Glenn Posner

Simulation-Based Education in Obstetrics and Gynaecology Training in Canada

Simulation is no longer the way of the future; it is the way of the now. As such, simulation-based education is becoming increasingly prevalent in medical and surgical training.1–4 Residents and residency program directors alike place value on simulation training and see a growing role for it in their respective learning and educating.5 The emphasis on the development of medical skills outside the operating room and away from the patient’s bedside has been motivated by various forces. Firstly, a steady reduction in resident duty hours has taken place in the past decade, and an overhaul of the 24-hour call shift is looming in Canada. Secondly, a decrease in operating time, which demands increased surgical efficiency, is a further stress on the operating room as a learning environment.6 Next, concerns regarding patient safety, in an increasingly litigious climate, have done away with the now archaic paradigm of “see one, do one, teach one.”7 This climate of increased patient safety has also led to a need for increased resident education in the intrinsic CanMEDS roles, as teamwork, leadership, health advocacy, professionalism, and communication skills are recognized as valuable skills. Lastly, as teaching centres care for increasingly complex patients, fewer routine cases become available for learners.6

Pelvic Examinations by Medical Trainees

SUMMARY Pelvic examination is an essential skill required by all medi-cal trainees, but its sensitive nature makes it challenging tolearn.Consentfor medical traineesto be involved in direct care ofexamining the patient should be obtained in all circum-stancesinclinics,labouranddeliveryareas,andsurgery,andfor procedures using anaesthesia and analgesia.As pelvic examination under anaesthesia is a component ofmost pelvic surgeries, consent for pelvic examination bymedical trainees is contained within consent for a surgicalprocedure.Verbal consent should be obtained for pelvic examinationsby medical trainees in clinics, labour and delivery areas, andemergency roomsMedical trainees should be appropriately chaperoned at alltimes to ensure the safety of the patient and the value of thelearning opportunity. REFERENCES 1. Hicks LK, Lin Y, Robertson DW, Robinson DL, and Woodrow SI.Understanding the clinical dilemmas that shape medical students’ ethicaldevelopment: questionnaire survey and focus group study. BMJ2001;322:709–10.2. Wall LL, Brown D. Ethical issues arising from the performance of pelvicexaminations by medical students on anesthetized patients. Am J ObstetGynecol 2004;190:319–23.3. Ubel PA, Jepson C, Silber-Isenstadt A. Don’t tell, don’t ask: a change inmedical student attitudes after obstetrics/gynecology clerkships towardsseeking consent for pelvic examinations on anesthetized patients. Am JObstet Gynecol 2003;188:575–9.4. American College of Obstetricians and Gynecologists. Statement of theACOG Committee on Ethics regarding ethical implications of pelvicexamination training. Available at: http://www.acog.org/from_home/publications/press_releases/nr04–25–03.cfm. Accessed February 20, 2006.5. Lawton FG, Redman WE, Luesley DM. Patient consent for gynaecologicalexamination. Br J Hosp Med 1990;44:326–9.6. Ubel PA, Silver-Isenstadt A. Are patients willing to participate in medicaleducation? J Clin Ethics 2000;11:230–5.7. Silver-Isenstadt A, Ubel PA. Erosion in medical students’ attitudes abouttelling patients they are students. J Gen Intern Med 1999;14:481–7.8. Bibby J, Boyd N, Redman CW, Luesley DM. Consent for vaginalexamination by students on anaesthetised patients. LancetNov12;2(8620):1150.9. Wilson RF. Unauthoized practice: teaching pelvic examination on womenunder anesthesia. JAMWA 2003;58:217–20.10. Magrane D, Gannon J, Miller CT. Student doctors and women in labor:attitudes and expectations. Obstet Gynecol 1996;88:298–302.11. O’Flynn N, Rymer J. Consent for teaching: the experience of womenattending a gynaecology clinic. MedEduc 2003; 37:1109–14Pelvic Examinations by Medical TraineesAPRIL

Too much small talk? Medical students' pelvic examination skills falter with pleasant patients

The competent performance of a female pelvic examination requires both technical proficiency and superlative communication skills. However, the ideal medium with which to assess these skills remains to be elucidated. Part‐task trainers (PTTs) offer an effective and affordable means of testing technical skills, but may not allow students to demonstrate their communication skills. Hybrids involving standardised patients (SPs) (SP–PTT) offer a more realistic assessment of communication, but students may feel awkward when examining the female genitalia.

