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1.  Improving Efficiency of Clinical Skills Training: A Randomized Trial 
Journal of General Internal Medicine  2013;28(8):1072-1077.
The rising number of medical students and the impact this has on students’ learning of clinical skills is a matter of concern. Cooperative learning in pairs, called dyad training, might help address this situation.
The aim of this study was to evaluate the effect of dyad training on students’ patient encounter skills.
Experimental, randomized, observer-blinded trial.
Forty-nine pre-clerkship medical students without prior clinical experience.
All students underwent a 4-h course on how to manage patient encounters. Subsequently, the students were randomized into a dyad practice group (n = 24) or a single practice group (n = 25). Both groups practiced for 4 h on four different case scenarios, using simulated patients. Students in the dyad group practiced together and took turns as the active participant, whereas students in the single group practiced alone.
Performance tests of patient encounter skills were conducted 2 weeks after the training by two blinded raters. Students had no clinical training during those weeks. A questionnaire-based evaluation surveyed students’ confidence in their patient management skills.
The dyad group scored significantly higher on the performance test, mean 40.7 % (SD 6.6), than the single group, mean 36.9 % (SD 5.8), P = 0.04, effect size 0.61. Inter-rater reliability was 0.69. The dyad group expressed significantly higher confidence in managing future clinical patient encounters than the single group, mean 7.6 (SD 0.9) vs. mean 6.5 (SD 1.1), respectively, P < 0.001, effect size 1.16.
Dyad training of pre-clerkship medical students’ patient encounter skills is effective, efficient, and prompts higher confidence in managing future patient encounters compared to training alone. This training format may help maintain high-quality medical training in the face of an increasing number of students in medical schools.
PMCID: PMC3710384  PMID: 23595928
clinical skills; medical students; co-operative learning; training efficiency
2.  Virtual-reality simulation to assess performance in hip fracture surgery 
Acta Orthopaedica  2014;85(4):403-407.
Background and purpose
Internal fixation of hip fractures is a common and important procedure that orthopedic surgeons must master early in their career. Virtual-reality training could improve initial skills, and a simulation-based test would make it possible to ensure basic competency of junior surgeons before they proceed to supervised practice on patients. The aim of this study was to develop a reliable and valid test with credible pass/fail standards.
20 physicians (10 untrained novices and 10 experienced orthopedic surgeons) each performed 3 internal fixation procedures of an undisplaced femoral neck fracture: 2 hook-pins, 2 screws, and a sliding hip screw. All procedures were preformed on a trauma simulator. Performance scores for each procedure were obtained from the predefined metrics of the simulator. The inter-case reliability of the simulator metrics was explored by calculation of intra-class correlation coefficient. Validity was explored by comparison between novices’ and experts’ scores using independent-samples t-test. A pass/fail standard was set by the contrasting-groups method and the consequences were explored.
The percentage of maximum combined score (PM score) showed an inter-case reliability of 0.83 (95% CI: 0.65–0.93) between the 3 procedures. The mean PM score was 30% (CI: 7–53) for the novices and 76% (CI: 68–83) for the experienced surgeons. The pass/fail standard was set at 58%, resulting in none of the novices passing the test and a single experienced surgeon failing the test.
The simulation-based test was reliable and valid in our setting, and the pass/fail standard could discriminate between novices and experienced surgeons. Potentially, training and testing of future junior surgeons on a virtual-reality simulator could ensure basic competency before proceeding to supervised practice on patients.
PMCID: PMC4105772  PMID: 24786902
3.  Quality of randomised controlled trials in medical education reported between 2012 and 2013: a systematic review protocol 
BMJ Open  2014;4(7):e005155.
Research in medical education has increased in volume over the past decades but concerns have been raised regarding the quality of trials conducted within this field. Randomised controlled trials (RCTs) involving educational interventions that are reported in biomedical journals have been criticised for their insufficient conceptual, theoretical framework. RCTs published in journals dedicated to medical education, on the other hand, have been questioned regarding their methodological rigour. The aim of this study is therefore to assess the quality of RCTs of educational interventions reported in 2012 and 2013 in journals dedicated to medical education compared to biomedical journals with respect to objective quality criteria.
