Are evaluations in simulated medical encounters reliable among rater types? A comparison between standardized patient and outside observer ratings of OSCEs.

Objective: By analyzing Objective Structured Clinical Examination (OSCE) evaluations of first-year interns' communication with standardized patients (SP), our study aimed to examine the differences between ratings of SPs and a set of outside observers with training in healthcare communication. Methods: Immediately following completion of OSCEs, SPs evaluated interns' communication skills using 30 items. Later, two observers independently coded video recordings using the same items. We conducted two-tailed t-tests to examine differences between SP and observers' ratings. Results: Rater scores differed significantly on 21 items (p < .05), with 20 of the 21 differences due to higher SP in-person evaluation scores. Items most divergent between SPs and observers included items related to empathic communication and nonverbal communication. Conclusion: Differences between SP and observer ratings should be further investigated to determine if additional rater training is needed or if a revised evaluation measure is needed. Educators may benefit from adjusting evaluation criteria to decrease the number of items raters must complete and may do so by encompassing more global questions regarding various criteria. Furthermore, evaluation measures may be strengthened by undergoing reliability and validity testing. Innovation: This study highlights the strengths and limitations to rater types (observers or SPs), as well as evaluation methods (recorded or in-person).

Impact of Simulation on Critical Care Fellows' Electroencephalography Learning.

Introduction Continuous electroencephalography (EEG) is an important monitoring modality in the intensive care unit and a key skill for critical care fellows (CCFs) to learn. Our objective was to evaluate with CCFs an EEG educational curriculum on a web-based simulator. Methods This prospective cohort study was conducted at a major academic medical center in Florida. After Institutional Review Board approval, 13 CCFs from anesthesiology, surgery, and pulmonary medicine consented to take an EEG curriculum. A 25-item EEG assessment was completed at baseline, after 10 EEG interpretations with a neurophysiologist, and after 10 clinically relevant EEG-based simulations providing clinical EEG interpretation hints. A 50-minute tutorial podcast was viewed after the baseline assessment. Main assessment outcomes included multiple outcomes related to web-based simulator performance: percent of hints used, percent of first words on EEG interpretation correct, and percent hint-based EEG interpretation score correct, with higher scores indicating more correct answers. Participants completed a 25-item EEG assessment before (baseline) and after the web-based simulator. Results All 13 CCFs completed the curriculum. Between scenarios, there were differences in percent of hints used (F9,108 = 11.7, p < 0.001), percent of first words correct (F9,108 = 13.6, p < 0.001), and overall percent hint-based score (F9,108 = 14.0, p < 0.001). Nonconvulsive status epilepticus had the lowest percent of hints used (15%) and the highest hint-based score (87%). Overall percent hint-based score (mean across all scenarios) was positively correlated with change in performance as the number of correct answers on the 25-item EEG assessment from before to after the web-based simulator activity (Spearman's rho = 0.67, p = 0.023). Conclusions A self-paced EEG interpretation curriculum involving a flipped classroom and screen-based simulation each requiring less than an hour to complete significantly improved CCF scores on the EEG assessment compared to baseline.

A Comparison of Central Venous Access to the Internal Jugular Vein and Two Standard Approaches to the Subclavian Vein: A Study of Cross-Sectional Areas Using Computed Tomography Scans.

Introduction The supraclavicular approach to the subclavian vein has been cited as having many advantages to the infraclavicular approach, including a larger short-axis cross-sectional area, a greater margin of safety, and fewer complications. Methods To examine whether a larger short-axis cross-sectional area of the subclavian vein at the supraclavicular fossa is a potential explanation for the reduction in attempts with the supraclavicular approach seen in a previous study, we examined computed tomography scans from 50 patients (24 M, 26 F). The short-axis cross-sectional areas of the subclavian vein at the mid-clavicular line, the subclavian vein in the supraclavicular fossa, and the internal jugular vein at the level of the thyroid cartilage were calculated. Results The internal jugular vein short-axis cross-sectional area was significantly larger than the subclavian vein short-axis cross-sections measured at each location. We found no difference between the short-axis cross-sectional areas of the subclavian vein or when comparing measurements as a factor of gender, age, or race. Weight had a significant relationship to the short-axis cross-sectional area of the internal jugular vein and subclavian vein at the mid-clavicular vein. Conclusions On supine computed tomographic imaging, the subclavian vein short-axis cross-section was not larger in the supraclavicular fossa than the mid-clavicular line. The short-axis cross-sectional area of the subclavian vein at the supraclavicular fossa does not appear to contribute to the decrease in attempts to access it. Weight, but not necessarily height, appears to be correlated with central vein size.

