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1.  Objective structured assessment of technical competence in transthoracic echocardiography: a validity study in a standardised setting 
BMC Medical Education  2013;13:47.
Competence in transthoracic echocardiography (TTE) is unrelated to traditional measures of TTE competence, such as duration of training and number of examinations performed. This study aims to explore aspects of validity of an instrument for structured assessment of echocardiographic technical skills.
The study included 45 physicians with three different clinical levels of echocardiography competence who all scanned the same healthy male following national guidelines. An expert in echocardiography (OG) evaluated all the recorded, de-identified TTE images blindly using the developed instrument for assessment of TTE technical skills. The instrument consisted of both a global rating scale and a procedure specific checklist. Two scores were calculated for each examination: A global rating score and a total checklist score. OG rated ten examinations twice for intra-rater reliability, and another expert rated the same ten examinations for inter-rater reliability. A small pilot study was then performed with focus on content validity. This pilot study included nine physicians who scanned three patients with different pathologies as well as different technical difficulties.
Validity of the TTE technical skills assessment instrument was supported by a significant correlation found between level of expertise and both the global score (Spearman 0.76, p<0.0001) and the checklist score (Spearman 0.74, p<0.001). Both scores were able to distinguish between the three levels of competence that were represented in the physician group. Reliability was supported by acceptable inter- and intra-rater values. The pilot study showed a tendency to improved scores with increasing expertise levels, suggesting that the instrument could also be used when pathologies were present.
We designed and developed a structured assessment instrument of echocardiographic technical skills that showed evidence of validity in terms of high correlations between test scores on a normal person and the level of physician competence, as well as acceptable inter- and intra-rater reliability scores. Further studies should, however, be performed to determine the adequate number of assessments needed to ensure high content validity and reliability in a clinical setting.
PMCID: PMC3621521  PMID: 23537204
Transthoracic echocardiography; Echocardiography; Assessment; Ultrasound; Global rating; Checklist
2.  Using Crash Data to Develop Simulator Scenarios for Assessing Novice Driver Performance 
Teenage drivers are at their highest crash risk in their first 6 months or first 1,000 mi of driving. Driver training, adult-supervised practice driving, and other interventions are aimed at improving driving performance in novice drivers. Previous driver training programs have enumerated thousands of scenarios, with each scenario requiring one or more skills. Although there is general agreement about the broad set of skills needed to become a competent driver, there is no consensus set of scenarios and skills to assess whether novice drivers are likely to crash or to assess the effects of novice driver training programs on the likelihood of a crash. The authors propose that a much narrower, common set of scenarios can be used to focus on the high-risk crashes of young drivers. Until recently, it was not possible to identify the detailed set of scenarios that were specific to high-risk crashes. However, an integration of police crash reports from previous research, a number of critical simulator studies, and a nationally representative database of serious teen crashes (the National Motor Vehicle Crash Causation Survey) now make identification of these scenarios possible. In this paper, the authors propose this novel approach and discuss how to create a common set of simulated scenarios and skills to assess novice driver performance and the effects of training and interventions as they relate to high-risk crashes.
PMCID: PMC3610562  PMID: 23543947
3.  Assessment of cardiac pathology by point-of-care ultrasonography performed by a novice examiner is comparable to the gold standard 
The aim of the study was to compare the diagnostic accuracy of point-of-care cardiac ultrasonography performed by a novice examiner against results from a specialist in cardiology with expert skills in echocardiography, with regard to the assessment of six clinically relevant cardiac conditions in a population of ward patients from the Department of Cardiology or the Department of Cardiothoracic Surgery.
Cardiac ultrasonography was performed by a novice examiner at the bedside and images were interpreted in a point-of-care context with dichotomous outcomes (yes/no). Six outcome categories were defined: 1) pericardial effusion (≥10 mm), 2) left ventricular dilatation (≥62 mm), 3) right ventricular dilatation (≥42 mm or ≥ left ventricular diameter), 4) left ventricular hypertrophy (≥13 mm), 5) left ventricular failure (EF ≤ 40%), 6) aortic stenosis (maximum flow velocity ≥3 m/s). The examiner was blinded to the patients’ medical history and results from previous echocardiographic examinations. Results from the interpreted point-of-care ultrasonography examination were compared with echocardiographic diagnosis made by a specialist in cardiology.
A total of 102 medical and surgical patients were included. Assessments were made in six categories totalling 612 assessments. There was agreement between the novice examiner and the specialist in 95.6% of the cases; overall sensitivity was 0.91 and specificity was 0.97. Positive predictive value was 0.92 and negative predictive value was 0.97. Kappa statistics showed good agreement between observers (κ=0.88).