Methods and analysis
RCTs published between 1 January 2012 and 31 December 2013 in English are included. The search strategy is developed with the help of experienced librarians to search online databases for key terms. All of the identified RCTs are screened based on their titles and abstracts individually by the authors and then compared in pairs to assess agreement. Data are extracted from the included RCTs by independently scoring each RCT using a data collection form. The data collection form consists of four steps. Step 1 includes confirmation of RCT eligibility; step 2 consists of the CONSORT checklist; step 3 consists of the Medical Education Research Study Quality Instrument framework; step 4 consists of a Medical Education Extension (MEdEx) to the CONSORT checklist. The MEdEx includes the following elements: Description of scientific background, explanation of rationale, quality of research questions and hypotheses, clarity in the description of the use of the intervention and control as well as interpretation of results.
Ethics and dissemination
This review is the first to systematically examine the quality of RCTs conducted in medical education. We plan to disseminate the results through publications and presentation at relevant conferences. Ethical approval is not sought for this review.
PMCID: PMC4120313  PMID: 25079932
EDUCATION & TRAINING (see Medical Education & Training); EPIDEMIOLOGY
4.  Medical students’ perception of dyad practice 
Training in pairs (dyad practice) has been shown to improve efficiency of clinical skills training compared with single practice but little is known about students’ perception of dyad practice. The aim of this study was to explore the reactions and attitudes of medical students who were instructed to work in pairs during clinical skills training. A follow-up pilot survey consisting of four open-ended questions was administered to 24 fourth-year medical students, who completed four hours of dyad practice in managing patient encounters. The responses were analyzed using thematic analysis. The students felt dyad practice improved their self-efficacy through social interaction with peers, provided useful insight through observation, and contributed with shared memory of what to do, when they forgot essential steps of the physical examination of the patient. However, some students were concerned about decreased hands-on practice and many students preferred to continue practising alone after completing the initial training. Dyad practice is well received by students during initial skills training and is associated with several benefits to learning through peer observation, feedback and cognitive support. Whether dyad training is suited for more advanced learners is a subject for future research.
PMCID: PMC4263787  PMID: 25073865
Dyad practice; Peer-learning; Clinical skills training
5.  Effect of Engaging Trainees by Assessing Peer Performance: A Randomised Controlled Trial Using Simulated Patient Scenarios 
BioMed Research International  2014;2014:610591.
Introduction. The aim of this study was to explore the learning effect of engaging trainees by assessing peer performance during simulation-based training. Methods. Eighty-four final year medical students participated in the study. The intervention involved trainees assessing peer performance during training. Outcome measures were in-training performance and performance, both of which were measured two weeks after the course. Trainees' performances were videotaped and assessed by two expert raters using a checklist that included a global rating. Trainees' satisfaction with the training was also evaluated. Results. The intervention group obtained a significantly higher overall in-training performance score than the control group: mean checklist score 20.87 (SD 2.51) versus 19.14 (SD 2.65) P = 0.003 and mean global rating 3.25 SD (0.99) versus 2.95 (SD 1.09) P = 0.014. Postcourse performance did not show any significant difference between the two groups. Trainees who assessed peer performance were more satisfied with the training than those who did not: mean 6.36 (SD 1.00) versus 5.74 (SD 1.33) P = 0.025. Conclusion. Engaging trainees in the assessment of peer performance had an immediate effect on in-training performance, but not on the learning outcome measured two weeks later. Trainees had a positive attitude towards the training format.
PMCID: PMC4054978  PMID: 24967383
6.  Postgraduate anaesthesiology education: protocol for a scoping review 
BMJ Open  2014;4(5):e004667.
The link between education and clinical practice is vital, yet the current state of research suggests there is a substantial gap between medical education research and practice. This too is the case in the domain of anaesthesiology education research, as much of the research focuses on simulation studies, and a narrow range of research methods. The aim of this study is to comprehensively review the existing literature in postgraduate anaesthesiology education research in order to identify key research priorities. The findings from this review will be used to establish a base for developing a strategic research programme in anaesthesia education and practice.
