Practicality of using galvanic skin response to measure intraoperative physiologic autonomic activation in operating room team members.

BACKGROUND: Physiologic and psychological stress are commonly experienced by operating room (OR) personnel, yet there is little research about the stress levels in OR teams and their impact on performance. Previously published procedures to measure physiologic activation are invasive and impractical for the OR. The purpose of this study was to determine the practicality of a new watch-sized device to measure galvanic skin response (GSR) in OR team members during high-fidelity surgical simulations. METHODS: Interprofessional OR teams wore sensors on the wrist (all) and ankle (surgeons and scrub nurses/technicians) during the orientation, case, and debriefing phases for 17 simulations of a surgical airway case. Data were compared across all simulation phases, collectively and for each professional group. RESULTS: Forty anesthesiology residents, 35 surgery residents, 27 OR nurses, 12 surgical technicians, and 7 CRNAs participated. Collectively, mean wrist GSR levels significantly increased from orientation phase to the case (0.40-0.62 µS; P < .001) and remained elevated even after the simulation was over (0.40-0.67 µS; P < .001). Surgery residents were the only group that demonstrated continued increases in wrist GSR levels throughout the entire simulation (change in GSR = 0.21 to 0.32 to 0.11 µS; P < .01). Large intraindividual differences (≤ 200 times) were found in both wrist and ankle GSR. There was no correlation between wrist and ankle data. CONCLUSION: Continuous GSR monitoring of all professionals during OR simulations is feasible, but would be difficult to implement in an actual OR environment. Large variation in individual levels of physiologic activation suggests complementary qualitative research is needed to better understand how people respond to stressful OR situations.

Prediction accuracy and financial savings of four screening tests for a sequential test of clinical performance.

BACKGROUND: Sequential testing of clinical performance is an effective strategy to reduce cost of testing. PURPOSE: To evaluate prediction accuracy and financial savings of 4 screening tests of clinical performance. METHODS: Screening tests were created from a 13-case examination taken by 434 medical students at 4 schools. Regression analysis determined prediction accuracy for 2 test outcomes. Financial savings were computed from published estimates. RESULTS: Zero false passes were obtained with the "Total Number of Cases Passed" screening test, but it saved only 27%. Sixty-two percent savings with 5% false passes occurred with the "Classification" screening test. The "Scale" and "Mini Test" screening tests would have excused 79% and 67% examinees with 5% and 1% false passes, respectively. CONCLUSIONS: Prediction accuracy varies with screening test and outcome measure. Sequential testing of clinical performance can save 40% to 60% with low false pass rates. However, programs need to consider loss of information for curriculum and individual feedback relative to financial savings.

Effectiveness of an occupational and environmental medicine curriculum as indicated by evaluation of medical student performance on an objective structured clinical examination.

Medical students must learn to recognize occupational and environmental-related illness. An occupational and environmental medicine curriculum can achieve this goal. The curriculum must be evaluated to ensure that medical students are learning to recognize exposure-related health conditions and to evaluate if this ability correlates with medical interviewing skills. A case, formatted for an Objective Structured Clinical Examination (OSCE), was developed to evaluate student performance on an exposure-related clinical problem. The OSCE results were analyzed to identify the areas that differentiated the students who recognized an exposure-related medical condition from those who did not. We conclude that an OSCE is an effective curriculum evaluation tool to assess whether a core occupational and environmental-related curriculum is contributing to student learning in exposure history-taking and associated clinical reasoning skills.

Simulation technology for health care professional skills training and assessment.

Changes in medical practice that limit instruction time and patient availability, the expanding options for diagnosis and management, and advances in technology are contributing to greater use of simulation technology in medical education. Four areas of high-technology simulations currently being used are laparoscopic techniques, which provide surgeons with an opportunity to enhance their motor skills without risk to patients; a cardiovascular disease simulator, which can be used to simulate cardiac conditions; multimedia computer systems, which includes patient-centered, case-based programs that constitute a generalist curriculum in cardiology; and anesthesia simulators, which have controlled responses that vary according to numerous possible scenarios. Some benefits of simulation technology include improvements in certain surgical technical skills, in cardiovascular examination skills, and in acquisition and retention of knowledge compared with traditional lectures. These systems help to address the problem of poor skills training and proficiency and may provide a method for physicians to become self-directed lifelong learners.

Implementation of a four-year multimedia computer curriculum in cardiology at six medical schools.