This study showed that a novice examiner was able to detect common and significant heart pathology in six different categories with good accuracy using POC ultrasonography.
PMCID: PMC3866928  PMID: 24330752
Point-of-care; Ultrasonography; Echocardiography; Bedside; Heart disease
4.  Assessing the Importance Given by Basketball Coaches to Training Contents 
Journal of Human Kinetics  2011;30:123-133.
The purpose of this study was to compare the importance given by novice, intermediate and experienced basketball coaches to training contents. To achieve this purpose, a sample composed of Portuguese basketball coaches (n = 212) described how they rate the importance of technical, tactical, physical and drill contents. According to the results, there is a wide-ranging differential from novice to experienced coaches. First, while experienced coaches tend to focus on tactical development, novice and intermediate coaches seem to privilege the improvement of technical skills. Second, whereas significant differences between novice and intermediate coaches were found, evidence confirmed that they were higher (both in number and weight) when comparing experienced coaches against novice and intermediate. The study provided strong support to justify the necessity to adjust coaches’ knowledge to players’ biological developmental, and could form the basis of focused interventions in coaching development.
PMCID: PMC3588642  PMID: 23486837
knowledge; coaching; assessment; experience
5.  Virtual Reality Uterine Resectoscopic Simulator: Face and Construct Validation and Comparative Evaluation in an Educational Environment 
This pilot study suggests that virtual reality resectoscopic systems have the potential to measure and improve the technical skills of novices before they operate on human patients.
Background and Objectives:
Recognizing that resectoscopic simulation may have an educational role, this pilot study was designed to evaluate the face validity and educational utility of a virtual reality uterine resectoscope training system.
A pilot prospective comparative study of novice and expert hysteroscopists' performance on a targeting exercise and myomectomy with the virtual loop electrode. At baseline, expert and novice resectoscopists each performed both exercises. Following instruction, novices practiced each exercise a total of 9 times with the 10th recorded as the training outcome. Results were compared both to baseline and to those of the experts. Data were analyzed with the paired t and Wilcoxon rank sum tests as appropriate.
At baseline, all experts touched 4 targets in a mean of 33 seconds with no perforations, compared to a mean of 2 for the 11 novices in a mean of 57 seconds (P=0.0034) with one perforation. In 3 minutes, the experts removed a mean of 97.3% of the virtual myoma, compared to 66.1% for the novices (P=0.0153). On the 10th “run,” novices touched a mean of 4 targets in a mean of 23 seconds, an improvement from baseline (P=0.0004) and improved to 89% on the myoma resection exercise (P=0.0515) 36.3% over baseline.
Although this pilot study has a relatively small sample size and represents the results at one institution, it demonstrates that virtual reality resectoscopic systems have the potential to measure and improve the technical skills of novices before they operate on human patients.
PMCID: PMC3148859  PMID: 21902963
Resectoscope; Hysteroscope; Virtual reality; Simulator
6.  Perk Station – Percutaneous Surgery Training and Performance Measurement Platform 
Image-guided percutaneous (through the skin) needle-based surgery has become part of routine clinical practice in performing procedures such as biopsies, injections and therapeutic implants. A novice physician typically performs needle interventions under the supervision of a senior physician; a slow and inherently subjective training process that lacks objective, quantitative assessment of the surgical skill and performance[S1]. Shortening the learning curve and increasing procedural consistency are important factors in assuring high-quality medical care.
This paper describes a laboratory validation system, called Perk Station, for standardized training and performance measurement under different assistance techniques for needle-based surgical guidance systems. The initial goal of the Perk Station is to assess and compare different techniques: 2D image overlay, biplane laser guide, laser protractor and conventional freehand. The main focus of this manuscript is the planning and guidance software system developed on the 3D Slicer platform, a free, open source software package designed for visualization and analysis of medical image data.
The prototype Perk Station has been successfully developed, the associated needle insertion phantoms were built, and the graphical user interface was fully implemented. The system was inaugurated in undergraduate teaching and a wide array of outreach activities. Initial results, experiences, ongoing activities and future plans are reported.
PMCID: PMC2817987  PMID: 19539446
Image Guidance; Needle Placement; Augmented Reality; Surgical Training
7.  Anesthesiology Residents-as-Teachers Program: A Pilot Study 
The role of residents as teachers has grown over time. Programs have been established within various specialties to formally develop these skills. Anesthesiology residents are frequently asked to provide supervision for novice learners and have numerous opportunities for teaching skills and clinical decision making. Yet, there are no educational programs described in the literature to train anesthesiology residents to teach novice learners.
To explore whether a resident-as-teacher program would increase anesthesiology residents' self-reported teaching skills.
