Simulation Training in Penile Implant Surgery: Assessment of Surgical Confidence and Knowledge With Cadaveric Laboratory Training.

INTRODUCTION: Constraints on surgical resident training (work-hour mandates, shorter training programs, etc.) and availability of expert surgical educators may limit the acquisition of prosthetic surgical skills. As a result, training courses are being conducted to augment the prosthetic surgery learning experience. AIM: To evaluate the impact of a hands-on cadaver-based teaching program on resident procedural knowledge and procedural confidence with placement of a penile prosthesis. MAIN OUTCOME MEASURE: Changes in procedural knowledge and self-confidence following a focused training program on penile prosthetics. METHODS: As part of the 2017 Society of Urologic Prosthetic Surgeons and the Sexual Medicine Society of North America Annual Meeting, 31 urology residents participated in a simulation lab in prosthetic urology. The lab included didactic lectures and a hands-on cadaveric laboratory. Participants completed surveys before and after the course. Wilcoxon Signed Rank tests for matched pairs were used to compare respondents' pre- and postcourse knowledge (% questions answered correctly) and confidence ratings. Prior implant experience was assessed. RESULTS: 31 residents participated in this study. The majority of the participants were 4th- (41.9%) and 5th-year residents (38.7%). Participants showed a significant improvement in procedural knowledge test scores (68.8±13.4 vs 74.2 ± 13.0, P < .05) and self-reported increased median surgical confidence levels (4 vs 3, P value < .001) after completion of the cadaveric course. Subgroup analysis demonstrated that residents with prosthetic surgery experience of <10 cases benefited the most. In addition, improvement in surgical confidence levels observed was greater than the improvement in surgical knowledge. The overall cost of the simulation training course was approximately $1,483 per resident. CONCLUSION: Simulation training in prosthetic surgery seems to improve surgical confidence and knowledge. Further research is needed to better understand the benefits and limitations of simulation training. Lentz AC, Rodríguez D, Davis LG. Simulation training in penile implant surgery: Assessment of surgical confidence and knowledge with cadaveric laboratory training. Sex Med 2018;6:332-338.

A Team-Based Online Game Improves Blood Glucose Control in Veterans With Type 2 Diabetes: A Randomized Controlled Trial.

OBJECTIVE: Rigorous evidence is lacking whether online games can improve patients' longer-term health outcomes. We investigated whether an online team-based game delivering diabetes self-management education (DSME) to patients via e-mail or mobile application (app) can generate longer-term improvements in hemoglobin A1c (HbA1c). RESEARCH DESIGN AND METHODS: Patients (n = 456) on oral diabetes medications with HbA1c ≥58 mmol/mol were randomly assigned between a DSME game (with a civics booklet) and a civics game (with a DSME booklet). The 6-month games sent two questions twice weekly via e-mail or mobile app. Participants accrued points based on performance, with scores posted on leaderboards. Winning teams and individuals received modest financial rewards. Our primary outcome measure was HbA1c change over 12 months. RESULTS: DSME game patients had significantly greater HbA1c reductions over 12 months than civics game patients (-8 mmol/mol [95% CI -10 to -7] and -5 mmol/mol [95% CI -7 to -3], respectively; P = 0.048). HbA1c reductions were greater among patients with baseline HbA1c >75 mmol/mol: -16 mmol/mol [95% CI -21 to -12] and -9 mmol/mol [95% CI -14 to -5] for DSME and civics game patients, respectively; P = 0.031. CONCLUSIONS: Patients with diabetes who were randomized to an online game delivering DSME demonstrated sustained and meaningful HbA1c improvements. Among patients with poorly controlled diabetes, the DSME game reduced HbA1c by a magnitude comparable to starting a new diabetes medication. Online games may be a scalable approach to improve outcomes among geographically dispersed patients with diabetes and other chronic diseases.

A randomized, controlled trial of team-based competition to increase learner participation in quality-improvement education.

