neurosurgical trainees. METHODS This study utilized retrospective database review and survey methodology to describe the current state of surgical training for first-year neurosurgical trainees. A committee of five residents designed this survey in an effort to capture factors that may influence the operative activity of trainees. RESULTS Nine out of a cohort of 20 first-year Canadian neurosurgical trainees that began training in July of 2008 participated in the study. The median number of cases completed by a resident during the initial three month neurosurgical rotation was 66, within which the trainee was identified as the primary surgeon in 12 cases. Intracranial hemorrhage and cerebrospinal fluid diversion procedures were the most common operations to have the trainee as primary surgeon. CONCLUSION Based on this pilot study, it appears that the operative activity of Canadian first-year residents is at least equivalent to the residents of other studied training systems with respect to volume and diversity of surgical activity.

A crash course on serious games design and assessment: A case study

The use of serious games in a wide variety of educational settings is gaining popularity, given their ability to engage and motivate learners - particularly the current generation, who have grown up regularly playing video games. However, despite the current “buzz” surrounding serious games, there are many bad examples; this has been attributed to developers supplanting game design without adequate attention to proper instructional design. Given the importance of instructional design, we have developed a tutorial (“minicourse”) that, combines “hands-on” activities and didactic instruction to emphasizes its role in the development and evaluation of serious games. By outlining the developmental process of several example serious games for health professions education, the tutorial also emphasizes the inherent interdisciplinary nature of serious games design and potential issues that may arise when an interdisciplinary team embarks on such a project. Here, we describe the tutorial by providing greater details regarding the “hands-on” activities, the material covered within the tutorial, and attendee perceptions regarding serious games before and after the tutorial. Our goal is to bring awareness to the importance of ensuring a balance between game design and instructional design when developing serious games.

Needs Assessment for Incoming PGY-1 Residents in Neurosurgical Residency

BACKGROUND Residents must develop a diverse range of skills in order to practice neurosurgery safely and effectively. The purpose of this study was to identify the foundational skills required for neurosurgical trainees as they transition from medical school to residency. METHODS Based on the CanMEDS competency framework, a web-based survey was distributed to all Canadian academic neurosurgical centers, targeting incoming and current PGY-1 neurosurgical residents as well as program directors. Using Likert scale and free-text responses, respondents rated the importance of various cognitive (e.g. management of raised intracranial pressure), technical (e.g. performing a lumbar puncture) and behavioral skills (e.g. obtaining informed consent) required for a PGY-1 neurosurgical resident. RESULTS Of 52 individuals contacted, 38 responses were received. Of these, 10 were from program directors (71%), 11 from current PGY-1 residents (58%) and 17 from incoming PGY-1 residents (89%). Respondents emphasized operative skills such as proper sterile technique and patient positioning; clinical skills such as lesion localization and interpreting neuro-imaging; management skills for common scenarios such as raised intracranial pressure and status epilepticus; and technical skills such as lumbar puncture and external ventricular drain placement. Free text answers were concordant with the Likert scale results. DISCUSSION We surveyed Canadian neurosurgical program directors and PGY-1 residents to identify areas perceived as foundational to neurosurgical residency education and training. This information is valuable for evaluating the appropriateness of a training programs goals and objectives, as well as for generating a national educational curriculum for incoming PGY-1 residents.

Direct motor evoked potentials and cortical mapping using the NIM® nerve monitoring system: A technical note.

Motor evoked potentials (MEPs) are commonly used to prevent neurological injury when operating in close proximity to the motor cortex or corticospinal pathway. We report a novel application of the NIM® nerve monitoring system (Medtronic@ NIM response 3.0) for intraoperative direct cortical (dc)-MEPs monitoring. A 69-year-old female patient presented with a 4month history of progressive left hemiparesis resulting from a large right sided posterior frontal meningioma that abutted and compressed the motor cortex. Motor cortical mapping and MEPs were indicated. The patient was anesthetized and maintained on total intravenous anesthetics. Compound muscle action potentials (CMAP) of the right upper limb were monitored using the NIM system. After a craniotomy was performed, we first used the Ojemann stimulator (monopolar) for dc-stimulation and then switched to use the monopolar nerve stimulator probe of the NIM system. The CMAP response was successfully elicited using the NIM stimulating probe (pulse width=250s, train frequency=7pulses/s, current=20mA). A gross total resection of the tumor was achieved with intermittent cortical mapping of MEPs. There were no intraoperative complications and the patients motor function was preserved after the surgery. In this case, we reported the successful use of the NIM nerve monitoring system to elicit dc-MEPs under general anesthesia. The advantages of using this system include a simple set up and application, neurosurgeon familiarity, wide availability and lower cost. dc-MEPs can be achieved using the NIM system. We conclude that the NIM nerve monitoring system is a feasible alternative to standard neurophysiological monitoring systems.