The RITE of Passage: Learning Styles and Residency In-Service Training Examination (RITE) Scores.

Introduction The objective of the pilot study was to determine the association between learning preferences and improvement in the American Academy of Neurology Residency In-Service Training Examination (RITE) scores from postgraduate year 2 (PGY-2) to postgraduate year 3 (PGY-3) in neurology residents. Methods Neurology residents at the University of Florida were approached to participate, and their consent was obtained. VARK inventory, representing four modalities (visual, aural, read/write, kinesthetic) of learning preferences, was completed by participants. Participants could pick more than one modality. The number of responses in each sensory domain was recorded, with higher numbers indicating stronger preference. Residents' performance on the RITE was recorded for PGY-2 and PGY-3. Results Seventeen residents completed the VARK inventory and 16 had data for RITE. Residents demonstrated overall positive change in RITE from PGY-2 to PGY-3 (mean change = 6%; 95%CI: 4%, 9%). The median number of responses was highest for the kinesthetic domain (median = 7, range = 1-12), followed by visual (median = 6, range = 2-12), aural (median = 4, range = 1-10), and read/write (median = 4, range = 1-10). Among VARK domains, the number of responses in read/write had the strongest correlation with mean change in RITE performance from PGY-2 to PGY-3 (r = 0.45; 95%CI: -0.08, 0.78); residents in the high read/write group (number of response above median) had greater mean change in RITE performance (9%; 95%CI: 6%, 12%) while those in the low read/write group showed little to no increase in RITE from PGY-2 to PGY-3 (2%; 95%CI: -1%, 6%). Conclusions Higher VARK survey responses in the read/write domain were related to greater change in RITE scores from PGY-2 to PGY-3. These findings seem intuitively obvious considering the format of the RITE. These pilot data permit further investigation of individual resident learning preference and how it relates to test performance. By understanding a resident's learning style, both educators and the resident will have an awareness of areas that need to be improved to be successful, which may be via remedial curricula and self-study activities.

Impact of Match Violations on Applicants' Perceptions and Rankings of Residency Programs.

Introduction The National Resident Matching Program (NRMP) requires all Match participants to adhere to a strict code of conduct known as the Match Participation Agreement, yet Match violations continue to occur. We sought to determine how interview experiences, including Match violations, impact applicants' perceptions and rankings of residency programs. Methods An electronic survey was sent to all accredited medical school Deans of Student Affairs and Association of American Medical Colleges Student Representatives for distribution to fourth-year medical students. Questions assessed pressures that residency programs placed on applicants during interview season and their impact on applicants. Both quantitative and qualitative data were collected. Results Of the 433 included respondents, 31.2% (n = 135) reported breaches of the NRMP Match Participation Agreement. Of those, 63% (n = 85) had a negative perception of the violating programs, and 37.8% (n = 51) were less likely to rank those programs highly. Violations included asking applicants about the locations of their other interviews (60.3%, n = 261), pressuring applicants to reveal their ranking (24.0%, n = 104), explicitly requesting applicants to reveal their ranking (6.5%, n = 28), asking applicants to provide a commitment before Match day (3.9%, n = 17), and other behavior that was felt to ignore the spirit of the Match (16.4%, n = 71). Implying that applicants would match into a program if they ranked it highly (37.2%, n = 161) was received positively by 65.2% (n = 105) of applicants experiencing this breach, with 42.2% (n = 68) ranking the program more highly. Three major themes impacting applicants' impressions of residency programs emerged from the qualitative data: interview experience, professionalism, and post-interview communication (PIC). Respondents overwhelmingly agreed that PIC should either be eliminated or that programs should set clear expectations for PIC. Conclusions Match violations continue to occur, despite the NRMP Match Participation Agreement. With the notable exception of communication implying that applicants would match into a program, applicants overwhelmingly view programs that commit these violations negatively and often rank these programs lower as a result.