OBJECTIVE: Several barriers challenge resident engagement in learning quality improvement (QI). We investigated whether the incorporation of team-based game mechanics into an evidence-based online learning platform could increase resident participation in a QI curriculum. DESIGN: Randomized, controlled trial. SETTING: Tertiary-care medical center residency training programs. PARTICIPANTS: Resident physicians (n = 422) from nine training programs (anesthesia, emergency medicine, family medicine, internal medicine, ophthalmology, orthopedics, pediatrics, psychiatry and general surgery) randomly allocated to a team competition environment (n = 200) or the control group (n = 222). INTERVENTION: Specialty-based team assignment with leaderboards to foster competition, and alias assignment to de-identify individual participants. MAIN OUTCOME MEASURES: Participation in online learning, as measured by percentage of questions attempted (primary outcome) and additional secondary measures of engagement (i.e. response time). Changes in participation measures over time between groups were assessed with a repeated measures ANOVA framework. RESULTS: Residents in the intervention arm demonstrated greater participation than the control group. The percentage of questions attempted at least once was greater in the competition group (79% [SD ± 32] versus control, 68% [SD ± 37], P= 0.03). Median response time was faster in the competition group (P= 0.006). Differences in participation continued to increase over the duration of the intervention, as measured by average response time and cumulative percent of questions attempted (each P< 0.001). CONCLUSIONS: Team competition increases resident participation in an online course delivering QI content. Medical educators should consider game mechanics to optimize participation when designing learning experiences.

A little healthy competition: using mixed methods to pilot a team-based digital game for boosting medical student engagement with anatomy and histology content.

BACKGROUND: Digital games have been demonstrated to be beneficial for a range of non-recreational purposes, with a particular focus on their value for education. There is a limited amount of research supporting their use for medical education, but their are several studies on their use in areas such as surgical training, and life-support re-training. However, a significant gap exists in demonstrating how they engage with learners and games can be used most effectively in medical education. This pilot study assessed the value of digital games for teaching anatomy, by evaluating participant engagement and their attitudes towards a team-based strategy game. METHODS: A digital game platform was designed, and then populated with anatomy questions developed by subject matter experts. Second year medical students were recruited to play three matches of the game. At the end of each match participants were asked to complete a Likert rating of their experiences of the game across five domains. Semi-structured interviews were conducted to assess engagement with the platform and perceived value to learners. RESULTS: Sixteen participants volunteered to participate. Post-match ratings indicated that participants had a generally positive experience with the game, with 89 % of respondents agreeing the game was engaging, 93 % of respondents agreeing the game was challenging and 74 % indicating they would like to play the game again if given the opportunity. A total of fourteen participants agreed to be interviewed after playing three matches of the game. Interview responses supported the findings of the post-match ratings that the game was considered enjoyable and engaging. Participants noted they particularly enjoyed the competitive aspect of the game, particularly the opportunity to play against peers they consider their academic equals. In addition to finding the game engaging interview participants indicated they perceived the game impacted on their knowledge around anatomy. In particular, participants noted that the game provided them unique insight into their knowledge strengths and deficits. CONCLUSIONS: This study demonstrated that digital games can engage medical students in traditionally-challenging areas such as anatomy and offer learners unique insights into their knowledge strengths and deficits.

An online spaced-education game among clinicians improves their patients' time to blood pressure control: a randomized controlled trial.

BACKGROUND: Many patients with high blood pressure (BP) do not have antihypertensive medications appropriately intensified at clinician visits. We investigated whether an online spaced-education (SE) game among primary care clinicians can decrease time to BP target among their hypertensive patients. METHODS AND RESULTS: A 2-arm randomized trial was conducted over 52 weeks among primary care clinicians at 8 hospitals. Educational content consisted of 32 validated multiple-choice questions with explanations on hypertension management. Providers were randomized into 2 groups: SE clinicians were enrolled in the game, whereas control clinicians received identical educational content in an online posting. SE game clinicians were e-mailed 1 question every 3 days. Adaptive game mechanics resent questions in 12 or 24 days if answered incorrectly or correctly, respectively. Clinicians retired questions by answering each correctly twice consecutively. Posting of relative performance among peers fostered competition. Primary outcome measure was time to BP target (<140/90 mm Hg). One hundred eleven clinicians enrolled. The SE game was completed by 87% of clinicians (48/55), whereas 84% of control clinicians (47/56) read the online posting. In multivariable analysis of 17 866 hypertensive periods among 14 336 patients, the hazard ratio for time to BP target in the SE game cohort was 1.043 (95% confidence interval, 1.007-1.081; P=0.018). The number of hypertensive episodes needed to treat to normalize one additional patient's BP was 67.8. The number of clinicians needed to teach to achieve this was 0.43. CONCLUSIONS: An online SE game among clinicians generated a modest but significant reduction in the time to BP target among their hypertensive patients. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00904007.

