Jason H. Szostek

Technology-Enhanced Simulation for Health Professions Education: A Systematic Review and Meta-analysis

CONTEXT Although technology-enhanced simulation has widespread appeal, its effectiveness remains uncertain. A comprehensive synthesis of evidence may inform the use of simulation in health professions education. OBJECTIVE To summarize the outcomes of technology-enhanced simulation training for health professions learners in comparison with no intervention. DATA SOURCE Systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. STUDY SELECTION Original research in any language evaluating simulation compared with no intervention for training practicing and student physicians, nurses, dentists, and other health care professionals. DATA EXTRACTION Reviewers working in duplicate evaluated quality and abstracted information on learners, instructional design (curricular integration, distributing training over multiple days, feedback, mastery learning, and repetitive practice), and outcomes. We coded skills (performance in a test setting) separately for time, process, and product measures, and similarly classified patient care behaviors. DATA SYNTHESIS From a pool of 10,903 articles, we identified 609 eligible studies enrolling 35,226 trainees. Of these, 137 were randomized studies, 67 were nonrandomized studies with 2 or more groups, and 405 used a single-group pretest-posttest design. We pooled effect sizes using random effects. Heterogeneity was large (I(2)>50%) in all main analyses. In comparison with no intervention, pooled effect sizes were 1.20 (95% CI, 1.04-1.35) for knowledge outcomes (n = 118 studies), 1.14 (95% CI, 1.03-1.25) for time skills (n = 210), 1.09 (95% CI, 1.03-1.16) for process skills (n = 426), 1.18 (95% CI, 0.98-1.37) for product skills (n = 54), 0.79 (95% CI, 0.47-1.10) for time behaviors (n = 20), 0.81 (95% CI, 0.66-0.96) for other behaviors (n = 50), and 0.50 (95% CI, 0.34-0.66) for direct effects on patients (n = 32). Subgroup analyses revealed no consistent statistically significant interactions between simulation training and instructional design features or study quality. CONCLUSION In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.

Comparative effectiveness of instructional design features in simulation-based education: Systematic review and meta-analysis

Background: Although technology-enhanced simulation is increasingly used in health professions education, features of effective simulation-based instructional design remain uncertain. Aims: Evaluate the effectiveness of instructional design features through a systematic review of studies comparing different simulation-based interventions. Methods: We systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, Scopus, key journals, and previous review bibliographies through May 2011. We included original research studies that compared one simulation intervention with another and involved health professions learners. Working in duplicate, we evaluated study quality and abstracted information on learners, outcomes, and instructional design features. We pooled results using random effects meta-analysis. Results: From a pool of 10 903 articles we identified 289 eligible studies enrolling 18 971 trainees, including 208 randomized trials. Inconsistency was usually large (I 2 > 50%). For skills outcomes, pooled effect sizes (positive numbers favoring the instructional design feature) were 0.68 for range of difficulty (20 studies; p < 0.001), 0.68 for repetitive practice (7 studies; p = 0.06), 0.66 for distributed practice (6 studies; p = 0.03), 0.65 for interactivity (89 studies; p < 0.001), 0.62 for multiple learning strategies (70 studies; p < 0.001), 0.52 for individualized learning (59 studies; p < 0.001), 0.45 for mastery learning (3 studies; p = 0.57), 0.44 for feedback (80 studies; p < 0.001), 0.34 for longer time (23 studies; p = 0.005), 0.20 for clinical variation (16 studies; p = 0.24), and −0.22 for group training (8 studies; p = 0.09). Conclusions: These results confirm quantitatively the effectiveness of several instructional design features in simulation-based education.

Cannabinoid hyperemesis: a case series of 98 patients.