The “Empty Chairs” Approach to Learning: Simulation-Based Train the Trainer Program in Mzuzu, Malawi

Together, a group of Canadian colleagues from St. Johns, Newfoundland, Calgary, Alberta (some via Doha) and London, Ontario introduced the first Train the Trainer in Simulation-Based Learning (TTT-SBL) program in Mzuzu Central Hospital and Mzuzu University in Malawi. The team led by Elaine Sigalet (Doha) and consisting of Ian Wishart (Calgary), Faizal Haji (London) and Adam Dubrowski (St. Johns) was invited to Malawi by Norman Lufesi to conduct a two-day TTT-SBL course for facilitators who teach an Emergency Triage, Assessment and Treatment (ETAT) plus Trauma course. The following technical report describes this course. All trainees-facilitators who took part in the first iteration of the TTT-SBL course were asked to participate in teaching an ETAT course and modify it to include elements of simulation. The new format of ETAT resulted in a reduction of time necessary to conduct the course from four days (based on historical data) to 2.5 days.

Board 343 - Research Abstract Development and Evaluation of a Contextually Relevant Measure of Cognitive Load for Simulation-Based Psychomotor Skills Training (Submission #951)

Introduction/Background Theoretically-based research exploring instructional design in healthcare simulation has emerged as a top priority.1–3 In turn, interest in cognitive load theory as a foundation for empirical investigation of instructional design principles in simulation has grown.1,4 An essential precursor to this line of inquiry is the development and evaluation of cognitive load (CL) measures that are appropriate for the healthcare simulation setting. To be effective, these measures should be unintrusive, sensitive to cognitive demands imposed by the simulated task and natural to the performer.5 The objectives of this study were to: 1) develop contextually relevant measures of CL based on secondary-task methodology and 2) generate preliminary validity evidence6 supporting their use in simulation-based psychomotor skills training. It was hypothesized that: 1) these measures of secondary-task performance would be sensitive to variations in CL within novices as cognitive demands change and between novices and experts when performing a psychomotor primary-task, and 2) similar patterns would be observed between experts and novices on subjective measures of cognitive load and primary-task performance. Methods . We developed a virtual vital signs monitor with a built-in visual stimulus detection secondary-task, in which participants monitor a baseline heart-rate and press a foot-pedal each time a pre-determined change (bradycardia or tachycardia) is observedThe software subsequently records two performance metrics: stimulus-detection error rate (SDER) and recognition reaction time (RRT)To evaluate the sensitivity of these metrics to variations in CL during simulation-based psychomotor skills training, five experts (surgical residents) and seven novices (medical students) completed a baseline stimulus-detection trial and a dual-task trial consisting of one-handed surgical knot tying on a part-task trainer, while monitoring for changes in heart-rateFollowing the dual-task trial, participants also completed a subjective rating of mental effort (SRME) using a previously developed scale.7 Primary-task (knot-tying) performance was assessed by total movements (TM) and time to complete (TC) a square knot.8 The first hypothesis was tested by analyzing differences in RRT and SDER from baseline to dual-task