Methods and analysis
We will employ the scoping review methodology outlined by Arksey and O'Malley (2005) to comprehensively search the literature pertaining to postgraduate anaesthesiology education. We will search relevant electronic databases (eg, MEDLINE, EMBASE) and grey literature. After conducting calibration exercises, two authors will independently apply inclusion criteria to all titles and abstracts and perform full-text review of all eligible articles. Data to be extracted will include basic information about the study (eg, location, design) as well as detailed information regarding the context of the research and type of education examined. Our results will be used to develop a framework of themes that outline the research currently being conducted and identify gaps in research.
Ethics and dissemination
This review is the first step in a strategic research plan in postgraduate anaesthesiology education. We plan to disseminate this research through publications, presentations and meetings with relevant stakeholders. Ethical approval was not sought for this scoping review.
PMCID: PMC4039826  PMID: 24840247
Medical Education & Training; Anaesthetics
7.  Designing web-apps for smartphones can be easy as making slideshow presentations 
BMC Research Notes  2014;7:94.
Limited clinician involvement in smartphone application development poses problems considering the extensive use of smartphones among medical professionals and patients.
We present a simple method for the clinician to develop simple web-apps using only an Internet browser and a text editor.
This method may help clinicians develop simple web-apps and increase clinician involvement in smartphone content.
PMCID: PMC3931664  PMID: 24552200
Smartphones; Apps; Clinician involvement
8.  No extensive experience in open procedures is needed to learn lobectomy by video-assisted thoracic surgery 
Lobectomies done by video-assisted thoracic surgery (VATS) result in fewer complications and less pain and save total costs compared with the traditional approach. However, the majority of procedures are still performed via open thoracotomies, because VATS lobectomy is considered difficult to learn, requiring experience in open surgery, and causing complications in the initial phase of the learning curve. The aim of this study was to describe a training model appreciating patient safety during training and to explore the initial learning curve for a trainee rather inexperienced in open surgery.
A trainee who had performed 14 lobectomies by thoracotomy was enrolled in a training programme at a high-volume VATS centre. The training model included courses and simulations followed by the selection of suitable patients operated on during close expert supervision. Data regarding time, a variety of quality indicators and complications were collected prospectively and compared with experts' performance.
Over 12 months, 29 of 214 VATS lobectomies were performed by the trainee. Twice, the supervisor had to finish the procedure due to technical difficulties. None of the operations were converted to open thoracotomy. Compared with experts, the trainee operated significantly slower [median 120 (range 74–160) vs 100 (range 42–255) min, P = 0.04]; had similar perioperative bleeding [median 100 (range 10–500) vs 50 (range 5–2500) ml, P = 0.79]; had earlier chest tube removal [median 1 (range 1–6) vs 2 (range 1–32) postoperative days, P < 0.001]; and reduced hospital stay [median 3 (range 1–10) vs 4 (range 1–41) days, P < 0.001]. Twenty-three (79%) patients had no complications, while 2 had atrial fibrillation. Pneumothorax after chest tube removal, incisional infection, prolonged pain and need for pleuracentesis were each seen once.
With thorough preparation of trainees and training on selected patients under close supervision, the learning curve can be overcome with good results even if the trainee has limited prior experience in open surgery.
PMCID: PMC3501313  PMID: 22968956
Thoracoscopy; Lobectomies; Education; Learning curve; Complications; Outcome
9.  International Multispecialty Consensus on How to Evaluate Ultrasound Competence: A Delphi Consensus Survey 
PLoS ONE  2013;8(2):e57687.
To achieve international consensus across multiple specialties on a generic ultrasound rating scale using a Delphi technique.
Ultrasound experts from Obstetrics-Gynaecology, Surgery, Urology, Radiology, Rheumatology, Emergency Medicine, and Gastro-Enterology representing North America, Australia, and Europe were identified. A multi-round survey was conducted to obtain consensus between these experts. Of 60 invited experts, 44 experts agreed to participate in the first Delphi round, 41 remained in the second round, and 37 completed the third Delphi round. Seven key elements of the ultrasound examination were identified from existing literature and recommendations from international ultrasound societies. All experts rated the importance of these seven elements on a five-point Likert scale in the first round and suggested potential new elements for the assessment of ultrasound skills. In the second round, the experts re-rated all elements and a third round was conducted to allow final comments. Agreement on which elements to include in the final rating scale was pre-defined as more than 80% of the experts rating an element four or five, on importance to the ultrasound examination.