Objective predictors of intern performance.

BACKGROUND: Residency programs select medical students for interviews and employment using metrics such as the United States Medical Licensing Examination (USMLE) scores, grade-point average (GPA), and class rank/quartile. It is unclear whether these metrics predict performance as an intern. This study tested the hypothesis that performance on these metrics would predict intern performance. METHODS: This single institution, retrospective cohort analysis included 244 graduates from four classes (2015-2018) who completed an Accreditation Council for Graduate Medical Education (ACGME) certified internship and were evaluated by program directors (PDs) at the end of the year. PDs provided a global assessment rating and ratings addressing ACGME competencies (response rate = 47%) with five response options: excellent = 5, very good = 4, acceptable = 3, marginal = 2, unacceptable = 1. PDs also classified interns as outstanding = 4, above average = 3, average = 2, and below average = 1 relative to other interns from the same residency program. Mean USMLE scores (Step 1 and Step 2CK), third-year GPA, class rank, and core competency ratings were compared using Welch's ANOVA and follow-up pairwise t-tests. RESULTS: Better performance on PD evaluations at the end of intern year was associated with higher USMLE Step 1 (p = 0.006), Step 2CK (p = 0.030), medical school GPA (p = 0.020) and class rank (p = 0.016). Interns rated as average had lower USMLE scores, GPA, and class rank than those rated as above average or outstanding; there were no significant differences between above average and outstanding interns. Higher rating in each of the ACGME core competencies was associated with better intern performance (p < 0.01). CONCLUSIONS: Better performance as an intern was associated with higher USMLE scores, medical school GPA and class rank. When USMLE Step 1 reporting changes from numeric scores to pass/fail, residency programs can use other metrics to select medical students for interviews and employment.

An online, interactive, screen-based simulator for learning basic EEG interpretation.

OBJECTIVE: Develop and pilot test a simulator that presents ten commonly encountered representative clinical contexts for trainees to learn basic electroencephalogram (EEG) interpretation skills. METHODS: We created an interactive web-based training simulator that allows self-paced, asynchronous learning and assessment of basic EEG interpretation skills. The simulator uses the information retrieval process via a free-response text box to enhance learning. Ten scenarios were created that present dynamic (scrolling) EEG tracings resembling the clinical setting, followed by questions with free-text answers. The answer was checked against an accepted word/phrase list. The simulator has been used by 76 trainees in total. We report pilot study results from the University of Florida's neurology residents (N = 24). Total percent correct for each scenario and average percent correct for all scenarios were calculated and correlated with most recent In-training Examination (ITE) and United States Medical License Examination (USMLE) scores. RESULTS: Neurology residents' mean percent correct scenario scores ranged from 27.1-86.0% with an average scenario score of 61.2% ± 7.7. We showed a moderately strong correlation r = 0.49 between the ITE and the average scenario score. CONCLUSION: We developed an online interactive EEG interpretation simulator to review basic EEG content and assess interpretation skills using an active retrieval approach. The pilot study showed a moderately strong correlation r = 0.49 between the ITE and the average scenario score. Since the ITE is a measure of clinical practice, this is evidence that the simulator can provide self-directed instruction and shows promise as a tool for assessment of EEG knowledge.

Prevalence and extent of industry support for program directors of surgical fellowships in the United States.