between experts and novices, using 2x2 repeated measures ANOVA and the Tukey test for post-hoc comparisonsThe second hypothesis was tested by analyzing differences between experts and novices SRME and on knot-tying performance, using the Kruskal-Wallis test and independent sample t-test respectively. Results . Analysis of secondary-task performance demonstrated a significant interaction between expertise (novice vsexpert) and task (single vsdual-task) for RRT (F(1,10)=9.947, p<0.01, partial eta2=0.89) and SDER (F(1,10)=81.133, p<0.0001, partial eta2=0.89)Pairwise comparisons revealed a significant increase in RRT and SDER from baseline to dual-task among novices (q=6.18, p<0.025 and q=16.45, p<0.01 respectively) but not among expertsIn addition, experts had significantly lower RRT and SDER compared to novices during dual-tasking (q=5.21, p<0.05 and q=14.88, p<0.01 respectively) but not at baselineSimilarly, compared to novices, experts had significantly lower dual-task SRME (chi2=5.316, p<0.021) and superior primary task performance with respect to TC (t=4.939, p<0.004), and TM (t=4.748, p<0.005). Conclusion We have developed an instrument for assessing CL that employs a contextually relevant secondary task (response to changes in vital signs). The measures generated from this instrument are sensitive to variations in CL among novices as cognitive demands change (i.e. single to dual-tasking) and between novices and experts performing a psychomotor skill. The difference in performance between novices and experts on these measures are similar to those seen on primary task performance (TC and TM) and subjective ratings of cognitive load, demonstrating preliminary validity evidence in the category of “response to other variables”6 for the two CL measures generated by our instrument (RRT and SDER). The Results indicate this instrument may be effective for measuring cognitive load during simulation-based psychomotor skills training of novice learners. References 1. Issenberg SB, Ringsted C, Østergaard D, Dieckmann P: Setting a Research Agenda for Simulation-Based Healthcare Education: Simulation in Healthcare 2011; 6(3):155–167. 2. Dieckmann P, Phero JC, Issenberg SB, Kardong-Edgren S, Østergaard D, Ringsted C: The first Research Consensus Summit of the Society for Simulation in Healthcare: conduction and a synthesis of the Results. Simulation in Healthcare 2011; 6(Suppl):S1–S9. 3. Cook DA, Hamstra SJ, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hatala R: Comparative effectiveness of instructional design features in simulation-based education: Systematic review and meta-analysis. Medical Teacher 2013; 35(1):e844–75. 4. van Merrienboer JJG, Sweller J: Cognitive load theory in health professional education: design principles and strategies. Medical Education 2010; 44(1):85–93. 5. Carswell C, Clarke D, Seales W: Assessing Mental Workload During Laparoscopic Surgery. Surgical Innovation 2005; 12(1):80–90. 6. Downing S: Validity - on the meaningful interpretation of assessment data. Medical Education 2003; 37:830–837. 7. Paas FG, Van Merriënboer JJG, Adam JJ: Measurement of cognitive load in instructional research. Perceptual and Motor Skills 1994; 79:419–430. 8. Xeroulis G, Park J, Moulton C, Reznick R, LeBlanc V, Dubrowski A: Teaching suturing and knot-tying skills to medical students: A randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback. Surgery 2007; 141(4):442–449. Disclosures Royal College of Physicians and Surgeons of Canada Fellowship for Studies in Medical Education L3 Communications, Montreal Quebec.