Two additional elements were suggested by more than 10% of the experts in the first Delphi round. Consensus was obtained to include these two new elements along with five of the original elements in the final assessment instrument: 1) Indication for the examination 2) Applied knowledge of ultrasound equipment 3) Image optimization 4) Systematic examination 5) Interpretation of images 6) Documentation of examination and 7) Medical decision making.
International multispecialty consensus was achieved on the content of a generic ultrasound rating scale. This is the first step to ensure valid assessment of clinicians in different medical specialties using ultrasound.
PMCID: PMC3585207  PMID: 23469051
10.  Short- and long-term transfer of urethral catheterization skills from simulation training to performance on patients 
BMC Medical Education  2013;13:29.
Inexperienced interns are responsible for most iatrogenic complications after urethral catheterization (UC). Although training on simulators is common, little is known about the transfer of learned skills to real clinical practice. This study aimed to evaluate the short- and long-term effects of UC simulated skills training on performance on real patients and to examine whether watching a video of the procedure immediately before assessment enhanced clinical performance.
This was an experimental study of the effect of a UC simulation-based skills course on medical students’ short-term (after one week) and long-term (after six weeks) performance. The additional effect of video instruction before performance testing on real patients was studied in a randomized trial. Sixty-four students participated in the study, which was preceded by a pilot study investigating the validity aspects of a UC assessment form.
The pilot study demonstrated sufficient inter-rater reliability, intra-class correlation coefficient 0.86, and a significant ability to discriminate between trainee performances when using the assessment form, p= 0.001. In the main study, more than 90% of students demonstrated an acceptable performance or better when tested on real patients. There was no significant difference in the total score between the one-week and the six-week groups when tested on real patients and no significant difference between the video and the control groups.
Medical students demonstrated good transfer of UC skills learned in the skills lab to real clinical situations up to six weeks after training. Simulated UC training should be the standard for all medical school curricula to reduce avoidable complications. However, this study did not demonstrate that an instructional video, as a supplement to simulated skills training, improved clinical UC performance.
Trial registration
Current Controlled Trials ISRCTN:ISRCTN90745002
PMCID: PMC3598217  PMID: 23433258
11.  Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized educational trial 
Several studies have found a positive effect on the learning curve as well as the improvement of basic psychomotor skills in the operating room after virtual reality training. Despite this, the majority of surgical and gynecological departments encounter hurdles when implementing this form of training. This is mainly due to lack of knowledge concerning the time and human resources needed to train novice surgeons to an adequate level. The purpose of this trial is to investigate the impact of instructor feedback regarding time, repetitions and self-perception when training complex operational tasks on a virtual reality simulator.
The study population consists of medical students on their 4th to 6th year without prior laparoscopic experience. The study is conducted in a skills laboratory at a centralized university hospital. Based on a sample size estimation 98 participants will be randomized to an intervention group or a control group. Both groups have to achieve a predefined proficiency level when conducting a laparoscopic salpingectomy using a surgical virtual reality simulator. The intervention group receives standardized instructor feedback of 10 to 12 min a maximum of three times. The control group receives no instructor feedback. Both groups receive the automated feedback generated by the virtual reality simulator. The study follows the CONSORT Statement for randomized trials. Main outcome measures are time and repetitions to reach the predefined proficiency level on the simulator. We include focus on potential sex differences, computer gaming experience and self-perception.
The findings will contribute to a better understanding of optimal training methods in surgical education.
Trial Registration
PMCID: PMC3311079  PMID: 22373062
Virtual reality simulation; Laparoscopy; Training; Salpingectomy; Feedback
12.  Educational climate seems unrelated to leadership skills of clinical consultants responsible of postgraduate medical education in clinical departments 
BMC Medical Education  2010;10:62.