OBJECTIVE To promote wider recognition and further understanding of cannabinoid hyperemesis (CH). PATIENTS AND METHODS We constructed a case series, the largest to date, of patients diagnosed with CH at our institution. Inclusion criteria were determined by reviewing all PubMed indexed journals with case reports and case series on CH. The institutions electronic medical record was searched from January 1, 2005, through June 15, 2010. Patients were included if there was a history of recurrent vomiting with no other explanation for symptoms and if cannabis use preceded symptom onset. Of 1571 patients identified, 98 patients (6%) met inclusion criteria. RESULTS All 98 patients were younger than 50 years of age. Among the 37 patients in whom duration of cannabis use was available, most (25 [68%]) reported using cannabis for more than 2 years before symptom onset, and 71 of 75 patients (95%) in whom frequency of use was available used cannabis more than once weekly. Eighty-four patients (86%) reported abdominal pain. The effect of hot water bathing was documented in 57 patients (58%), and 52 (91%) of these patients reported relief of symptoms with hot showers or baths. Follow-up was available in only 10 patients (10%). Of those 10, 7 (70%) stopped using cannabis and 6 of these 7 (86%) noted complete resolution of their symptoms. CONCLUSION Cannabinoid hyperemesis should be considered in younger patients with long-term cannabis use and recurrent nausea, vomiting, and abdominal pain. On the basis of our findings in this large series of patients, we propose major and supportive criteria for the diagnosis of CH.

Comparative effectiveness of technology-enhanced simulation versus other instructional methods: a systematic review and meta-analysis.

Abstract To determine the comparative effectiveness of technology-enhanced simulation, we summarized the results of studies comparing technology-enhanced simulation training with nonsimulation instruction for health professions learners. We systematically searched databases including MEDLINE, Embase, and Scopus through May 2011 for relevant articles. Working in duplicate, we abstracted information on instructional design, outcomes, and study quality. From 10,903 candidate articles, we identified 92 eligible studies. In random-effects meta-analysis, pooled effect sizes (positive numbers favoring simulation) were as follows: satisfaction outcomes, 0.59 (95% confidence interval, 0.36–0.81; n = 20 studies); knowledge, 0.30 (0.16–0.43; n = 42); time measure of skills, 0.33 (0.00–0.66; n = 14); process measure of skills, 0.38 (0.24–0.52; n = 51); product measure of skills, 0.66 (0.30–1.02; n = 11); time measure of behavior, 0.56 (−0.07 to 1.18; n = 7); process measure of behavior, 0.77 (−0.13 to 1.66; n = 11); and patient effects, 0.36 (−0.06 to 0.78; n = 9). For 5 studies reporting comparative costs, simulation was more expensive and more effective. In summary, in comparison with other instruction, technology-enhanced simulation is associated with small to moderate positive effects.

Simulation training for breast and pelvic physical examination: a systematic review and meta-analysis

Breast and pelvic examinations are challenging intimate examinations. Technology‐based simulation may help to overcome these challenges.

Validation of a method for measuring medical students' critical reflections on professionalism in gross anatomy

Improving professional attitudes and behaviors requires critical self reflection. Research on reflection is necessary to understand professionalism among medical students. The aims of this prospective validation study at the Mayo Medical School and Cleveland Clinic Lerner College of Medicine were: (1) to develop and validate a new instrument for measuring reflection on professionalism, and (2) determine whether learner variables are associated with reflection on the gross anatomy experience. An instrument for assessing reflections on gross anatomy, which was comprised of 12 items structured on five‐point scales, was developed. Factor analysis revealed a three‐dimensional model including low reflection (four items), moderate reflection (five items), and high reflection (three items). Item mean scores ranged from 3.05 to 4.50. The overall mean for all 12 items was 3.91 (SD = 0.52). Internal consistency reliability (Cronbachs α) was satisfactory for individual factors and overall (Factor 1 α = 0.78; Factor 2 α = 0.69; Factor 3 α = 0.70; Overall α = 0.75). Simple linear regression analysis indicated that reflection scores were negatively associated with teamwork peer scores (P = 0.018). The authors report the first validated measurement of medical student reflection on professionalism in gross anatomy. Critical reflection is a recognized component of professionalism and may be important for behavior change. This instrument may be used in future research on professionalism among medical students. Anat Sci Educ 6: 232–238.