The pressures of a changing health care system are making inroads on the commitment and effort that both basic science and clinical faculty can give to medical education. A tool that has the potential to compensate for decreased faculty time and thereby to improve medical education is multimedia computer instruction that is applicable at all levels of medical education, developed according to instructional design principles, and supported by evidence of effectiveness. The authors describe the experiences of six medical schools in implementing a comprehensive computer-based four-year curriculum in bedside cardiology developed by a consortium of university cardiologists and educational professionals. The curriculum consisted of ten interactive, patient-centered, case-based modules focused on the history, physical examination, laboratory data, diagnosis, and treatment. While an optimal implementation plan was recommended, each institution determined its own strategy. Major goals of the project, which took place from July 1996 to June 1997, were to identify and solve problems of implementation and to assess learners' and instructors' acceptance of the system and their views of its value. A total of 1,586 students used individual modules of the curriculum 6,131 times. Over 80% of students rated all aspects of the system highly, especially its clarity and educational value compared with traditional lectures. The authors discuss the aspects of the curriculum that worked, problems that occurred (such as difficulties in scheduling use of the modules in the third year), barriers to change and ways to overcome them (such as the type of team needed to win acceptance for and oversee implementation of this type of curriculum), and the need in succeeding years to formally assess the educational effectiveness of this and similar kinds of computer-based curricula.

Are medical students ready to provide HIV-prevention counseling?

PURPOSE: To determine whether medical students were prepared to assess risk and counsel patients about prevention of HIV infection, and whether HIV-related experience produced better knowledge and counseling skills. METHOD: In 1995, students at four North Carolina medical schools interviewed a standardized patient portraying a young woman concerned about HIV infection. The standardized patient recorded whether students asked risk-behavior questions and provided risk-reduction advice. A 21-item questionnaire assessed the students' knowledge of HIV testing and prevention. Students indicated whether they had had experience in educational settings related to HIV or STDs. RESULTS: 415 students completed both the patient interview and the questionnaire. Many failed to ask the patient about several HIV-risk behaviors. Although nearly all (98%) inquired about condom use, fewer than two thirds asked about the patient's history of STDs, number of sexual partners, or specific sexual practices. Most students advised the patient to use condoms. The average score on the knowledge test was 79%; 70% of students confused anonymous with confidential testing, more than half overestimated the risk of HIV transmission from a needle stick, and nearly one in ten did not know how to use a condom. Educational exposures did not produce significantly better risk assessment, counseling information, or knowledge scores. CONCLUSION: A majority of experienced medical students did not assess several important risk factors of a patient concerned about HIV infection, and many would have provided incorrect information related to HIV testing and prevention of infection. Patient contact in traditional clinical settings did not influence prevention knowledge or behavior. More innovative methods are needed to train students in HIV-infection prevention and counseling.

Development of a measure of medical faculty attitudes toward clinical evaluation of students.

PURPOSE: This research involved the development, and in particular the evaluation of the reliability, of scales to measure medical faculty attitudes toward clinical evaluation (ACE) of medical students. The intent was to create measures that yield reliable data and have practical utility in medical education research and faculty development. METHOD: A systematic, eight-step scale development protocol was used to create the instrument. In early 1993 factor analysis was used on data from 217 clinical faculty at four medical schools to refine the measures. Internal consistency and test-retest reliability analyses were performed. Analyses were also done to determine whether the attitude scores were influenced by such faculty demographic attributes as employing medical school, gender, age, tenure track status, academic rank, or academic department. RESULTS: An initial pool of 52 items was reduced to 30 items based on iterative reliability studies. Factor analysis on the 30 items yielded two scales: (1) Quality of Evaluation Procedures, 12 items, alpha = .81; and (2) Content of Departmental Evaluations, eight items, alpha = .85. Test-retest reliabilities (12 weeks) for the scales were .67 and .74, respectively. Faculty demographics did not influence attitudes about the quality of evaluation procedures. However, family physicians showed a slightly more positive attitude toward the content of departmental evaluations than did physicians in five other medical specialties. CONCLUSION: The goal of developing reliable measures of faculty attitudes toward clinical evaluation of medical students has been achieved. With baseline reliabilities established, future research should assess the validity and utility of the scales, especially in the context of clinical practice examinations.

Standardized patient encounters. A method for teaching and evaluation.

The primary goal of medical education is to foster development of clinical competence in trainees at all levels. Variable clinical experience, inconsistent methods of instruction, and ambiguous evaluation criteria undermine this goal. Standardized patients, trained to consistently portray a wide variety of clinical cases, can help overcome many of these educational problems. This article describes the development and application of standardized patients throughout medical training at The University of Texas Medical Branch, Galveston, in the freshman interviewing course, the second-year physical diagnosis course, third-year clerkships, a fourth-year final exercise, and residency training. Development of this program is discussed in the context of a broader literature in medical education, and investigation of variables affecting standardized patient and student performance is reported. Future directions for use of standardized patients in monitoring and promoting the development of clinical competence are discussed.