An online spaced-education game to teach and assess medical students: a multi-institutional prospective trial.

PURPOSE: To investigate whether a spaced-education (SE) game can be an effective means of teaching core content to medical students and a reliable and valid method of assessing their knowledge. METHOD: This nine-month trial (2008-2009) enrolled students from three U.S. medical schools. The SE game consisted of 100 validated multiple-choice questions-explanations in preclinical/clinical domains. Students were e-mailed two questions daily. Adaptive game mechanics re-sent questions in three or six weeks if answered, respectively, incorrectly or correctly. Questions expired if not answered on time (appointment dynamic). Students retired questions by answering each correctly twice consecutively (progression dynamic). Posting of relative performance fostered competition. Main outcome measures were baseline and completion scores. RESULTS: Seven-hundred thirty-one students enrolled. Median baseline score was 53% (interquartile range [IQR] 16) and varied significantly by year (P<.001, dmax=2.08), school (P<.001, dmax=0.75), and gender (P<.001, d=0.38). Median completion score was 93% (IQR 12) and varied significantly by year (P=.001, dmax=1.12), school (P<.001, dmax=0.34), and age (P=.019, dmax=0.43). Scores did not differ significantly between years 3 and 4. Seventy percent of enrollees (513/731) requested to participate in future SE games. CONCLUSIONS: An SE game is an effective and well-accepted means of teaching core content and a reliable and valid method to assess student knowledge. SE games may be valuable tools to identify and remediate students who could benefit from additional educational support.

An online spaced-education game for global continuing medical education: a randomized trial.

OBJECTIVE: To assess the efficacy of a "spaced-education" game as a method of continuing medical education (CME) among physicians across the globe. BACKGROUND: The efficacy of educational games for the CME has yet to be established. We created a novel online educational game by incorporating game mechanics into "spaced education" (SE), an evidence-based method of online CME. METHODS: This 34-week randomized trial enrolled practicing urologists across the globe. The SE game consisted of 40 validated multiple-choice questions and explanations on urology clinical guidelines. Enrollees were randomized to 2 cohorts: cohort A physicians were sent 2 questions via an automated e-mail system every 2 days, and cohort B physicians were sent 4 questions every 4 days. Adaptive game mechanics re-sent the questions in 12 or 24 days if answered incorrectly and correctly, respectively. Questions expired if not answered on time (appointment dynamic). Physicians retired questions by answering each correctly twice-in-a-row (progression dynamic). Competition was fostered by posting relative performance among physicians. Main outcome measures were baseline scores (percentage of questions answered correctly upon initial presentation) and completion scores (percentage of questions retired). RESULTS: A total of 1470 physicians from 63 countries enrolled. Median baseline score was 48% (interquartile range [IQR] 17) and, in multivariate analyses, was found to vary significantly by region (Cohen dmax = 0.31, P = 0.001) and age (dmax = 0.41, P < 0.001). Median completion score was 98% (IQR 25) and varied significantly by age (dmax = 0.21, P < 0.001) and American Board of Urology certification (d = 0.10, P = 0.033) but not by region (multivariate analyses). Question clustering reduced physicians' performance (d = 0.43, P < 0.001). Seventy-six percent of enrollees (1111/1470) requested to participate in future SE games. CONCLUSIONS: An online SE game can substantially improve guidelines knowledge and is a well-accepted method of global CME delivery.

An online spaced-education game to teach and assess residents: a multi-institutional prospective trial.