Board 166 - Program Innovations AbstractA Utilization Focused Evaluation of Simulation within the Emergency Triage Assessment and Treatment (ETAT) Program in Malawi (Submission #969)

Introduction/Background Malawi has among the highest pediatric mortality rates in the world, exceeding 120 deaths/1000 admissions in some hospitals.1,2 Fifty to eighty two percent of these deaths occur within 48 hours of admission2,3 and many are attributable to deficiencies in the care received by critically ill children, which may in part be due to inadequate health worker training.2 Recent introduction of educational programs, such as Emergency Triage Assessment and Treatment (ETAT) have reduced mortality by 10% at some centers.3 As ETAT incorporates elements of simulation, national interest in developing simulation training capacity has grown. At the request of the Malawi Ministry of Health (MMoH), members of the International Pediatric Simulation Society (IPSS) have evaluated ETAT, to delineate strengths and weaknesses in simulation pedagogy within the program, and identify opportunities and threats to the development of simulation-based education in the country. Methods An eight person multidisciplinary team of simulation experts from IPSS travelled to Malawi in May 2013 to conduct the evaluation. A utilization focused evaluation framework known as the Context, Input, Process, Product (CIPP)4 model was adopted to guide the process. For each CIPP element, multiple data sources were collected, including field notes and interviews with stakeholders completed during site visits to the MMoH, central and district hospitals, rural healthcare centers and both medical and nursing training colleges; direct observations of an ETAT course; and follow up interviews with faculty and participants. Borrowing on the SWOT (strengths, weaknesses, opportunities and threats) matrix,5 data were organized as drivers (strengths and opportunities) or barriers (weaknesses and threats). Our evaluation revealed that although simulation is incorporated as an educational tool within ETAT, it may be significantly underutilized. Evaluation of context identified primary drivers to be buy in from the MMoH for national scale-up of ETAT and support from faculty for revising the curriculum to align with simulation best practices. Barriers included high patient volumes and staff shortages, limiting time for faculty and participants to attend ETAT training. However, this was also identified as an opportunity to incorporate in-situ simulation into ETAT. The evaluation of input identified access to simulation materials (e.g. mannequins, animal models and patients for ‘clinical practice’) to meet educational needs as a driver. Conversely, the increasing number of trainees and limited number of trainers were identified as barriers. Drivers identified during process evaluation included passionate faculty keenly interested in developing their simulation skills, opportunities for interprofessional education and team training (given ETAT is delivered in an interdisciplinary fashion) and dedicated moments for simulation training within the course. Barriers included lack of faculty training in simulation pedagogy, resulting in limited scenario based training, no debriefing and failure to facilitate deliberate practice.6 Finally, product evaluation revealed that participants perceived ETAT training significantly improved their skills. However, severe clinical resource shortages, resulting in a mismatch between what participants are taught and what they can deliver was identified as a significant barrier to subsequent improvement in pediatric outcomes. Results: Conclusion Recent evidence suggests training health workers through educational programs incorporating simulation significantly impacts pediatric mortality, supporting arguments for capacity development of simulation in Malawi. Our evaluation reveals faculty development and enhancement of simulation pedagogy within ETAT are the most pressing needs in this regard. This may be facilitated through a ‘train the trainers’ program focused on best practices in simulation.7 We are currently developing such a program, with anticipated rollout in 2014. Subsequent evaluation of its impact on the delivery and effectiveness of future ETAT courses is planned. Once a highly trained cadre of simulation educators has been established, development of programs beyond ETAT (e.g. in-situ simulation in healthcare facilities) may be explored. However, in such low resource settings, educational content must be appropriately matched to the realities of clinical practice. References 1. You D, New JR, Wardlaw T: Levels & Trends in Child Mortality. New York, NY: United Nations Children’s Fund 2012; 1-32. Available at: http://www.childinfo.org/files/Child_Mortality_Report_2012.pdf. 2. Lufesi N: Assessment of Hospital Based Child Care Services in Malawi: Final Report. Malawi Ministry of Health Acute Respiratory Infections Control Program; 2010:1-42. 3. Robison JA, Ahmad ZP, Nosek CA, Durand C, Namathanga A, Milazi R, Thomas A, Soprano JV, Mwansambo C, Kazembe PN, Torrey SB: Decreased Pediatric Hospital Mortality After an Intervention to Improve Emergency Care in Lilongwe, Malawi. PEDIATRICS 2012; 130(3):e676-82. 4. Stufflebeam D: The CIPP model for program evaluation, Evaluation models: Viewpoints on educational and human services evaluation. Edited by Madaus G, Scriven M, Stufflebeam D. Boston, Kluwer-Nijhoff, 1983, pp 117-41. 5. Gordon J, Hazlett C, Cate Ten O, Mann K, Kilminster S, Prince K, O’Driscoll E, Snell L, Newble D: Strategic planning in medical education: enhancing the learning environment for students in clinical settings. Medical Education 2000; 34(10):841-850. 6. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB: Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence. Academic Medicine. 2011;86(6):706-711. 7. Dorman K, Derbew M, Henok F, Desalegn D, Dubrowski A, Satterthwaite L, Pittini R, Tajirian T, Kneebone R, Bello F, Byrne N: A Training Cascade for Interprofessional Surgical and Obstetrical Care in Ethiopia. In: 2012 Abstracts, Canadian Conference on Global Health 2012: 29. Disclosures Royal College of Physicians and Surgeons of Canada Fellowship for Studies in Medical Education

Simple partial seizures in a 70-year- old female.

History A 70 year-old female presented with a history of recurrent stereotyped “spells” over the past six years. She described involuntary horizontal saccadic eye movements as the initial event. This was followed by tonic deviation of her head to the left. There was intermittent jerking of her head to the left and quivering of her lower lip and jaw. There was no loss of awareness but it was difficult for her to speak during the spells which typically lasted three to four minutes. Her speech was slurred for a further five to ten minutes. The spells had recurred approximately twice a year until a recent increase in their frequency (four episodes in three months), prompting the patient to seek medical attention. She had a history of migraines, chronic obstructive lung disease, a 50 pack-year smoking history, and several remote minor surgeries including ureteral stenting, appendectomy, hemorrhoidectomy, and hysterectomy. She had been involved in two motor vehicle accidents, 28 years and 6 years earlier, with no recognized craniocerebral injury on either occasion. Her family history was not contributory.