Measuring Faculty Reflection on Adverse Patient Events: Development and Initial Validation of a Case-Based Learning System

ABSTRACTBACKGROUNDCritical reflection by faculty physicians on adverse patient events is important for changing physician’s behaviors. However, there is little research regarding physician reflection on quality improvement (QI).OBJECTIVETo develop and validate a computerized case-based learning system (CBLS) to measure faculty physicians’ reflections on adverse patient events.DESIGNProspective validation study.PARTICIPANTSStaff physicians in the Department of Medicine at Mayo Clinic Rochester.MAIN MEASURESThe CBLS was developed by Mayo Clinic information technology, medical education, and QI specialists. The reflection questionnaire, adapted from a previously validated instrument, contained eight items structured on five-point scales. Three cases, representing actual adverse events, were developed based on the most common error types: systems, medication, and diagnostic. In 2009, all Mayo Clinic hospital medicine, non-interventional cardiology, and pulmonary faculty were invited to participate. Faculty reviewed each case, determined the next management step, rated case generalizability and relevance, and completed the reflection questionnaire. Factor analysis and internal consistency reliability were calculated. Associations between reflection scores and characteristics of faculty and patient cases were determined.KEY RESULTSForty-four faculty completed 107 case reflections. The CBLS was rated as average to excellent in 95 of 104 (91.3%) completed satisfaction surveys. Factor analysis revealed two levels of reflection: Minimal and High. Internal consistency reliability was very good (overall Cronbach’s α = 0.77). Item mean scores ranged from 2.89 to 3.73 on a five-point scale. The overall reflection score was 3.41 (standard deviation 0.64). Reflection scores were positively associated with case generalizability (p = 0.001), and case relevance (p = 0.02).CONCLUSIONSThe CBLS is a valid method for stratifying faculty physicians’ levels of reflection on adverse patient events. Reflection scores are associated with case generalizability and relevance, indicating that reflection improves with pertinent patient encounters. We anticipate that this instrument will be useful in future research on QI among low versus high-reflecting physicians.

A Strategy to Reduce Interruptions at Hospital Morning Report

BACKGROUND The learning atmosphere of hospital morning report is frequently interrupted by nonurgent beeper pages to participating residents. INTERVENTION During 176 consecutive internal medicine morning reports, 1 of the 4 chief residents at a single academic medical center collected and answered house staff pages during the 30-minute conference. RESULTS A total of 884 pages were answered during this period. Of these, 743 could wait until after the end of morning report, resulting in more than 4 interruptions averted per session. Over half of the pages were from nursing personnel. There was no significant decrease in the total number of pages or nurse pages during the observation period. DISCUSSION In summary, our simple system of holding intern pages resulted in a dramatic reduction in interruptions during hospital morning report.

