Leadership lessons from military education for postgraduate medical curricular improvement.

BACKGROUND: quality medical education includes both teaching and learning of data-driven knowledge, and appropriate technical skills and tacit behaviours, such as effective communication and professional leadership. But these implicit behaviours are not readily adaptable to traditional medical curriculum models. This manuscript explores a medical leadership curriculum informed by military education. CONTEXT: our paediatric anaesthesia residents expressed a strong desire for more leadership opportunity within the training programme. Upon exploration, current health care models for leadership training were limited to short didactic presentations or lengthy certificate programmes. We could not find an appropriate model for our 1-year fellowship. INNOVATION: in collaboration with the US Naval Academy, we modified the 'Leadership Education and Development Program' curriculum to introduce daily and graduated leadership opportunities: starting with low-risk decision-making tasks and progressing to independent professional decision making and leadership. Each resident who opted into the programme had a 3-month role as team leader and spent 9 months as a team member. At the end of the first year of this curriculum both quantitative assessment and qualitative reflection from residents and faculty members noted significantly improved clinical and administrative decision making. The second-year residents' performance showed further improvement. IMPLICATIONS: medical education has long emphasised subject-matter knowledge as a prime focus. However, in competency-based medical education, new curriculum models are needed. Many helpful models can be found in other professional fields. Collaborations between professional educators benefit the students, who are learning these new skills, the medical educators, who work jointly with other professionals, and the original curriculum designer, who has an opportunity to reflect on the strengths and weaknesses of his or her model.

Affordable simulation for small-scale training and assessment.

INTRODUCTION: High-fidelity patient simulation is increasingly recognized as an effective means of team training, acquisition and maintenance of technical and professional skills, and reliable performance assessment; however, finding a cost effective solution to providing such instruction can be difficult. This report describes the rationale, design, and appropriateness of a portable simulation model and example of its successful use at national meetings. METHODS: The Stanford Simulation Group, in association with several other centers, developed a portable Pediatric Simulation Training and Assessment Program (Pediatric Anesthesia in-Situ Simulation) and presented it at two national meetings. The technical challenges and costs of development are outlined, and a satisfaction survey was conducted at the completion of the program. RESULTS: All respondents (100%) either agreed or strongly agreed that the course was useful, met expectations, was enjoyable, and that the scenarios were realistic. CONCLUSIONS: The Portable Simulation Training and Assessment Program (Pediatric Anesthesia in-Situ Simulation) presents innovative educational and financial opportunities to assist in both training and assessment of critical emergency response skills at smaller institutions and allows specialized instruction in an in situ setting.

Patient simulation: a literary synthesis of assessment tools in anesthesiology.

High-fidelity patient simulation (HFPS) has been hypothesized as a modality for assessing competency of knowledge and skill in patient simulation, but uniform methods for HFPS performance assessment (PA) have not yet been completely achieved. Anesthesiology as a field founded the HFPS discipline and also leads in its PA. This project reviews the types, quality, and designated purpose of HFPS PA tools in anesthesiology. We used the systematic review method and systematically reviewed anesthesiology literature referenced in PubMed to assess the quality and reliability of available PA tools in HFPS. Of 412 articles identified, 50 met our inclusion criteria. Seventy seven percent of studies have been published since 2000; more recent studies demonstrated higher quality. Investigators reported a variety of test construction and validation methods. The most commonly reported test construction methods included "modified Delphi Techniques" for item selection, reliability measurement using inter-rater agreement, and intra-class correlations between test items or subtests. Modern test theory, in particular generalizability theory, was used in nine (18%) of studies. Test score validity has been addressed in multiple investigations and shown a significant improvement in reporting accuracy. However the assessment of predicative has been low across the majority of studies. Usability and practicality of testing occasions and tools was only anecdotally reported. To more completely comply with the gold standards for PA design, both shared experience of experts and recognition of test construction standards, including reliability and validity measurements, instrument piloting, rater training, and explicit identification of the purpose and proposed use of the assessment tool, are required.

Building faculty community: fellowship in graduate medical education administration.

INTRODUCTION: The Department of Graduate Medical Education at Stanford Hospital and Clinics has developed a professional training program for program directors. This paper outlines the goals, structure, and expected outcomes for the one-year Fellowship in Graduate Medical Education Administration program. BACKGROUND: The skills necessary for leading a successful Accreditation Council for Graduate Medical Education (ACGME) training program require an increased level of curricular and administrative expertise. To meet the ACGME Outcome Project goals, program directors must demonstrate not only sophisticated understanding of curricular design but also competency-based performance assessment, resource management, and employment law. Few faculty-development efforts adequately address the complexities of educational administration. As part of an institutional-needs assessment, 41% of Stanford program directors indicated that they wanted more training from the Department of Graduate Medical Education. INTERVENTION: To address this need, the Fellowship in Graduate Medical Education Administration program will provide a curriculum that includes (1) readings and discussions in 9 topic areas, (2) regular mentoring by the director of Graduate Medical Education (GME), (3) completion of a service project that helps improve GME across the institution, and (4) completion of an individual scholarly project that focuses on education. RESULTS: The first fellow was accepted during the 2008-2009 academic year. Outcomes for the project include presentation of a project at a national meeting, internal workshops geared towards disseminating learning to peer program directors, and the completion of a GME service project. The paper also discusses lessons learned for improving the program.