An 8-session interactive Anesthesiology Residents-as-Teachers (ART) Program was developed to emphasize 6 key teaching skills. During a 2-year period, 14 anesthesiology residents attended the ART program. The primary outcome measure was resident self-assessment of their teaching skills across 14 teaching domains, before and 6 months after the ART program. Residents also evaluated the workshops for quality with a 9-item, postworkshop survey. Paired t testing was used for analysis.
Resident self-assessment led to a mean increase in teaching skills of 1.04 in a 5-point Likert scale (P < .001). Residents reported the greatest improvement in writing/using teaching objectives (+1.29, P < .001), teaching at the bedside (+1.57, P  =  .002), and leading case discussions (+1.64, P  =  .001). Residents rated the workshops 4.2 out of 5 (3.9–4.7).
Residents rated their teaching skills as significantly improved in 13 of 14 teaching domains after participation in the ART program. The educational program required few resources and was rated highly by residents.
PMCID: PMC3546586  PMID: 24294434
8.  Can the feedback of patient assessments, brief training, or their combination, improve the interpersonal skills of primary care physicians? A systematic review 
Improving quality of primary care is a key focus of international health policy. Current quality improvement efforts place a large focus on technical, clinical aspects of quality, but a comprehensive approach to quality improvement should also include interpersonal care. Two methods of improving the quality of interpersonal care in primary care have been proposed. One involves the feedback of patient assessments of interpersonal care to physicians, and the other involves brief training and education programmes. This study therefore reviewed the efficacy of (i) feedback of real patient assessments of interpersonal care skills, (ii) brief training focused on the improvement of interpersonal care (iii) interventions combining both (i) and (ii)
Systematic review of randomised controlled trials. Three electronic databases were searched (CENTRAL, Medline and Embase) and augmented by searches of the bibliographies of retrieved articles. The quality of studies was appraised and results summarised in narrative form.
Nine studies were included (two patient based feedback studies and seven brief training studies). Of the two feedback studies, one reported a significant positive effect. Only one training study reported a significant positive effect.
There is limited evidence concerning the effects of patient based feedback. There is reasonable evidence that brief training as currently delivered is not effective, although the evidence is not definitive, due to the small number of trials and the variation in the training methods and goals. The lack of effectiveness of these methods may reflect a number of issues, such as differences in the effectiveness of the interventions in experienced practitioners and those in training, the lack of theory linking feedback to behaviour change, failure to provide sufficient training or to use a comprehensive range of behaviour change techniques. Further research into both feedback and brief training interventions is required before these interventions are routinely introduced to improve patient satisfaction with interpersonal care in primary care. The interventions to be tested in future research should consider using insights from the wider literature on communication outside primary care, might benefit from a clearer theoretical basis, and should examine the use of combined brief training and feedback.
PMCID: PMC2542366  PMID: 18715516
9.  Eye Movement Patterns for Novice Teen Drivers Does 6 Months of Driving Experience Make a Difference? 
Attention to the road is essential to safe driving, but the development of appropriate eye glance scanning behaviors may require substantial driving experience. Novice teen drivers may focus almost exclusively on the road ahead rather than scanning the mirrors, and when performing secondary tasks, they may spend more time with eyes on the task than on the road. This paper examines the extent to which the scanning of novice teens improves with experience. For this study, 18 novice teen (younger than 17.5 years old) and 18 experienced adult drivers performed a set of in-vehicle tasks and a baseline driving segment on a test track, the teens within 4 weeks of licensure and then again 6 months later. This paper addresses the following questions: Did teen eye glance performance improve from initial assessment? Did teens and adults still differ after 6 months? Results for some tasks showed that rearview and left mirror–window (LM-W) glances improved for teens from initial testing to the 6-month follow-up and that some differences between teens and adults at initial testing were no longer significant at the 6-month follow-up, suggesting significant learning effects. The frequency of rearview and LM-W glances during secondary tasks improved among teens at the 6-month follow-up, but teens still had significantly fewer glances to mirrors than did adults when engaged in a secondary task.
PMCID: PMC2744974  PMID: 19763225
10.  A model for teaching bedside detection of glass in wounds 
Emergency Medicine Journal : EMJ  2007;24(6):413-416.
Emergency physicians often manage wounds contaminated with glass. Even when glass is visible on x rays, removal may require real‐time bedside imaging.
To assess whether novices can be easily trained to accurately detect tiny glass foreign bodies (GFBs) using low‐power portable fluoroscopy.
21 medical students with no prior experience using fluoroscopy were taught to detect 1 mm GFBs in chicken legs either by training over three separate days or by training on 1 day. Skills were reassessed at 3 months. The number of mean correct responses was compared between groups using analysis of variance (ANOVA) and by examination of 95% CIs.
