Richard L. George

The Relationship Between Confidence and Competence in the Development of Surgical Skills

BACKGROUNDnConfidence is a crucial trait of any physician, but its development and relationship to proficiency are still unknown. This study aimed to evaluate the relationship between confidence and competency of medical students undergoing basic surgical skills training.nnnMETHODSnMedical students completed confidence surveys before and after participating in an introductory workshop across 2 samples. Performance was assessed via video recordings and compared with pretraining and posttraining confidence levels.nnnRESULTSnOverall, 150 students completed the workshop over 2 years and were evaluated for competency. Most students (88%) reported improved confidence after training. Younger medical students exhibited lower pretraining confidence scores but were just as likely to achieve competence after training. There was no association between pretraining confidence and competence, but confidence was associated with demonstrated competence after training (p < 0.001).nnnCONCLUSIONSnMost students reported improved confidence after a surgical skills workshop. Confidence was associated with competency only after training. Future training should investigate this relationship on nonnovice samples and identify training methods that can capitalize on these findings.

In situ simulation to assess workplace attitudes and effectiveness in a new facility.

Introduction In situ simulation within new facilities holds the promise of identifying latent safety threats. The aim of this study was to identify if in situ simulation can also impact important employee perceptions and attitudes. Methods In the current study, health care professionals of an adult, urban, community teaching hospital level 1 trauma center participated in simulated scenarios in a new emergency department. Before and after the simulated scenarios, participants provided responses to the variables regarding their ability to work in the new facility and other work-related variables. Results Significant increases in communication (P = 0.05), facility clinical readiness (P < 0.05), self-efficacy (P < 0.01), trauma readiness (P < 0.01), and work space satisfaction (P < 0.05) were found from presimulation to postsimulation. The results also demonstrated a significant decrease from presimulation to postsimulation with performance beliefs (P < 0.001). Finally, cardiac readiness did not reveal a significant change from presimulation to postsimulation. Discussion In situ simulation exercises before practicing clinically in a new facility can both increase familiarity with new clinical environments and impact important organizational outcomes. Thus, simulation in a new work space can influence factors important to employees, organizations, and patients.

Trajectories of daily PTSD symptoms in recent traumatic injury victims.

OBJECTIVEnPrior research has identified different PTSD symptom (PTSS) trajectories over months and years posttrauma that warrant different levels of clinical attention. Earlier identification of at-risk trauma victims can facilitate efficient and appropriate intervention efforts.nnnMETHODnUsing latent class growth analysis, we examined daily PTSS trajectories beginning 6 weeks postinjury in 68 injury victims. Resulting classes were compared on key characteristics at 6 and 21 weeks postinjury.nnnRESULTSnThree trajectories were identified: a nonreactive class (67.8%) with low initial symptom levels that remained low, a moderate-stable class (27.9%) with elevated symptom levels that remained constant, and a severe-increasing class (4.4%) with high symptom levels that increased.nnnCONCLUSIONSnHigh-risk injury victims can be identified by their daily PTSS, allowing for early identification of those at risk for elevated distress and in greater need for intervention. (PsycINFO Database Record

The utility of hair cortisol concentrations in the prediction of PTSD symptoms following traumatic physical injury

RATIONALEnAlthough cortisol alterations have been associated with posttraumatic stress disorder (PTSD) and PTSD symptoms (PTSS), the direction of association is mixed. Cortisol which is measured in blood, saliva, or urine is subject to transient factors that may confound results. Recent advances in cortisol sampling techniques provide novel opportunities to address these inconsistencies. Hair cortisol sampling is a non-invasive method for the retrospective assessment of long-term integrated cortisol, yet its utility at predicting PTSS has not been assessed in acute injury victims.nnnOBJECTIVEnThe aim of this prospective study was to examine whether higher levels of hair cortisol concentrations (HCC) were associated with increases in PTSS following traumatic physical injury.nnnMETHODnFrom January 2012 to May 2013, injury victims admitted to a level-1 Midwestern trauma center were recruited during their routine trauma clinic appointment within 30-days post-injury. Thirty participants had sufficient hair length to obtain 3-cm hair samples for cortisol assay. These participants completed PTSS assessments in relation to their recent injury at both the baseline and follow-up assessments (within 30- and 60-days post-injury, respectively).nnnRESULTSnHierarchical regression analyses - which controlled for baseline PTSS, age, and sex - revealed that higher HCC predicted significant increases in overall PTSS at follow-up. Higher HCC also predicted increases in the avoidance/numbing subscale symptoms of PTSS. Dividing the avoidance symptoms and numbing symptoms into two separate clusters (consistent with the 4-factor DSM-5 model of PTSD) revealed that HCC was only marginally associated with numbing, but not with avoidance symptoms.nnnCONCLUSIONnHair sampling is a feasible method for assessing integrated cortisol levels soon after traumatic physical injury. This study suggests that elevated HCC may serve as a biomarker of risk for the development of posttraumatic symptomatology, and identifies specific symptoms that may be targeted for intervention in those with high HCC in the aftermath of injury.

Current challenges in dedifferentiated fat cells research

ABSTRACT Dedifferentiated fat cells show great promises as a novel cell source for stem cell research. It has many advantages when used for cell–based therapeutics including abundance, pluripotency, and safety. However, there are many obstacles researchers need to overcome to make the next big move in DFAT cells research. In this review, we summarize the current main challenges in DFAT cells research including cell culture purity, phenotypic properties, and dedifferentiation mechanisms. The common methods to produce DFAT cells as well as the cell purity issue during DFAT cell production have been introduced. Current approaches to improve DFAT cell purity have been discussed. The phenotypic profile of DFAT cells have been listed and compared with other stem cells. Further studies on elucidating the underlying dedifferentiation mechanisms will dramatically advance DFAT cell research.

Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study

Objectives. Management of mechanically ventilated patients may pose a challenge to novice residents, many of which may not have received formal dedicated critical care instruction prior to starting their residency training. There is a paucity of data regarding simulation and mechanical ventilation training in the medical education literature. The purpose of this study was to develop a curriculum to educate first-year residents on addressing and troubleshooting ventilator alarms. Methods. Prospective evaluation was conducted of seventeen residents undergoing a twelve-hour three-day curriculum. Residents were assessed using a predetermined critical action checklist for each case, as well as pre- and postcurriculum multiple-choice cognitive knowledge questionnaires and confidence surveys. Results. Significant improvements in cognitive knowledge, critical actions, and self-reported confidence were demonstrated. The mean change in test score from before to after intervention was +26.8%, and a median score increase of 25% was noted. The ARDS and the mucus plugging cases had statistically significant improvements in critical actions, p < 0.001. A mean increase in self-reported confidence was realized (1.55 to 3.64), p = 0.049. Conclusions. A three-day simulation curriculum for residents was effective in increasing competency, knowledge, and confidence with ventilator management.

Pediatric Trauma Boot Camp: A Simulation Curriculum and Pilot Study

Trauma is a leading cause of morbidity and mortality in infants and children worldwide. Trauma education is one of the most commonly reported deficiencies in pediatric emergency medicine (PEM) training. In this study, we describe the creation of a pediatric trauma boot camp in which trainees basic knowledge, level of confidence, teamwork, and communication skills are assessed. The primary goal of this pilot study was to create a simulation-based pediatric trauma curriculum for PEM fellows and emergency medicine residents utilizing Kerns curricular conceptual framework. This was a pilot, prospective, single cohort, exploratory, observational study utilizing survey methodology and a convenience sample. The curriculum consisted of a two-day experience that included confidence surveys, a cognitive multiple-choice questionnaire, and formative and summative simulation scenarios. At the conclusion of this intensive simulation-based trauma boot camp participants reported increased confidence and demonstrated significant improvement in the basic knowledge and performance of the management of pediatric trauma cases in a simulated environment.

The association between daily PTSD symptom severity and alcohol-related outcomes in recent traumatic injury victims

The self-medication hypothesis proposes that individuals experiencing posttraumatic stress disorder (PTSD) symptoms may use alcohol (or other substances) to self-medicate distress, while the mutual maintenance hypothesis proposes that alcohol use also exacerbates or maintains distress. Existing research largely supports the self-medication hypothesis. However, findings are often based upon retrospective reporting of problems and assessment of symptoms anchored to a trauma occurring in the remote past. To improve on these retrospective designs, the current study examined the relationship between daily PTSD symptom severity and alcohol-related outcomes during the early phase of recovery following a traumatic physical injury. Specifically, 36 injury victims reported on PTSD symptom severity, alcohol craving, alcohol consumption, and negative drinking consequences thrice daily (morning, afternoon, night) over 7 days beginning 6 weeks postinjury. Results indicated relationships between PTSD symptom severity and alcohol craving/negative consequences when these experiences were assessed concurrently within the same signal (particularly during the nighttime assessments). Prospective models found that nighttime PTSD symptom severity was related to negative drinking consequences occurring the following morning, even after controlling for consumption level, suggesting a more general behavioral regulation problem. Results were less supportive of the mutual maintenance hypothesis. Collectively, these results suggest that health interventions targeting PTSD symptom severity in recent injury victims—particularly when delivered at night—may be able to prevent problematic alcohol use.

Development, Validation, and Implementation of a Medical Judgment Metric:

Background: Medical decision making is a critical, yet understudied, aspect of medical education. Aims: To develop the Medical Judgment Metric (MJM), a numerical rubric to quantify good decisions in practice in simulated environments; and to obtain initial preliminary evidence of reliability and validity of the tool. Methods: The individual MJM items, domains, and sections of the MJM were built based on existing standardized frameworks. Content validity was determined by a convenient sample of eight experts. The MJM instrument was pilot tested in four medical simulations with a team of three medical raters assessing 40 participants with four levels of medical experience and skill. Results: Raters were highly consistent in their MJM scores in each scenario (intraclass correlation coefficient 0.965 to 0.987) as well as their evaluation of the expected patient outcome (Fleiss’s Kappa 0.791 to 0.906). For each simulation scenario, average rater cut-scores significantly predicted expected loss of life or stabilization (Cohen’s Kappa 0.851 to 0.880). Discussion: The MJM demonstrated preliminary evidence of reliability and validity.

Mechanical Ventilation Boot Camp Curriculum

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased morbidity and mortality. A three-day simulation-based boot camp serves to provide one-on-one instruction with a critical care provider. These intensivists may dispense personalized immediate feedback as learners engage in hands-on practice with a real mechanical ventilator. Multiple different pathologies can be reviewed that may not be encountered in the clinical setting. Learners can visualize immediate consequences of their actions and may troubleshoot and ask questions, all while in a safe learning environment. We describe the use of human-patient simulators connected to breathing simulators and mechanical ventilators. Potential curriculum executors should be aware of the cost of the equipment and the time needed to dedicate to boot camp execution; however, this intensive interactive training has been shown to increase provider competency, knowledge, and confidence in ventilator management. This curriculum outline provides guidance on how to execute a simulation-based boot camp to train providers on the management of mechanically ventilated patients.