BACKGROUND: While games are frequently used in resident education, there is little evidence supporting their efficacy. We investigated whether a spaced-education (SE) game can be both a reliable and valid method of assessing residents' knowledge and an effective means of teaching core content. STUDY DESIGN: The SE game consisted of 100 validated multiple-choice questions and explanations on core urology content. Residents were sent 2 questions each day via email. Adaptive game mechanics re-sent the questions in 2 or 6 weeks if answered incorrectly and correctly, respectively. Questions expired if not answered on time (appointment dynamic). Residents retired questions by answering each correctly twice in a row (progression dynamic). Competition was fostered by posting relative performance among residents. Main outcomes measures were baseline scores (percentage of questions answered correctly on initial presentation) and completion scores (percentage of questions retired). RESULTS: Nine hundred thirty-one US and Canadian residents enrolled in the 45-week trial. Cronbach alpha reliability for the SE baseline scores was 0.87. Baseline scores (median 62%, interquartile range [IQR] 17%) correlated with scores on the 2008 American Urological Association in-service examination (ISE08), 2009 American Board of Urology qualifying examination (QE09), and ISE09 (r = 0.76, 0.46, and 0.64, respectively; all p < 0.001). Baseline scores varied by sex, country, medical degree, and year of training (all p ≤ 0.001). Completion scores (median 100%, IQR 2%) correlated with ISE08 and ISE09 scores (r = 0.35, p < 0.001 for both). Seventy-two percent of enrollees (667 of 931) requested to participate in future SE games. CONCLUSIONS: An SE game is a reliable and valid means to assess residents' knowledge and is a well-accepted method by which residents can master core content.

Do chief resident scores on the in-service examination predict their performance on the American Board of Urology Qualifying Examination?

PURPOSE: The American Urological Association In-Service Examination and the American Board of Urology Qualifying Examination are written multiple choice tests that cover all domains in urology. We investigated whether In-Service Examination performance could identify chief residents who scored in the lowest quartile on the Qualifying Examination. MATERIALS AND METHODS: All urology chief residents in the United States and Canada in 2008 and 2009 were eligible to participate in this study. In-Service Examination 2008 and Qualifying Examination 2009 performance data were obtained from the American Urological Association and American Board of Urology, respectively. Data were analyzed with the Pearson correlation and descriptive statistics. RESULTS: Of the 257 American and Canadian chief residents who completed the Qualifying Examination 2009, 194 (75%) enrolled in this study and were included in analysis. Overall In-Service Examination 2008 scores correlated significantly with Qualifying Examination 2009 scores (r=0.55, p<0.001), accounting for 30% of score variance. Substantial variability in In-Service Examination-Qualifying Examination rankings was notable among individual residents. An In-Service Examination 2008 cutoff percentile rank of 40% identified chief residents in the lowest quartile on the Qualifying Examination 2009 with 71% sensitivity, 77% specificity, and a likelihood ratio of 3.1 and 0.4 (positive and negative likelihood ratios, respectively). CONCLUSIONS: The substantial variability of In-Service Examination-Qualifying Examination performance among individual chief residents limits In-Service Examination predictive utility. A single In-Service Examination score should not be used to make a high stakes judgment about an individual resident. In-Service Examination scores should be used as 1 part of an overall evaluation program to prospectively identify residents who could benefit from additional educational support.

Impact on clinical behavior of face-to-face continuing medical education blended with online spaced education: a randomized controlled trial.

BACKGROUND: Spaced education (SE) is a novel, evidence-based form of online learning. We investigated whether an SE program following a face-to-face continuing medical education (CME) course could enhance the course's impact on providers' clinical behaviors. METHODS: This randomized controlled trial was conducted from March 2009 to April 2010, immediately following the Current Clinical Issues in Primary Care (Pri-Med) CME conference in Houston, Texas. Enrolled providers were randomized to receive the SE program immediately after the live CME event or 18 weeks later (wait-list controls). The SE program consisted of 40 validated questions and explanations covering 4 clinical topics. The repetition intervals were adapted to each provider based on his or her performance (8- and 16-day intervals for incorrect and correct answers, respectively). Questions were retired when answered correctly twice in a row. At week 18, a behavior change survey instrument was administered simultaneously to providers in both cohorts. RESULTS: Seventy-four percent of participants (181/246) completed the SE program. Of these, 97% (176/181) submitted the behavior change survey. Across all 4 clinical topics, providers who received SE reported significantly greater change in their global clinical behaviors as a result of the CME program (p-values .013 to < .001; effect size 0.7). Ninety-seven percent (175/179) requested to participate in future SE supplements to live CME courses. Eighty-six percent (156/179) agreed or strongly agreed that the SE program enhanced the impact of the live CME conference. DISCUSSION: Online spaced education following a live CME course can significantly increase the impact of a face-to-face course on providers' self-reported global clinical behaviors.