Reliability and validity of an objective structured clinical examination for assessing the clinical performance of residents.

Clinical performance of residents should be assessed as reliably and validly as possible. This study investigated the reliability and validity of an objective structured clinical examination (OSCE) for assessing clinical performance of internal medicine residents. Residents were required to take a 17-patient OSCE in their first and second year. Reliability of the OSCE was 0.40. Validity studies indicated second-year students were significantly better than third-year students for five of six OSCE skill scores; first-year students were significantly better for three scores. Resident's scores for diagnosis, plan, and total significantly increased on their second OSCE. Generally faculty overall ratings of residents' clinical performance did not correlate with OSCE scores. American Board of Internal Medicine certifying examination scores were consistently positively correlated only with diagnosis. This 17-case OSCE is a feasible method for obtaining moderately reliable, valid data not available from other sources about the clinical performance of residents. More cases should be added to increase its reliability.

Improving compliance with preventive medicine procedures in a house staff training program.

Performance of health maintenance procedures by internal medicine house staff is inadequate, yet little has been published outlining means to improve performance rates. We prospectively studied the effectiveness of a reminder system to improve screening by Pap smear, rectal examination with stool guaiac test, breast examination, and pneumococcal vaccine administration in two resident outpatient clinics. Performance of these preventive health measures was determined during a six-week baseline period and again after five months of chart reminders to residents in one clinic, and after six months without reminders. For the intervention, a physician's assistant screened each chart and attached a reminder to the front indicating which procedures were overdue based on published recommendations. Health screening behavior was not significantly different between the two resident clinics during baseline. After the five-month reminder intervention, residents in both groups moderately increased their preventive health activities over baseline; however, only the reminded group showed significant improvement (chi 2 = 11.60, P less than .001). Six months after remainders were discontinued there was no difference in overall performance between the two clinics (chi 2 = 2.79, NS). The reminded group did preserve its significant improvement over the baseline phase (chi 2 = 6.12, P less than .01). This simple reminder system had a modest but statistically significant positive impact on health screening behavior. Despite this improvement, absolute rates of screening remained below 50% in both clinics.

An objective measure of clinical performance.

Studies repeatedly have shown the clinical performance of students and residents to be less than expected by faculty. Because evaluation methods substantially influence education, poor performance can be improved with better clinical evaluation methods. This study evaluated a standardized method to measure clinical performance in which trained actual and simulated patients were organized in a multiple-station format for efficient testing of examinees on 17 cases in less than four hours. Specific checklists completed by patients and predetermined scoring protocols yielded reliable data and reduced faculty time. Data from 204 students in three clerkships were consistent with previous research showing case specificity and substantial case-to-case variability. As a group however, the students' overall total scores were very similar. This suggests that clinical education is inconsistent and that a profile of an examinee's performance is more accurate than a single overall score. Validity of this standardized clinical examination was supported by significant but moderate correlations with faculty ratings of ward performance and the medicine subtest of the National Board of Medical Examiners test, part II. Direct per-student costs were $21.00. This standardized objective examination of clinical skills is feasible for use in training programs and will provide reliable and valid data on clinical performance not available through typical methods.

A comparative evaluation of text formats in a medical school course.

Information mapping, a system of instruction design for categorizing, sequencing and graphically presenting printed information for highly technical communication in business, seemed ideally suited for presenting the technical procedures of the general screening physical examination to medical students. To evaluate the impact of this new text format one half of the class received a conventional text for those procedures and the other half used an information mapped text. Cognitive test scores were not significantly different. However, the information mapped text was rated significantly more favorably on six dimensions. Students using the mapped text also spent significantly more time studying it than those using the conventional text.

Successful treatment of chronic idiopathic urticaria and angioedema with cimetidine alone.

We have studied a 50-year-old white man with chronic urticaria and angioedema who has responded to treatment with cimetidine alone for over 2 yr. In a double-blind, placebo-controlled study, cimetidine alone was at least as effective as chlorpheniramine in relief of urticaria and angioedema. Additionally, cimetidine significantly inhibited (p less than 0.01) the wheal response to histamine when it was compared to placebo. The inhibition of wheal response to histamine by cimetidine was significantly higher (p less than 0.05) than chlorpheniramine. The presence of predominantly H2- rather than H1-histamine receptors in the cutaneous blood vessels may be responsible for the therapeutic effects of cimetidine in this patient.