Update in General Internal Medicine: Evidence Published in 2016

Three general internists reviewed articles from the 2016 issues of 7 general internal medicine journals with high impact factors: New England Journal of Medicine, The Lancet, JAMA, BMJ, Annals of Internal Medicine, JAMA Internal Medicine, and PLoS Medicine. Two other internists identified articles by reviewing 2016 editions of ACP Journal Club, NEJM Journal Watch, Evidence Updates (now called Evidence Alerts), the BMJ database Evidence Based Medicine, and the Cochrane Database of Systematic Reviews. We used a modified Delphi method to select 8 studies on the basis of their clinical impact, relevance to everyday practice, strength of evidence, and breadth of application. The articles we selected compare strategies for smoking cessation, define when to use aspirin for primary prevention, offer guidelines for the management of patients receiving long-term opioids, determine whether acetaminophen is effective for treating low back pain, evaluate the role of oxygen in patients with chronic obstructive pulmonary disease (COPD), examine the association between proton-pump inhibitors (PPIs) and chronic kidney disease (CKD), assess how the route of estrogen replacement affects the risk for ischemic stroke in postmenopausal women, and compare the bleeding risks associated with different anticoagulants. Preventive Health Smokers Who Quit Abruptly Are More Likely to Achieve Abstinence Than Smokers Who Quit Gradually Lindson-Hawley N Banting M West R et al Gradual versus abrupt smoking cessation: a randomized, controlled noninferiority trial. Ann Intern Med 2016 164 585 92 26975007 Background: Some smokers who want to quit smoking prefer gradual reduction to abrupt cessation. Prior research comparing gradual reduction with abrupt cessation has yielded conflicting results. A 2012 Cochrane meta-analysis demonstrated no difference between cessation methods (1), whereas an observational study suggested that abrupt cessation was more effective than gradual reduction (2). Thus, whether smoking cessation through gradual reduction is as effective as abrupt cessation is unclear. This randomized, controlled study was done to determine whether abstinence rates achieved through gradual smoking reduction were noninferior to abstinence rates achieved through abrupt cessation at 4 weeks (the primary end point) and 6 months. Findings: Smokers in England (n= 697; mean age, 49 years; 50% male) were randomly assigned to quit smoking abruptly or to quit smoking gradually. The gradual cessation group reduced cigarette use by 50% by the end of 1 week and 75% by the end of 2 weeks, and then quit. Both groups used a 21-mg patch for nicotine replacement therapy. The gradual cessation group used patches before and after the quit date, whereas the abrupt cessation group used patches only after the quit date. Both groups received weekly behavioral support for 4 weeks after the quit date and then again at 8 weeks. At 4 weeks, 39% of the participants in the gradual cessation group and 49% in the abrupt cessation group were abstinent (relative risk, 0.80 [95% CI, 0.66 to 0.93]). At 6 months, 16% of the gradual cessation group and 22% of the abrupt cessation group were abstinent (relative risk, 0.71 [CI, 0.46 to 0.91]). Participants who were more interested in quitting abruptly at baseline were more likely to be abstinent at 4 weeks regardless of whether they had been assigned to the abrupt cessation group or the gradual cessation group. Cautions: The study was unblinded. Ninety-four percent of participants were white. The behavioral support that participants received may not be widely available and may be necessary to achieve these high quit rates. Implications: Clinicians can advise patients interested in smoking cessation that compared with quitting gradually, quitting abruptly is more likely to lead to abstinence at 4 weeks and 6 months. Low-Dose Aspirin Is Modestly Beneficial for Primary Prevention of Cardiovascular Events and Colorectal Cancer Bibbins-Domingo K; U.S. Preventive Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164:836-45. [PMID: 27064677] doi:10.7326/M16-0577 Bibbins-Domingo K U.S. Preventive Services Task Force Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force recommendation statement Ann Intern Med 2016 164 836 45 27064677 Background: Aspirin is beneficial for secondary prevention of cardiovascular disease, but its role in primary prevention of cardiovascular disease and colorectal cancer is uncertain. Findings: Three systematic reviews (35) by the U.S. Preventive Services Task Force (USPSTF) support the following recommendations. Aspirin is recommended for primary prevention in some people with a risk for cardiovascular disease exceeding 10% (6), average bleeding risk, a life expectancy of 10 years or more, and a willingness to take daily low-dose aspirin for at least 10 years. For people aged 50 to 59 years, the USPSTF recommends aspirin for the primary prevention of myocardial infarction, ischemic stroke, and colorectal cancer, because the moderate, combined benefit of preventing these conditions outweighs the small risk for bleeding. For people aged 60 to 69 years, the USPSTF recommends individualizing the decision to use aspirin for primary prevention of these conditions because the combined benefit outweighs the risk by a smaller amount. For people younger than 50 years and those aged 70 years or older, evidence is insufficient to support any recommendation for aspirin as primary prevention of cardiovascular disease, and thus there is no recommendation for aspirin as primary prevention of the combined conditions. In addition, the guidelines do not recommend using aspirin only for primary prevention of colorectal cancer. The systematic reviews showed that aspirin reduced nonfatal myocardial infarction by 22%, with no consistent reduction in nonfatal stroke (except for the Womens Health Study, which reported a 19% reduction in nonfatal stroke). The pooled estimates for mortality from cardiovascular disease and mortality from all other causes showed only minimal or no benefit from aspirin. The incidence of and mortality from colorectal cancer were similar in people who did and did not take aspirin for 10 or fewer years. In contrast, for people who took aspirin for more than 10 years, it reduced colorectal cancer incidence by 40%, and after 20 years, it reduced colorectal cancer mortality by 33%. Even with low doses, the risk for major gastrointestinal bleeding increased by 58%, but the absolute bleeding risk varied. Older age, male sex, use of concomitant medications, and a history of ulcers or gastrointestinal bleeding increased the risk for bleeding. Some studies also reported an increased risk for hemorrhagic stroke. Cautions: The optimal dose of aspirin is not known. The USPSTF supports the use of 81 mg/d, but trials have included dosages from 75 mg/d to 325 mg/d. Implications: The decision to use aspirin for the primary prevention of cardiovascular events and colorectal cancer is most beneficial in patients aged 50 to 59 years who have a 10% or greater risk for cardiovascular disease during the next 10 years. Aspirin seems to reduce the incidence of colorectal cancer after 10 years and to reduce mortality from colorectal cancer after 20 years, but its use is not recommended for the primary prevention of colorectal cancer alone because the benefits do not outweigh the harms. Treatment of Common Disorders in Internal Medicine CDC Provides Recommendations on Prescribing Opioids for Chronic Pain Not Secondary to Cancer, Palliation, or End-of-Life Care Dowell D Haegerich TM Chou R CDC Guideline for prescribing opioids for chronic painUnited States, 2016. JAMA 2016 315 1624 45 26977696 Background: Prescription opioid overdose led to more than 20000 deaths in 2015, and an additional 2.1 million Americans were addicted to these medications (7). Despite these problems, opioids continue to be widely prescribed to treat the estimated 25.3 million Americans with chronic pain (8). To address these issues, the Centers for Disease Control and Prevention (CDC) updated its 2014 systematic review and released guidelines for primary care clinicians to use when prescribing opioids to patients with chronic pain unrelated to cancer, palliation, or end-of-life care. Findings: The CDC recommends assessment of the following 3 areas: risk and benefit when opioids are being started or continued, short-term and long-term effectiveness to guide decisions about dose adjustment and discontinuation, and misuse and harm in combination with risk mitigation. The CDC released 12 recommendations. The primary recommendation is to treat chronic pain with nonopioid therapies. Opioids should be prescribed only when benefits exceed risks. Benefits and risks should be reassessed within days of starting opioids to ensure that pain and function have improved. If opioids are continued, risks and benefits should be reassessed at least every 3 months. Reassessments should include a review of records for all prescribers if the state has a comprehensive drug-monitoring program to identify additional sources of opioids and other drugs that might complicate opioid use. Only immediate-release opioids should be prescribed initially, prescribers should reassess benefits and risks before prescribing more than 50 morphine milligram equivalents per day, and they should avoid prescribing more than 90 morphine milligram equivalents per day. Prescribers should consider naloxone coprescriptions to treat overdose, and they should offer treatment when an opioid use disorder is identified. Cautions: These guidelines apply to primary care clinicians who are caring for patients with chronic pain that is not related to cancer, palliation, or end-of-life care. Implications: P