Online "spaced education progress-testing" of students to confront two upcoming challenges to medical schools.

PURPOSE: U.S. medical students will soon complete only one licensure examination sequence, given near the end of medical school. Thus, schools are challenged to identify poorly performing students before this high-stakes test and help them retain knowledge across the duration of medical school. The authors investigated whether online spaced education progress-testing (SEPT) could achieve both aims. METHOD: Participants were 2,648 students from four U.S. medical schools; 120 multiple-choice questions and explanations in preclinical and clinical domains were developed and validated. For 34 weeks, students randomized to longitudinal progress-testing alone (LPTA) received four new questions (with answers/ explanations) each week. Students randomized to SEPT received the identical four questions each week, plus two-week and six-week cycled reviews of the questions/explanations. During weeks 31-34, the initial 40 questions were re-sent to students to assess longer-term retention. RESULTS: Of the 1,067 students enrolled, the 120-question progress-test was completed by 446 (84%) and 392 (74%) of the LPTA and SEPT students, respectively. Cronbach alpha reliability was 0.87. Scores were 39.9%, 51.9%, 58.7%, and 58.8% for students in years 1-4, respectively. Performance correlated with Step 1 and Step 2 Clinical Knowledge scores (r = 0.52 and 0.57, respectively; P < .001) and prospectively identified students scoring below the mean on Step 1 with 75% sensitivity, 77% specificity, and 41% positive predictive value. Cycled reviews generated a 170% increase in learning retention relative to baseline (P < .001, effect size 0.95). CONCLUSIONS: SEPT can identify poorly performing students and improve their longer-term knowledge retention.

Durable improvements in prostate cancer screening from online spaced education a randomized controlled trial.

CONTEXT: Prostate cancer screening with prostate-specific antigen (PSA) is frequently performed, counter to clinical practice guidelines. BACKGROUND: It was hypothesized that an e-mail-based intervention termed "spaced education" could reduce clinicians' inappropriate screening for prostate cancer. DESIGN: The study was conducted as an RCT. SETTING/PARTICIPANTS: The study involved 95 primary care clinicians in eight Veterans Affairs medical centers from January 2007 to February 2009. INTERVENTION: Participants were randomized into two cohorts: spaced education clinicians received four isomorphic cycles of nine e-mails over 36 weeks (zero to two e-mails per week), whereas control clinicians received no intervention. Each e-mail presented a clinical scenario and asked whether it was appropriate to obtain a PSA test. Participants received immediate feedback after submitting their answers. MAIN OUTCOME MEASURES: The primary outcome was the number and percentage of inappropriate PSA screening tests ordered. Inappropriate testing was defined as use of PSA for prostate cancer screening in patients aged >76 or <40 years. Appropriateness of screening was dichotomized based on patient age at time of screening. Patients with PSA testing for non-screening reasons were excluded using a validated protocol. Logistic regression with adjustment for patient clustering by clinician was performed. Analyses were conducted in 2009. RESULTS: During the intervention period (Weeks 1-36), clinicians receiving spaced education e-mails ordered significantly fewer inappropriate PSA screening tests than control clinicians (10.5% vs 14.2%, p=0.041). Over the 72-week period following the intervention (Weeks 37-108), spaced education clinicians continued to order fewer inappropriate tests compared to controls (7.8% vs 13.1%, respectively, p=0.011), representing a 40% relative reduction in inappropriate screening. CONCLUSIONS: Spaced education durably improves the prostate cancer screening behaviors of clinicians and represents a promising new methodology to improve patient care across healthcare systems.

Online spaced education generates transfer and improves long-term retention of diagnostic skills: a randomized controlled trial.