BACKGROUND: Fellowship program directors have a considerable influence on the future practice patterns of their trainees. Multiple studies have demonstrated that industry can also exert substantial influence on the practice patterns of physicians as a whole. The purpose of this study is to quantify industry support of fellowship program directors across surgical subspecialties and to assess the prevalence of this support within specific subspecialties. METHODS: Fellowship program directors for acute care, breast, burn, cardio-thoracic, critical care, colon and rectal, endocrine, hepato-pancreato-biliary, minimally invasive, plastic, oncologic, pediatric, and vascular surgery for 2017 were identified using a previously described database. The Open Payments Database for 2017 was queried and data regarding general payments, research, associated research payments, and ownership were obtained. The national mean and median payouts to nonfellowship program director surgeons were used to determine subspecialties with substantial industry support. RESULTS: Five hundred and seventy-six fellowship program directors were identified. Of these, 77% of the fellowship program directors had a presence on the Open Payments Database. The subspecialties with the most fellowship program directors receiving any industry payment, regardless of amount, included vascular (93.5%), cardio-thoracic (92.8%), minimally invasive surgery (90.5%), plastics (85.3%), and colon and rectal (81.0%). The subspecialty with the greatest mean payment was minimally invasive surgery (21,175 US dollars); the greatest median payment was vascular (1,871 US dollars). The 3 most common types of payments were for general compensation (31.4%), consulting fees (28.7%), and travel and lodging (14.7%). Vascular surgery had the greatest percentage of fellowship program directors receiving research payments (48%). The greatest amount paid to any individual fellowship program director was 382,368 US dollars. Excluding outliers, fellowship program directors received substantially more payments than those received on average by general surgeons. CONCLUSION: The majority of fellowship program directors receive some industry support. Most payments are for compensation for noncontinuing medical education related services and consulting fees. Certain specialties were more likely to have industry payments than others. Overall, only a minority of fellowship program directors received research support from industry. We advocate for transparent discussions between fellowship program directors and their trainees to help foster healthy academic-industry collaborations.

Isolation gowns as a potential work hazard.

OBJECTIVES: Isolation gowns are used as a barrier to bacterial transmission from patient to provider and vice versa. If an isolation gown is ineffective, the patient and provider have a potential breach of safety and increased infection risk. This study compared the bacterial permeability of differently rated, commonly uses isolation gowns to assess their effectiveness in preventing simulated bacterial transmittance, and thus contamination, from patient to provider. METHODS: Serial dilutions of Staphylococcus epidermidis in sterile saline were applied to a simulated skin surface. Unrated and Levels 1 through 4 non-sterile isolation gowns contacted the solution, simulating patient contact. Both sides of the contaminated gowns were then cultured on blood agar by rolling a sterile swab across the gown and evenly inoculating the culture plate. Colony counts from inside and outside of the gowns were compared. Separately, S. epidermidis was placed on a sample of each gown and scanning electron microscopy was used to visualize the contaminated gowns' physical structure. RESULTS: Mean bacterial transmittance from outside of the gown (i.e. patient contact side) to inside of the gowns (i.e. provider clothing or skin side) based on gown rating was as follows: unrated: 50.4% (SD 9.0%); Level 1: 39.7% (SD 11.2%); Level 2: 16.3% (SD 10.3%); Level 3: 0.3% (SD 0.8%); Level 4: 0.0% (SD 0.0%). Scanning electron microscope imaging of unrated, Level 1, and Level 2 gowns revealed gown pore sizes much larger than the bacteria. The Welch one-way analysis of variance statistic showed significant difference dependent on gown-level rating. CONCLUSIONS: Unrated, Level 1, and Level 2 isolation gowns do not provide effective bacterial isolation barriers when bacteria like S. epidermidis make contact with one side of the gown material. Not studied, but implied, is that unrated and lower rated isolation gowns would be as or even more physically permeable to virus particles, which are much smaller than bacteria.

Application of an objective structured clinical examination to evaluate and monitor intern's proficiency of hand hygiene and personal protective equipment use in the United States.