Managing Expectations of Surgical Training: A National Perspective on Gynaecologic Endoscopy Practice

OBJECTIVE To determine if the opinion of obstetrics and gynaecology postgraduate trainees differs from practising gynaecologists with respect to the expected endoscopic surgical skill set of a general gynaecologist upon graduation from residency. METHODS An electronic survey was designed, validated, and pre-tested. It was sent to 775 Canadian obstetrics and gynaecology residents, fellows, and practising physicians through the Society of Obstetricians and Gynaecologists of Canadas electronic mailing list. Survey respondents were asked their opinion on the level of training (no extra post-residency training vs. fellowship) required to perform various endoscopic procedures. RESULTS We received 301 responses (39% response rate). Obstetrics and gynaecology trainees and practising physicians agreed on the training and skill level necessary to perform many endoscopic procedures. However, there were significant differences of opinion among trainees and practising physicians regarding advanced endoscopic procedures such as laparoscopic hysterectomy, cystotomy and enterotomy repair, and appendectomy. More trainees felt that a general gynaecologist without additional post-residency surgical training should be competent to perform such procedures, while practising physicians felt fellowship training was necessary. CONCLUSION Our survey highlights the different expectations of learners versus those in practice with regard to skills required to perform certain endoscopic procedures, particularly laparoscopic hysterectomy. Trainees who responded believed that after graduation from residency any obstetrician-gynaecologist should be able to perform more advanced endoscopic procedures, but practising physicians did not agree. This discordance between learners and practising colleagues highlights an important educational challenge in obstetrics and gynaecology surgical training. Greater clarification of what is expected of our training programs would be beneficial for both residents and training programs.

The Physician as Chameleon: The Hidden Role of the Resident Physician

As the Royal College gears up for the release of the 2015 update to the CanMEDS roles,1 I have been thinking about a competency that our residents struggle to master each and every day—the physician as chameleon. How often do we hear our trainees inquire, “how would you like me to . . . ?” when faced with a routine task in the operating room or the case room? Many of us have different routines for dealing with term pre-labour rupture of membranes, cervical ripening, fascial closure, uterine second layer, achieving pneumoperitoneum at laparoscopy, etc. . . . the list is endless. Beyond simple mastery of our specialty, residents are tasked with memorizing our preferences so that they can impress us by pretending to be mini-versions of us. I remember one of my own mentors being mortified when he assisted me with a Caesarean section after I graduated. I asked for polysorb to close the fascia—“but you usually close with PDS [polydioxanone sutures]!” he exclaimed. “No,” I clarified, “you close with PDS and I closed with PDS when I operated with you. I close with polysorb.”

The quandary of the sacred vagina: exploring the value of gynaecological teaching associates.

In 1997, at the Montreal General Hospital, I performed my first pelvic examination on a gynaecological teaching associate (GTA). ‘My ovary is the size of an almond’, she said, ‘a little over to the left’. Awkward and hurried, with a group of students behind me in line, this was my introduction to the pelvic examination. I certainly appreciated the opportunity she presented, but I still did not want to cause her discomfort. Despite valuing the guidance a live patient was able to provide, to this day I feel as though I was unable to fully learn the nuances of the sensitive examination because I felt rushed and nervous.

Foundational Elements of Applied Simulation Theory: Development and Implementation of a Longitudinal Simulation Educator Curriculum

Simulation-based education has gained popularity, yet many faculty members feel inadequately prepared to teach using this technique. Fellowship training in medical education exists, but there is little information regarding simulation or formal educational programs therein. In our institution, simulation fellowships were offered by individual clinical departments. We recognized the need for a formal curriculum in educational theory. Kern’s approach to curriculum development was used to develop, implement, and evaluate the Foundational Elements of Applied Simulation Theory (FEAST) curriculum. Needs assessments resulted in a 26-topic curriculum; each biweekly session built upon the previous. Components essential to success included setting goals and objectives for each interactive session and having dedicated faculty, collaborative leadership and administrative support for the curriculum. Evaluation data was collated and analyzed annually via anonymous feedback surveys, focus groups, and retrospective pre-post self-assessment questionnaires. Data collected from 32 fellows over five years of implementation showed that the curriculum improved knowledge, challenged thinking, and was excellent preparation for a career in simulation-based medical education. Themes arising from focus groups demonstrated that participants valued faculty expertise and the structure, practicality, and content of the curriculum. We present a longitudinal simulation educator curriculum that adheres to a well-described framework of curriculum development. Program evaluation shows that FEAST has increased participant knowledge in key areas relevant to simulation-based education and that the curriculum has been successful in meeting the needs of novice simulation educators. Insights and practice points are offered for educators wishing to implement a similar curriculum in their institution.