BACKGROUND: Retention of learning from surgical training is often limited, especially if the knowledge and skills are used infrequently. Using histopathology diagnostic skills as an experimental system, we compared knowledge transfer and retention between bolus Web-based teaching (WBT) modules and online spaced education, a novel email-based method of online education founded on the spacing effect. STUDY DESIGN: All US urology residents were eligible to participate. Enrollees were randomized to 1 of 2 cohorts. Cohort 1 residents received 3 cycles/repetitions of spaced education on prostate-testis histopathology (weeks 1 to 16) and 3 WBT modules on bladder-kidney (weeks 14 to 16). Cohort 2 residents received 3 cycles of spaced education on bladder-kidney (weeks 1 to 16) and 3 WBT modules on prostate-testis (weeks 14 to 16). Each daily spaced education email presented a clinical scenario with histopathology image and asked for a diagnosis. Participants received immediate feedback after submitting their answers. Each cycle/repetition was 4 weeks long and consisted of 20 questions with unique images. WBT used the identical content and delivery system, with questions aggregated into three 20-question modules. Long-term retention of all 4 topics was assessed during weeks 18 to 45. RESULTS: Seven-hundred and twenty-four urology residents enrolled. Spaced education and WBT were completed by 77% and 66% of residents, respectively. Spaced education and WBT generated mean long-term score increases of 15.2% (SD 15.3%) and 3.4% (SD 16.3%), respectively (p < 0.01). Spaced education increased long-term learning efficiency 4-fold. CONCLUSIONS: Online spaced education generates transfer of histopathology diagnostic skills and substantially improves their long-term retention. Additional research is needed to determine how spaced education can optimize learning, transfer, and retention of surgical skills.

Adaptive spaced education improves learning efficiency: a randomized controlled trial.

PURPOSE: Spaced education is a novel form of online education that harnesses the 2 psychology research findings of spacing and testing effects. Spaced education is delivered by daily emails containing clinically relevant multiple choice questions. To take advantage of the spacing effect the questions are repeated at fixed intervals for a fixed number of repetitions. An adaptive spaced education system was developed to customize spacing intervals and the number of repetitions based on learner knowledge level. To determine whether this system improves learning efficiency I performed a randomized trial to compare the learning efficiency of adaptive vs nonadaptive spaced education systems among surgery students at 2 medical schools. MATERIALS AND METHODS: A total of 62 year 3 students were randomized to identical course content in adaptive or nonadaptive spaced education formats. The course consisted of 40 validated, spaced education items on the 4 urology topics benign prostatic hyperplasia, erectile dysfunction, prostate cancer and prostate specific antigen screening. The nonadaptive cohort received daily emails containing 2 questions with a linear review of the material 20 days after initial presentation. The adaptive cohort received daily emails via an adaptive algorithm that limited the repetition of mastered content. Each cohort completed a validated end of course test. RESULTS: The adaptive cohort answered significantly fewer spaced education items than the nonadaptive cohort (p = 0.001) but achieved comparable end of course test scores (p = 0.37). The adaptive algorithm increased learning efficiency by 38%. CONCLUSIONS: Adaptive spaced education boosts learning efficiency.

Interactive spaced education to assess and improve knowledge of clinical practice guidelines: a randomized controlled trial.

OBJECTIVE: To determine whether Interactive Spaced Education (ISE) is an effective and acceptable form of graduate and continuing medical education (GME/CME), using clinical practice guideline (CPG) education as an experimental system. SUMMARY BACKGROUND DATA: ISE is a novel form of online education, which combines the pedagogical merits of the spacing and testing effects. Its efficacy for GME and CME is not known. METHODS: One-hundred sixty urologists and 320 urology residents were randomized to 1 of 2 cohorts. We developed and validated 48 ISE items (questions and answers) on 5 urology CPGs (hematuria and priapism [HP]; staghorn calculi, infertility, and antibiotic use [SIA]). Physicians were sent 3 emails a week, each containing 2 questions. Content was repeated 3 times over 20 weeks. Cohort A physicians received the 3-cycle ISE course on HP, with 24 control items on SIA in cycle 3. Cohort B physicians received the 3-cycle ISE course on SIA, with 24 control items on HP in cycle 3. RESULTS: The ISE program was completed by 71% urologists and 83% residents. Cohort A scores on HP increased from mean 44.9% in cycle 1% to 75.7% in cycle 3, a 57% relative increase compared with controls (P < 0.001; Cohen effect size, 2.2). Similarly, cohort B scores on SIA increased from 45.2% in cycle 1% to 69.5% in cycle 3, a 56% relative increase compared with controls (P < 0.001; effect size, 2.2). Eighty-four percent of all participants requested to enroll in further ISE programs. CONCLUSIONS: ISE is an effective and well-accepted form of GME and CME and is a promising new methodology to improve CPG knowledge.