PURPOSE: To determine if an objective structured clinical examination (OSCE) could be used to evaluate and monitor hand hygiene and personal protective equipment (PPE) proficiency for medical interns in the United States. METHODS: Interns in July 2015 (N=123, Cohort 1) without OSCE-based contact precaution evaluation and teaching were evaluated early 2016 by OSCE for hand hygiene and PPE proficiency. They performed poorly. Therefore, the new interns entering July 2016 (N=151, Cohort 2) were immediately tested in the same OSCE station as Cohort 1 and provided feedback and teaching. Cohort 2 was then retested in the OSCE station early 2017. The Mann Whitney U test was used to compare Cohort 1 vs. Cohort 2 performances on checklist items. Cohort 2 performance differences at the beginning and end of the intern year were compared using McNemar's X2 test for paired nominal data. RESULTS: Checklist items were scored, summed and reported as percent correct. In Cohort 2, the mean percent correct was higher in posttest than pretest, 92% vs. 77% )(P <0 .0001). The passing rate (100% correct) was significantly higher, 55% vs. 16%. Comparing Cohort 1 and Cohort 2 at the end of intern year, the mean percent correct was higher for Cohort 2 compared to Cohort 1, 95% vs 90% (P < 0.0001). 55% of the Cohort 2 passed (a perfect score) compared to 24% in Cohort 1 (P < 0.0001). CONCLUSION: An OSCE can be utilized to evaluate and monitor hand hygiene and PPE proficiency for interns in the United States.

Reduced Complications of Supraclavicular Approach in Simulated Central Venous Access: Applicability to Military Medicine.

In a study with 76 anesthesia providers on a mixed reality simulator, central venous access via the supraclavicular approach to the subclavian vein, without ultrasonography required less attempts compared to the infraclavicular approach. Participants had shorter times to venous access and larger improvements in confidence. Results from this simulation-based study indicate that the supraclavicular approach may deserve consideration as an alternative approach for central venous access in deployed military environments. The use of ultrasonography during the supraclavicular approach to the subclavian vein is also described which may improve its safety profile. This technique could be more appropriate in scenarios when central venous access is preferred over intraosseous access for patients being transported to another location for further care.

Gender Diversity in General Surgery Residency Leadership.

OBJECTIVE: This study aimed to evaluate the proportion and characteristics of women who serve in general surgery program director (PD) and associate program director (APD) positions in the United States. DESIGN: General surgery programs (n = 276) and directors were identified using the Association for Program Directors in Surgery website; information was cross-referenced with American Medical Association FREIDA and Accreditation Council for Graduate Medical Education databases, current to July 1, 2017. Each program's website was accessed to determine the gender and academic ranking of faculty. RESULTS: Results reveal a preponderance of men in PD and APD positions. Women accounted for 18.4% (n = 51) of the 276 PD positions, with more women in APD positions (29.6%). There was no correlation between gender of PD and the corresponding APD, (χ2 = 0.68, p = 0.41; Phi coefficient = -0.0695). Of those with academic appointments, men who were PDs were more likely to be full professors when compared to women PDs (38.5% vs 24.1%, respectively). The median number of days since appointment to PD was similar in both groups (1461 days for men vs 1377 for women, p = 0.18), although more men have held PD positions longer. Programs with a higher proportion of women faculty were more likely to have a woman PD (p = 0.0397), but not those with more women residents (p = 0.225) or a woman Department Chair (p = 0.56). CONCLUSIONS: Among general surgery program directorship, men continue to hold more positions of educational leadership, although the trend appears to be shifting toward a more equal balance, particularly in those programs with proportionately more women faculty. This discrepancy may be due to academic rank or length of tenure. As more women hold academic positions in the field of general surgery, an increase in the representation of this group in leadership is anticipated. Although senior leadership (PD) positions remain disproportionately held by men, APD positions are filled by a greater percentage of women than academic surgical faculty, although the absolute percentage remains less than 50%. Educational leadership may be a viable path to academic leadership for both women and men.

Visualization Improves Supraclavicular Access to the Subclavian Vein in a Mixed Reality Simulator.