The educational climate is crucial in postgraduate medical education. Although leaders are in the position to influence the educational climate, the relationship between leadership skills and educational climate is unknown. This study investigates the relationship between the educational climate in clinical departments and the leadership skills of clinical consultants responsible for education.
The study was a trans-sectional correlation study. The educational climate was investigated by a survey among all doctors (specialists and trainees) in the departments. Leadership skills of the consultants responsible for education were measured by multi-source feedback scores from heads of departments, peer consultants, and trainees.
Doctors from 42 clinical departments representing 21 specialties participated. The response rate of the educational climate investigation was moderate 52% (420/811), Response rate was high in the multisource-feedback process 84.3% (420/498). The educational climate was scored quite high mean 3.9 (SD 0.3) on a five-point Likert scale. Likewise the leadership skills of the clinical consultants responsible for education were considered good, mean 5.4 (SD 0.6) on a seven-point Likert scale. There was no significant correlation between the scores concerning the educational climate and the scores on leadership skills, r = 0.17 (p = 0.29).
This study found no relation between the educational climate and the leadership skills of the clinical consultants responsible for postgraduate medical education in clinical departments with the instruments used. Our results indicate that consultants responsible for education are in a weak position to influence the educational climate in the clinical department. Further studies are needed to explore, how heads of departments and other factors related to the clinical organisation could influence the educational climate.
PMCID: PMC2955595  PMID: 20858255
13.  What is the impact of a national postgraduate medical specialist education reform on the daily clinical training 3.5 years after implementation? A questionnaire survey 
BMC Medical Education  2010;10:46.
Many countries have recently reformed their postgraduate medical education (PGME). New pedagogic initiatives and blueprints have been introduced to improve quality and effectiveness of the education. Yet it is unknown whether these changes improved the daily clinical training. The purpose was to examine the impact of a national PGME reform on the daily clinical training practice.
The Danish reform included change of content and format of specialist education in line with outcome-based education using the CanMEDS framework. We performed a questionnaire survey among all hospital doctors in the North Denmark Region. The questionnaire included items on educational appraisal meetings, individual learning plans, incorporating training issues into work routines, supervision and feedback, and interpersonal acquaintance. Data were collected before start and 31/2 years later. Mean score values were compared, and response variables were analysed by multiple regression to explore the relation between the ratings and seniority, type of hospital, type of specialty, and effect of attendance to courses in learning and teaching among respondents.
Response rates were 2105/2817 (75%) and 1888/3284 (58%), respectively. We found limited impact on clinical training practice and learning environment. Variances in ratings were hardly affected by type of hospital, whereas belonging to the laboratory specialities compared to other specialties was related to higher ratings concerning all aspects.
The impact on daily clinical training practice of a national PGME reform was limited after 31/2 years. Future initiatives must focus on changing the pedagogical competences of the doctors participating in daily clinical training and on implementation strategies for changing educational culture.
PMCID: PMC2902490  PMID: 20565832
14.  Combining a leadership course and multi-source feedback has no effect on leadership skills of leaders in postgraduate medical education. An intervention study with a control group 
Leadership courses and multi-source feedback are widely used developmental tools for leaders in health care. On this background we aimed to study the additional effect of a leadership course following a multi-source feedback procedure compared to multi-source feedback alone especially regarding development of leadership skills over time.
Study participants were consultants responsible for postgraduate medical education at clinical departments. Study design: pre-post measures with an intervention and control group. The intervention was participation in a seven-day leadership course. Scores of multi-source feedback from the consultants responsible for education and respondents (heads of department, consultants and doctors in specialist training) were collected before and one year after the intervention and analysed using Mann-Whitney's U-test and Multivariate analysis of variances.
There were no differences in multi-source feedback scores at one year follow up compared to baseline measurements, either in the intervention or in the control group (p = 0.149).
The study indicates that a leadership course following a MSF procedure compared to MSF alone does not improve leadership skills of consultants responsible for education in clinical departments. Developing leadership skills takes time and the time frame of one year might have been too short to show improvement in leadership skills of consultants responsible for education. Further studies are needed to investigate if other combination of initiatives to develop leadership might have more impact in the clinical setting.
PMCID: PMC2797774  PMID: 20003311

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