Examination of CI overlap and ANOVA suggested that asymptotic accuracy was achieved after 15–30 training specimens. The final accuracy was similar between protocols, was comparable to prior accuracy reports of plain film radiography and was maintained in both protocols at the 3 month follow‐up: 10.9 (0.3) and 12.0 (0.8; out of 15).
Novices can easily be taught to detect GFBs using fluoroscopy, with accuracy comparable to that achieved by radiologists using plain films. Further studies are needed to assess doctors' use of the technique in real patients.
PMCID: PMC2658276  PMID: 17513538
11.  Microteaching, an efficient technique for learning effective teaching 
Microteaching, a teacher training technique currently practiced worldwide, provides teachers an opportunity to perk up their teaching skills by improving the various simple tasks called teaching skills. With the proven success among the novice and seniors, microteaching helps to promote real-time teaching experiences. The core skills of microteaching such as presentation and reinforcement skills help the novice teachers to learn the art of teaching at ease and to the maximum extent. The impact of this technique has been widely seen in various forms of education such as health sciences, life sciences, and other areas. The emerging changes in medical curricula by the Medical Council of India and the role of medical teachers envisage the need of this special training of teachers and monitoring of their skills for their continued efficient performance at any age. The alleged limitations of microteaching can be minimized by implementing this at the departmental level in several sequences. The author made literature search of research and review articles in various educational databases, journals, and books. From the reference list of published articles, books were also reviewed. This paper presents an outline of the various phases of microteaching, core teaching skills, implementation aspects, and the impact of microteaching on medical education.
PMCID: PMC3724377  PMID: 23914219
Microteaching; medical education; teacher training; teaching skills; teach-re teach
12.  Multiplane Transesophageal Echocardiography for Multiclinical Dilemmas 
Acta Informatica Medica  2011;19(3):138-141.
Transesophageal echocardiography was introduced 4 decades ago. Its use have had very limited clinical indication. Now it has become very useful clinical tool. Indications for its use are almost as indications for transthoracic echocardiography, especially to assess deeper cardiovascular structures. Transesophageal echocardiography is semi-invasive examination with small number of complications.
Aim of the study
To determine usefulness of transesophageal echocardiography in various cardiac conditions based in our experience. Also to encourage use of transesophageal echocardiography as reliable examination.
All of the patients signed a Term of Free Informed Consent, approved from Ethics Committee. We enrolled 425 patients who have done TEE in last 5 years (2006-2010) by authors. Medical history and Clinical evaluation was carefully performed by expert cardiologists. Procedures were performed in two different centers using machines, PHILIPS iE33 and Siemens accuson CV 70, with equipment attached to a multi frequency 2.5 to 3.5 MHz for TTE and 7.0 MHz for TEE multiplane transducer. TEE were performed and images were obtained according to the standard recommandations.
The results were analyzed by a standard method of descriptive statistics using Pivot Table of Excel Office 2007. Results. We have analyzed 425 transesophageal echocardiography . The examination of the thoracic aorta in severe hypertension patients was conducted in 96 cases; atrial fibrillation in 118; aortic dissection 49 cases, aortic stenosis was evaluated in 28 cases; finding of source of emboli 36 cases; suspicion for aneurysm of the thoracic aorta in 14 cases, 11 cases with suspected endocarditis; the type of intervention for mitral valve was evaluated in 28 cases. Interatrial septum abnormalities 37 cases; and miscellaneous 18 cases. No minor or mayor complications happened.
Transesophageal echocardiography can elucidate many dubious serious conditions immediately after it is performed. So, we think that transesophageal echocardiography is very useful tool in everyday clinical use, almost without complications if it is done correctly.
PMCID: PMC3570941  PMID: 23408794
transesophageal echocardiography; transthoracic echocardiography; echocardiography.
13.  Barriers and Facilitators to Home Computer and Internet Use Among Urban Novice Computer Users of Low Socioeconomic Position 
Despite the increasing penetration of the Internet and amount of online health information, there are significant barriers that limit its widespread adoption as a source of health information. One is the “digital divide,” with people of higher socioeconomic position (SEP) demonstrating greater access and usage compared to those from lower SEP groups. However, as the access gap narrows over time and more people use the Internet, a shift in research needs to occur to explore how one might improve Internet use as well as website design for a range of audiences. This is particularly important in the case of novice users who may not have the technical skills, experience, or social connections that could help them search for health information using the Internet. The focus of our research is to investigate the challenges in the implementation of a project to improve health information seeking among low SEP groups. The goal of the project is not to promote health information seeking as much as to understand the barriers and facilitators to computer and Internet use, beyond access, among members of lower SEP groups in an urban setting.