Special anesthetic considerations for stereotactic radiosurgery in children.

Children present special anesthetic considerations, not only in their unique pharmacologic and physiologic attributes but also in the types of anesthetic care they require. A new neurosurgical technique, the gamma knife, is particularly challenging for pediatric anesthesia providers because of its extended duration, multiple site procedures, and anesthetic requirements associated with the use of a stereotactic frame.

An analysis of factors influencing postanesthesia recovery after pediatric ambulatory tonsillectomy and adenoidectomy.

BACKGROUND: Many factors contribute to prolonged length of stay (LOS) for pediatric patients in the postanesthesia care unit (PACU). We designed this prospective study to identify the pre- and postoperative factors that prolong LOS. METHODS: We studied 166 children, aged 1-18 yr, who underwent tonsillectomy and adenoidectomy or tonsillectomy and adenoidectomy, and bilateral myringotomy with tube insertion under general anesthesia. The primary outcome measure was the time spent in the PACU until predetermined discharge criteria were met. RESULTS: The number of episodes of postoperative nausea and vomiting, patient age, and number of oxygen desaturations contributed significantly (P < 0.05) to prolonged LOS. Each episode of postoperative nausea and vomiting (P < 0.05) or oxygen desaturation to <95% (P < 0.05) increased the patient's LOS by 0.5 h. History of upper respiratory tract infection, emergence agitation, and parental anxiety did not significantly predict increased LOS. CONCLUSION: This investigation is the first composite view of LOS in pediatric patients. The significance of identifying patients at risk of prolonged LOS prior to anesthesia is of use not only in allocating PACU resource and staffing needs, but also for improving quality of care and ensuring a minimally traumatic anesthetic experience for our pediatric patients and their families.

Avian flu (H5N1): its epidemiology, prevention, and implications for anesthesiology.

Avian flu, influenza A subtype H5N1, is an emergent and virulent disease that poses a threat to the health and safety of the world community. Avian flu is 1 of more than 25 influenza A viruses that reside primarily in birds but also infect humans and other mammals. Avian flu is responsible for the current outbreak in Asia; H5N1 has now displayed probable human-to-human transmission; it could be a harbinger of a global epidemic. Anesthesiologists are exposed to a risk for infection when they are involved in airway instrumentation of infected patients. Given the evidence of emerging resistance to common antiviral agents used to treat H5N1 influenza virus and limited supply of H5N1 vaccine, prevention is our best protection. The following article will detail the virology and preventive public health practices for H5N1. This knowledge can also be used to define and prevent other yet unidentified infectious threats.

Blood loss during posterior spinal fusion surgery in patients with neuromuscular disease: is there an increased risk?

BACKGROUND: Scoliosis surgery in paediatric patients can carry significant morbidity associated with intraoperative blood loss and the resultant transfusion therapy. Patients with neuromuscular disease may be at an increased risk for this intraoperative blood loss, but it is unclear if this is because of direct vascular pathophysiological changes or the fact that neuromuscular patients typically have more extensive orthopaedic disease and more vertebral segments involved. This study examined the risk of extensive blood loss (>50% of total blood volume) in patients with neuromuscular disease compared with patients who did not have neuromuscular disease when the extent of the surgery (number of segments fused), age and preoperative coagulation profile where taken into consideration. METHODS: Retrospective chart review of 163 paediatric patients was preformed. Patients who carried a diagnosis of preexisting neuromuscular disease were classified as such. Idiopathic, traumatic and iatrogenic scoliosis were classified as nonneuromuscular. Extensive blood loss was defined as >50% of estimated total blood volume. Logistic regression was used to predict the risk of extensive blood loss between the two groups when age, weight, extent of surgery was controlled for and anaesthetic and surgical techniques remained similar. RESULTS: Patients with neuromuscular disease did not vary significantly in age, weight, or preoperative haematocrit and platelet count from patients without neuromuscular disease. Neuromuscular patients did have significantly more vertebral segments fused. When this difference was controlled for statistically, neuromuscular patients had an almost seven times higher risk (adjusted odds ration 6.9, P < 0.05) of losing >50% of their estimated total blood volume during scoliosis surgery. CONCLUSIONS: Patients with neuromuscular disease can present various anaesthetic challenges during scoliosis surgery, among these is the inherent risk of extensive blood loss. Recognizing this may help anaesthesiologists and surgeons more accurately prepare for and treat intraoperative blood loss during scoliosis surgery in patients with neuromuscular disease.