BACKGROUND: We investigated whether visual augmentation (3D, real-time, color visualization) of a procedural simulator improved performance during training in the supraclavicular approach to the subclavian vein, not as widely known or used as its infraclavicular counterpart. METHODS: To train anesthesiology residents to access a central vein, a mixed reality simulator with emulated ultrasound imaging was created using an anatomically authentic, 3D-printed, physical mannequin based on a computed tomographic scan of an actual human. The simulator has a corresponding 3D virtual model of the neck and upper chest anatomy. Hand-held instruments such as a needle, an ultrasound probe, and a virtual camera controller are directly manipulated by the trainee and tracked and recorded with submillimeter resolution via miniature, 6 degrees of freedom magnetic sensors. After Institutional Review Board approval, 69 anesthesiology residents and faculty were enrolled and received scripted instructions on how to perform subclavian venous access using the supraclavicular approach based on anatomic landmarks. The volunteers were randomized into 2 cohorts. The first used real-time 3D visualization concurrently with trial 1, but not during trial 2. The second did not use real-time 3D visualization concurrently with trial 1 or 2. However, after trial 2, they observed a 3D visualization playback of trial 2 before performing trial 3 without visualization. An automated scoring system based on time, success, and errors/complications generated objective performance scores. Nonparametric statistical methods were used to compare the scores between subsequent trials, differences between groups (real-time visualization versus no visualization versus delayed visualization), and improvement in scores between trials within groups. RESULTS: Although the real-time visualization group demonstrated significantly better performance than the delayed visualization group on trial 1 (P = .01), there was no difference in gain scores, between performance on the first trial and performance on the final trial, that were dependent on group (P = .13). In the delayed visualization group, the difference in performance between trial 1 and trial 2 was not significant (P = .09); reviewing performance on trial 2 before trial 3 resulted in improved performance when compared to trial 1 (P < .0001). There was no significant difference in median scores (P = .13) between the real-time visualization and delayed visualization groups for the last trial after both groups had received visualization. Participants reported a significant improvement in confidence in performing supraclavicular access to the subclavian vein. Standard deviations of scores, a measure of performance variability, decreased in the delayed visualization group after viewing the visualization. CONCLUSIONS: Real-time visual augmentation (3D visualization) in the mixed reality simulator improved performance during supraclavicular access to the subclavian vein. No difference was seen in the final trial of the group that received real-time visualization compared to the group that had delayed visualization playback of their prior attempt. Training with the mixed reality simulator improved participant confidence in performing an unfamiliar technique.

Bench to Bedside: The Effectiveness of a Professional Development Program Focused on Biomedical Sciences and Action Research.

A three-year, National Institutes of Health-funded residential project at a southeastern research university immersed 83 secondary science teachers in a summer institute called "Bench to Bedside." Teachers were provided with knowledge, skills, experiences, and incentives to improve their science teaching and increase their awareness of scientific processes, technologies, and careers by examining the translational medicine continuum of basic to clinical research. This was done with the help of medical school researchers, clinical personnel, biotechnology entrepreneurs, program mentors, and prior year participants. A critical component of the institute was the preparation and implementation of an action research project that reflected teachers' newly acquired knowledge and skills. Action research proposals were critiqued by project team members and feedback provided prior to action research implementation in schools during the following year. Teachers shared their action research with colleagues and project team at a symposium and online as a critical step in networking the teachers. Results of a mixed methods program evaluation strategy indicate that the program produced significant gains in teachers' confidence to explain advanced biosciences topics, development of action research skills, and formation of a statewide biosciences network of key stakeholders. Constraints of time, variation in teacher content and action research background, technology availability, and school-related variables, among others, are discussed.

A mixed-reality part-task trainer for subclavian venous access.