The purpose was to qualitatively describe participants’ self-identified barriers and facilitators to computer and Internet use during a 1-year pilot study as well as the challenges encountered by the research team in the delivery of the intervention.
Between August and November 2005, 12 low-SEP urban individuals with no or limited computer and Internet experience were recruited through a snowball sampling. Each participant received a free computer system, broadband Internet access, monthly computer training courses, and technical support for 1 year as the intervention condition. Upon completion of the study, participants were offered the opportunity to complete an in-depth semistructured interview. Interviews were approximately 1 hour in length and were conducted by the project director. The interviews were held in the participants’ homes and were tape recorded for accuracy. Nine of the 12 study participants completed the semistructured interviews. Members of the research team conducted a qualitative analysis based on the transcripts from the nine interviews using the crystallization/immersion method.
Nine of the 12 participants completed the in-depth interview (75% overall response rate), with three men and six women agreeing to be interviewed. Major barriers to Internet use that were mentioned included time constraints and family conflict over computer usage. The monthly training classes and technical assistance components of the intervention surfaced as the most important facilitators to computer and Internet use. The concept of received social support from other study members, such as assistance with computer-related questions, also emerged as an important facilitator to overall computer usage.
This pilot study offers important insights into the self-identified barriers and facilitators in computer and Internet use among urban low-SEP novice users as well as the challenges faced by the research team in implementing the intervention.
PMCID: PMC2223190  PMID: 17951215
Digital divide; health information seeking; health disparities
14.  No transfer of calibration between action and perception in learning a golf putting task 
We assessed calibration of perception and action in the context of a golf putting task. Previous research has shown that right-handed novice golfers make rightward errors both in the perception of the perfect aiming line from the ball to the hole and in the putting action. Right-handed experts, however, produce accurate putting actions but tend to make leftward errors in perception. In two experiments, we examined whether these skill-related differences in directional error reflect transfer of calibration from action to perception. In the main experiment, three groups of right-handed novice participants followed a pretest, practice, posttest, retention test design. During the tests, directional error for the putting action and the perception of the perfect aiming line were determined. During practice, participants were provided only with verbal outcome feedback about directional error; one group trained perception and the second trained action, whereas the third group did not practice. Practice led to a relatively permanent annihilation of directional error, but these improvements in accuracy were specific to the trained task. Hence, no transfer of calibration occurred between perception and action. The findings are discussed within the two-visual-system model for perception and action, and implications for perceptual learning in action are raised.
PMCID: PMC3204108  PMID: 21814859
Perceptual learning; Far aiming; Calibration; Two-visual-system model; Transfer
15.  Improving communication between physicians and patients who speak a foreign language. 
BACKGROUND: Communication between physicians and patients is particularly challenging when patients do not speak the local language (in Switzerland, they are known as allophones). AIM: To assess the effectiveness of an intervention to improve communication skills of physicians who deal with allophone patients. DESIGN OF STUDY: 'Before-and-after' intervention study, in which both patients (allophone and francophone) and physicians completed visit-specific questionnaires assessing the quality of communication. SETTING: Two consecutive samples of patients attending the medical outpatient clinic of a teaching hospital in French-speaking Switzerland. METHOD: The intervention consisted of training physicians in communicating with allophone patients and working with interpreters. French-speaking patients served as the control group. The outcomes measured were: patient satisfaction with care received and with communication during consultation; and provider (primary care physician) satisfaction with care provided and communication during consultation. RESULTS: At baseline, mean scores of patients' assessments of communication were lower for allophone than for francophone patients. At follow-up, five out of six of the scores of allophone patients showed small increases (P < 0.05) when compared with French-speaking patients: explanations given by physician; respectfulness of physician; communication; overall process of the consultation; and information about future care. In contrast, physicians' assessments did not change significantly. Finally, after the intervention, the proportion of consultations with allophone patients in which professional interpreters were present increased significantly from 46% to 67%. CONCLUSIONS: The quality of communication as perceived by allophone patients can be improved with specific training aimed at primary care physicians.
PMCID: PMC1314645  PMID: 14694667
16.  Understanding cardiac “echo” reports 
Canadian Family Physician  2006;52(7):869-874.
To help referring physicians extract clinically useful information from transthoracic echocardiography (TTE) reports, highlighting current practice and innovations that are reflected with increasing frequency in reports issued by echocardiac laboratories.
Echocardiography is an established science. The field has a large body of literature, including peer-reviewed articles and textbooks describing the physics, techniques, and clinical applications of TTE.
Transthoracic echocardiography is a basic tool for diagnosis and follow-up of heart disease. Items of interest in TTE reports can be categorized. In clinical practice, TTE results are best interpreted with a view to underlying cardiac physiology and patients’ clinical status. Knowing the inherent limitations of TTE will help referring physicians to interpret results and to avoid misdiagnoses based on false assumptions about the procedure.