Validation of a clinical rotation evaluation for physician assistant students

BackgroundWe conducted a prospective validation study to develop a physician assistant (PA) clinical rotation evaluation (PACRE) instrument. The specific aims of this study were to 1) develop a tool to evaluate PA clinical rotations, and 2) explore associations between validated rotation evaluation scores and characteristics of the students and rotations.MethodsThe PACRE was administered to rotating PA students at our institution in 2016. Factor analysis, internal consistency reliability, and associations between PACRE scores and student or rotation characteristics were determined.ResultsOf 206 PACRE instruments sent, 124 were returned (60.2% response). Factor analysis supported a unidimensional model with a mean (SD) score of 4.31 (0.57) on a 5-point scale. Internal consistency reliability was excellent (Cronbach α=0.95). PACRE scores were associated with students’ gender (P = .01) and rotation specialty (P = .006) and correlated with students’ perception of being prepared (r = 0.32; P < .001) and value of the rotation (r = 0.57; P < .001).ConclusionsThis is the first validated instrument to evaluate PA rotation experiences. Application of the PACRE questionnaire could inform rotation directors about ways to improve clinical experiences. The findings of this study suggest that PA students must be adequately prepared to have a successful experience on their rotations. PA programs should consider offering transition courses like those offered in many medical schools to prepare their students for clinical experiences. Future research should explore whether additional rotation characteristics and educational outcomes are associated with PACRE scores.