INTRODUCTION: Mixed-reality (MR) procedural simulators combine virtual and physical components and visualization software that can be used for debriefing and offer an alternative to learn subclavian central venous access (SCVA). We present a SCVA MR simulator, a part-task trainer, which can assist in the training of medical personnel. METHODS: Sixty-five participants were involved in the following: (1) a simulation trial 1; (2) a teaching intervention followed by trial 2 (with the simulator's visualization software); and (3) trial 3, a final simulation assessment. The main test parameters were time to complete SCVA and the SCVA score, a composite of efficiency and safety metrics generated by the simulator's scoring algorithm. Residents and faculty completed questionnaires presimulation and postsimulation that assessed their confidence in obtaining access and learner satisfaction questions, for example, realism of the simulator. RESULTS: The average SCVA score was improved by 24.5 (n=65). Repeated-measures analysis of variance showed significant reductions in average time (F=31.94, P<0.0001), number of attempts (F=10.56, P<0.0001), and score (F=18.59, P<0.0001). After the teaching intervention and practice with the MR simulator, the results no longer showed a difference in performance between the faculty and residents. On a 5-point scale (5=strongly agree), participants agreed that the SCVA simulator was realistic (M=4.3) and strongly agreed that it should be used as an educational tool (M=4.9). CONCLUSIONS: An SCVA mixed simulator offers a realistic representation of subclavian central venous access and offers new debriefing capabilities.

Automated, real-time fresh gas flow recommendations alter isoflurane consumption during the maintenance phase of anesthesia in a simulator-based study.

BACKGROUND: The Low Flow Wizard (LFW) provides real-time guidance for user optimization of fresh gas flow (FGF) settings during general inhaled anesthesia. The LFW can continuously inform users whether it determines their FGF to be too little, efficient, or too much, and its color-coded recommendations respond in real time to changes in FGF performed by users. Our study objective was to determine whether the LFW feature, as implemented in the Dräger Apollo workstation, alters FGF selection and thereby volatile anesthetic consumption without affecting patient care. METHODS: To reduce potentially confounding variables, we used a human patient simulator that consumes and exhales volatile anesthetics. Standard monitoring was provided for the patient initially with invasive arterial blood pressure added after anesthetic induction. In this within-group study, each of 17 participants acted as his or her own control. Each participant was asked to anesthetize an identical simulated patient twice using a Dräger Apollo workstation, first with the LFW feature disabled and subsequently enabled. The volatile anesthetic was isoflurane. Both simulation runs were set up to have similar time durations for the different phases of anesthesia: induction, incision, and maintenance. Emergence was not simulated. The isoflurane vaporizer was weighed before and after each simulation run on a digital scale to verify total computed volatile liquid anesthetic consumption. In addition, the product of FGF (reported by the Apollo) times the isoflurane volumetric concentration (sampled by a multigas analyzer at the equivalent of the FGF hose for the Apollo) was integrated over time to obtain isoflurane consumption rate (on-the-fly anesthetic consumption rate measurement). RESULTS: The maintenance isoflurane consumption rate and FGF were significantly lower with the LFW display enabled than without (P = 0.005). The mean reduction in FGF was 53.6% (95% confidence interval, 39.2%-67.9%). There was no significant difference in alveolar isoflurane concentration (P = 0.13 for differences <0.1%). The isoflurane consumption measurement closely matched the consumption measured via the digital scale. CONCLUSIONS: Our data in a simulated anesthetic suggest that enabling the display of FGF efficiency data by the LFW results in a median percent reduction in volatile liquid anesthetic consumption rate of 53.2%. Since the lower limit of the 95% confidence interval for the median is 39.4%, this finding is likely to translate into cost savings and less waste anesthetic gas generated in the clinical setting and released into the atmosphere.

Detecting Social Desirability Bias Using Factor Mixture Models.

Based on the conceptualization that social desirable bias (SDB) is a discrete event resulting from an interaction between a scale's items, the testing situation, and the respondent's latent trait on a social desirability factor, we present a method that makes use of factor mixture models to identify which examinees are most likely to provide biased responses, which items elicit the most socially desirable responses, and which external variables predict SDB. Problems associated with the common use of correlation coefficients based on scales' total scores to diagnose SDB and partial correlations to correct for SDB are discussed. The method is demonstrated with an analysis of SDB in the Attitude toward Interprofessional Service-Learning scale with a sample of students from health-related fields.