A structured approach to reading TTE reports can assist physicians in extracting clinically useful information from them, while avoiding common pitfalls.
PMCID: PMC1781094  PMID: 16893150
17.  Clinical application and laboratory protocols for performing contrast echocardiography 
Indian Heart Journal  2013;65(3):337-346.
Technically difficult echocardiographic studies with suboptimal images remain a significant challenge in clinical practice despite advances in imaging technologies over the past decades. Use of microbubble ultrasound contrast for left ventricular opacification and enhancement of endocardial border detection during rest or stress echocardiography has become an essential component of the operation of the modern echocardiography laboratory. Contrast echocardiography has been demonstrated to improve diagnostic accuracy and confidence across a range of indications including quantitative assessment of left ventricular systolic function, wall motion analysis, and left ventricular structural abnormalities. Enhancement of Doppler signals and myocardial contrast echocardiography for perfusion remain off-label uses. Implementation of a contrast protocol is feasible for most laboratories and both physicians and sonographers will require training in contrast specific imaging techniques for optimal use. Previous concerns regarding the safety of contrast agents have since been addressed by more recent data supporting its excellent safety profile and overall cost-effectiveness.
PMCID: PMC3861153  PMID: 23809394
Contrast echocardiography; Laboratory protocols; Ultrasound settings
18.  Evaluation of colonoscopy technical skill levels by use of an objective kinematic-based system 
Gastrointestinal endoscopy  2010;73(2):315-321.e1.
Colonoscopy requires training and experience to ensure accuracy and safety. Currently, no objective, validated process exists to determine when an endoscopist has attained technical competence. Kinematics data describing movements of laparoscopic instruments have been used in surgical skill assessment to define expert surgical technique. We have developed a novel system to record kinematics data during colonoscopy and quantitatively assess colonoscopist performance.
To use kinematic analysis of colonoscopy to quantitatively assess endoscopic technical performance.
Prospective cohort study.
Tertiary-care academic medical center.
This study involved physicians who perform colonoscopy.
Application of a kinematics data collection system to colonoscopy evaluation.
Main Outcome Measurements
Kinematics data, validated task load assessment instrument, and technical difficulty visual analog scale.
All 13 participants completed the colonoscopy to the terminal ileum on the standard colon model. Attending physicians reached the terminal ileum quicker than fellows (median time, 150.19 seconds vs 299.86 seconds; p < .01) with reduced path lengths for all 4 sensors, decreased flex (1.75 m vs 3.14 m; P = .03), smaller tip angulation, reduced absolute roll, and lower curvature of the endoscope. With performance of attending physicians serving as the expert reference standard, the mean kinematic score increased by 19.89 for each decrease in postgraduate year (P < .01). Overall, fellows experienced greater mental, physical, and temporal demand than did attending physicians.
Small cohort size.
Kinematic data and score calculation appear useful in the evaluation of colonoscopy technical skill levels. The kinematic score appears to consistently vary by year of training. Because this assessment is nonsubjective, it may be an improvement over current methods for determination of competence. Ongoing studies are establishing benchmarks and characteristic profiles of skill groups based on kinematics data.
PMCID: PMC3113705  PMID: 21111413
19.  Feasibility of Remote Real-Time Guidance of a Cardiac Examination Performed by Novices Using a Pocket-Sized Ultrasound Device 
Background. The potential of pocket-sized ultrasound devices (PUDs) to improve global healthcare delivery is limited by the lack of a suitable imaging protocol and trained users. Therefore, we investigated the feasibility of performing a brief, evidence-based cardiac limited ultrasound exam (CLUE) through wireless guidance of novice users. Methods. Three trainees applied PUDs on 27 subjects while directed by an off-site cardiologist to obtain a CLUE to screen for LV systolic dysfunction (LVSD), LA enlargement (LAE), ultrasound lung comets (ULC+), and elevated CVP (eCVP). Real-time remote audiovisual guidance and interpretation by the cardiologist were performed using the iPhone 4/iPod (FaceTime, Apple, Inc.) attached to the PUD and transmitted data wirelessly. Accuracy and technical quality of transmitted images were compared to on-site, gold-standard echo thresholds. Results. Novice versus sonographer imaging yielded technically adequate views in 122/135 (90%) versus 130/135 (96%) (P < 0.05). CLUE's combined SN, SP, and ACC were 0.67, 0.96, and 0.90. Technical adequacy (%) and accuracy for each abnormality (n) were LVSD (85%, 0.93, n = 5), LAE (89%, 0.74, n = 16), ULC+ (100%, 0.94, n = 5), and eCVP (78%, 0.91, n = 1). Conclusion. A novice can perform the CLUE using PUD when wirelessly guided by an expert. This method could facilitate PUD use for off-site bedside medical decision making and triaging of patients.