Remote solutions for telementoring point-of-care ultrasound echocardiography: The RESOLUTE study

To the Editor, Point-of-care ultrasound (POCUS), which has revolutionised patient assessment, traditionally relies on the availability of a skilled operator to acquire and interpret images. Although the relevant declarative knowledge needed to perform POCUS is generally available (e.g., medical literature, web-based videos), teaching the required psychomotor skills is challenging without the physical presence of an instructor. Telementoring is a novel, evolving technology in medical education that permits remote instruction of a skill through videoconferencing. We sought to demonstrate that the psychomotor skills required to perform cardiac POCUS can be acquired through telementoring. After institutional ethics review approval (REB 2016081401H), 33 intensive care unit nurses with no previous sonography training were recruited. Participants interacted with a high-fidelity transthoracic echocardiography simulator (VIMEDIX; CAE Healthcare, Ville St-Laurent, QC, Canada) connected via REACTS video conferencing software to a remotely located instructor (R.C.). Following a video-conferenced instructional period, each participant was remotely guided to obtain five standard POCUS views. The simulator was then randomized to one of four pre-set pathologies (anterior myocardial infarction, cardiac tamponade, dilated cardiomyopathy, ventricular fibrillation). The instructor then remotely guided the participant to obtain the views required to diagnose the underlying pathology. Both the subject and instructor were blinded to the pathology. To facilitate psychomotor instruction, two web cameras provided vantage points for the instructor to assess the probe’s position. Instruction of cardinal movements was simplified by colour-coding the probe. Additionally, we utilized the feature of REACTS software that allows the instructor to overlay a pointer (red dot) on the live-feed to direct probe placement on the mannequin (Figure). The instructional period needed to orient participants took a mean (SD) of 142 (40) sec, and the time required to obtain the five standardized POCUS images was 324 (116) sec. The remote instructor subsequently required 84 (49) sec to guide the participants through a focused POCUS examination and obtain a diagnosis of the underlying preset pathology. The acquired loops were subsequently reviewed by two experts (S.M., B.H.) who rated them using a previously validated scale for assessing POCUS image quality. Using the rapid assessment of competence in echocardiography score, both reviewers judged that more than 90% of the echo loops were of sufficient quality for basic image interpretation (scores were C 3), and each correctly identified 32 of 33 cardiac pathologies. We acknowledge that this simulator study has limitations, but we believe that the demonstration that psychomotor skills can be telementored has important E. K. H. Choo, MD (&) R. Chen, MD D. T. T. Tran, MD B. Sohmer, MD Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada e-mail: choo.eugene@gmail.com

Simulation in the clinical setting: towards a standard lexicon

Simulation-based educational activities are happening in the clinical environment but are not all uniform in terms of their objectives, delivery, or outputs. While these activities all provide an opportunity for individual and team training, nuances in the location, timing, notification, and participants impact the potential outcomes of these sessions and objectives achieved. In light of this, there are actually many different types of simulation-based activity that occur in the clinical environment, which has previously all been grouped together as “in situ” simulation. However, what truly defines in situ simulation is how the clinical environment responds in its’ natural state, including the personnel, equipment, and systems responsible for care in that environment. Beyond individual and team skill sets, there are threats to patient safety or quality patient care that result from challenges with equipment, processes, or system breakdowns. These have been labeled “latent safety threats.” We submit that the opportunity for discovery of latent safety threats is what defines in situ simulation and truly differentiates it from what would be more rightfully called “on-site” simulation. The distinction between the two is highlighted in this article, as well as some of the various sub-types of in situ simulation.

Doctors Behaving Badly and the Tyranny of Peer Pressure.

Far too frequently, a colleague or superior may say something inappropriate in the operating room while a patient is anaesthetized. Remaining silent is akin to condoning the behaviour, and often we may even find ourselves getting in on the joke. As medical professionals, we must curb this behaviour, which is disrespectful of our patients, harmful to our trainees, and derogatory towards our colleagues. Our first action must be to accept that this is a real problem; this should be followed by constructive support through education about our current behaviour. Leaders in the OR must speak up, and all staff members in the OR should be made to feel that they can express their concerns without retribution.