PMCID: PMC3762173  PMID: 24024032
20.  Diagnostic ability of hand-held echocardiography in ventilated critically ill patients 
Critical Care  2003;7(5):R84-R91.
Study objectives
To compare the diagnostic capability of recently available hand-held echocardiography (HHE) and of conventional transthoracic echocardiography (TTE) used as a gold standard in critically ill patients under mechanical ventilation.
A prospective and descriptive study.
The general intensive care unit of a teaching hospital.
All mechanically ventilated patients requiring a TTE study with a full-feature echocardiographic platform (Sonos 5500®; Philips Medical Systems, Andover, MA, USA) also underwent an echocardiographic examination using a small battery-operated device (33 × 23 cm2, 3.5 kg) (Optigo®; Philips Medical Systems).
Each examination was performed independently by two intensivists experienced in echocardiography and was interpreted online. For each patient, the TTE videotape was reviewed by a cardiologist experienced in echocardiography and the final interpretation was used as a reference diagnosis.
During the study period, 106 TTE procedures were performed in 103 consecutive patients (age, 59 ± 18 years; Simplified Acute Physiology Score, 46 ± 14; body mass index, 26 ± 9 kg/m2; positive end-expiratory pressure, 8 ± 4 cmH2O). The number of acoustic windows was comparable using HHE and TTE (233/318 versus 238/318, P = 0.72). HHE had a lower overall diagnostic capacity than TTE (199/251 versus 223/251 clinical questions solved, P = 0.005), mainly due to its lack of spectral Doppler capability. In contrast, diagnostic capacity based on two-dimensional imaging was comparable for both approaches (129/155 versus 135/155 clinical questions solved, P = 0.4). In addition, HHE and TTE had a similar therapeutic impact in 45 and 47 patients, respectively (44% versus 46%, P = 0.9).
HHE appears to have a narrower diagnostic field when compared with conventional TTE, but promises to accurately identify diagnoses based on two-dimensional imaging in ventilated critically ill patients.
PMCID: PMC270721  PMID: 12974974
critical care; diagnostic techniques and procedures; echocardiography; echocardiography Doppler; therapeutics.
21.  Contrast echocardiography in Canada: Canadian Cardiovascular Society/Canadian Society of Echocardiography position paper 
As an adjunct to transthoracic, transesophageal and stress echocardiography, contrast echocardiography (CE) improves the diagnostic accuracy of technically suboptimal studies when used in conjunction with harmonic imaging.
Intravenous ultrasound contrast agents are indicated for left ventricular (LV) opacification and improvement of LV endocardial border delineation in patients with suboptimal acoustic windows. Demonstrated benefits of CE include improvement in the accuracy of LV measurements, regional wall motion assessment, evaluation of noncompaction cardiomyopathy, thrombus detection, Doppler signal enhancement and conjunctive use with stress echocardiography. Studies have shown the value of CE in the assessment and quantification of myocardial perfusion, and recent clinical trials have suggested a role for contrast perfusion imaging in the stratification of patients with suspected coronary artery disease.
While it adds some time and cost to the echocardiographic study, CE frequently obviates the need for additional specialized, expensive and less accessible cardiac investigations, and allows for prompt and optimal subsequent patient management. Despite its proven advantages, CE is presently underused in Canada, and this situation will, unfortunately, not improve until several barriers to its use are overcome. Resolving these important hurdles is vital to the future of CE and to its eventual implementation into clinical practice of promising contrast-based diagnostic and therapeutic applications, including the assessment of perfusion by myocardial CE.
PMCID: PMC2649184  PMID: 17440639
Contrast; Echocardiography; Imaging; Perfusion
22.  Outcome errors are not necessary for learning orthopedic bone drilling 
Canadian Journal of Surgery  2009;52(2):98-102.
When learning orthopedic bone drilling, a surgical trainee relies on internally generated and externally provided feedback. The quality and type of feedback often varies in the clinical environment, thus affecting skill acquisition. We investigated the effect of feedback on technical error (plunging) when novice surgical trainees learned bone drilling.
Medical students (n = 22) and experienced postgraduate surgical residents (n = 4) drilled bicortical holes in a lamb femur under 1 of 3 feedback conditions: no feedback, self-generated feedback and externally generated feedback. Novices performed a retention test (10 bicortical holes) 1 week after the initial training. We measured plunge depth, the clinically relevant outcome, using computer-assisted methods.
During the initial experiment, the plunges of novices who were exposed to external feedback were similar to those of residents in the experienced group. Novices in the self-generated feedback group plunged more than those in the external feedback group or those in the experienced group (p = 0.002). All novices plunged similarly on the retention test, a measure of true skill learning.
When learning bicortical bone drilling, feedback related to plunging is not necessary to achieve a competent level of performance. In addition, although external feedback facilitates the achievement of better outcomes, it does not improve learning. It is suggested that to minimize plunging, trainees should learn how to optimize their drilling through the bone rather than how to prevent the plunge.
PMCID: PMC2663499  PMID: 19399203
23.  The Effect of Virtual Endoscopy Simulator Training on Novices: A Systematic Review 
PLoS ONE  2014;9(2):e89224.
Advances in virtual endoscopy simulators have paralleled an interest in medical simulation for gastrointestinal endoscopy training.
The primary objective was to determine whether the virtual endoscopy simulator training could improve the performance of novices.
A systematic review.
Randomized controlled trials (RCTs) that compared virtual endoscopy simulator training with bedside teaching or any other intervention for novices were collected.
Novice endoscopists.
The PRISMA statement was followed during the course of the research. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched (up to July 2013). Data extraction and assessment were independently performed.
Main outcome measurements
Independent procedure completion, total procedure time and required assistance.
Fifteen studies (n = 354) were eligible for inclusion: 9 studies designed for colonoscopy training, 6 for gastroscopy training. For gastroscopy training, procedure completed independently was reported in 87.7% of participants in simulator training group compared to 70.0% of participants in control group (1 study; 22 participants; RR 1.25; 95% CI 1.13–1.39; P<0.0001). For colonoscopy training, procedure completed independently was reported in 89.3% of participants in simulator training group compared to 88.9% of participants in control group (7 study; 163 participants; RR 1.10; 95% CI 0.88–1.37; P = 0.41; I2 = 85%).
The included studies are quite in-homogeneous with respect to training schedule and procedure.
Virtual endoscopy simulator training might be effective for gastroscopy, but so far no data is available to support this for colonoscopy.
PMCID: PMC3931711  PMID: 24586609
24.  Objective classification of residents based on their psychomotor laparoscopic skills 
Surgical Endoscopy  2009;24(5):1031-1039.
From the clinical point of view, it is important to recognize residents’ level of expertise with regard to basic psychomotor skills. For that reason, surgeons and surgical organizations (e.g., Acreditation Council for Graduate Medical Education, ACGME) are calling for assessment tools that credential residents as technically competent. Currently, no method is universally accepted or recommended for classifying residents as “experienced,” “intermediates,” or “novices” according to their technical abilities. This study introduces a classification method for recognizing residents’ level of experience in laparoscopic surgery based on psychomotor laparoscopic skills alone.
For this study, 10 experienced residents (>100 laparoscopic procedures performed), 10 intermediates (10–100 procedures performed), and 11 novices (no experience) performed four tasks in a box trainer. The movements of the laparoscopic instruments were recorded with the TrEndo tracking system and analyzed using six motion analysis parameters (MAPs). The MAPs of all participants were submitted to principal component analysis (PCA), a data reduction technique. The scores of the first principal components were used to perform linear discriminant analysis (LDA), a classification method. Performance of the LDA was examined using a leave-one-out cross-validation.
Of 31 participants, 23 were classified correctly with the proposed method, with 7 categorized as experienced, 7 as intermediates, and 9 as novices.
The proposed method provides a means to classify residents objectively as experienced, intermediate, or novice surgeons according to their basic laparoscopic skills. Due to the simplicity and generalizability of the introduced classification method, it is easy to implement in existing trainers.
PMCID: PMC2860557  PMID: 19915915
Assessment; Classification; Minimally invasive surgery; Motion analysis; Training
25.  Echocardiography in the Era of Multimodality Cardiovascular Imaging 
BioMed Research International  2013;2013:310483.
Echocardiography remains the most frequently performed cardiac imaging investigation and is an invaluable tool for detailed and accurate evaluation of cardiac structure and function. Echocardiography, nuclear cardiology, cardiac magnetic resonance imaging, and cardiovascular-computed tomography comprise the subspeciality of cardiovascular imaging, and these techniques are often used together for a multimodality, comprehensive assessment of a number of cardiac diseases. This paper provides the general cardiologist and physician with an overview of state-of-the-art modern echocardiography, summarising established indications as well as highlighting advances in stress echocardiography, three-dimensional echocardiography, deformation imaging, and contrast echocardiography. Strengths and limitations of echocardiography are discussed as well as the growing role of real-time three-dimensional echocardiography in the guidance of structural heart interventions in the cardiac catheter laboratory.
PMCID: PMC3708397  PMID: 23878804

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