Medical students can learn the basic application, analytic, evaluative, and psychomotor skills of critical care medicine.

OBJECTIVE: To determine whether fourth-year medical students can learn the basic analytic, evaluative, and psychomotor skills needed to initially manage a critically ill patient. DESIGN: Student learning was evaluated using a performance examination, the objective structured clinical examination (OSCE). Students were randomly assigned to one of two clinical scenarios before the elective. After the elective, students completed the other scenario, using a crossover design. SETTING: Five surgical intensive care units in a tertiary care university teaching hospital. PARTICIPANTS: Forty fourth-year medical students enrolled in the critical care medicine (CCM) elective. INTERVENTIONS: All students evaluated a live "simulated critically ill" patient, requested physiologic data from a nurse, ordered laboratory tests, received data in real time, and intervened as they deemed appropriate. MEASUREMENTS AND MAIN RESULTS: Student performance of specific behavioral objectives was evaluated at five stations. They were expected to a) assess airway, breathing, and circulation in appropriate sequence; b) prepare a manikin for intubation, obtain an acceptable airway on the manikin, demonstrate bag-mouth ventilation, and perform acceptable laryngoscopy and intubation; c) provide appropriate mechanical ventilator settings; d) manage hypotension; and e) request and interpret pulmonary artery data and initiate appropriate therapy. OSCEs were videotaped and reviewed by two faculty members masked to time of examination. A checklist of key behaviors was used to evaluate performance. The primary outcome measure was the difference in examination score before and after the rotation. Secondary outcomes included the difference in scores at each rotation. The mean preelective score was 57.0%+/-8.3% compared with 85.9%+/-7.4% (p<.0001) after the elective. Significant improvement was demonstrated at each station except station I. CONCLUSION: Fourth-year medical students without a CCM elective do not possess the basic cognitive and psychomotor skills necessary to initially manage critically ill patients. After an appropriate 1-month CCM elective, students' thinking and application skills required to initially manage critically ill patients improved markedly, as demonstrated by an OSCE using a live simulated "patient" and manikin.

Teaching medical students complex cognitive skills in the intensive care unit.

OBJECTIVE: To determine if fourth-year medical students can learn the high-level cognitive skills needed to manage critically ill patients during a critical care medicine elective designed in accordance with established educational principles. DESIGN: Students were randomly assigned to take one of two examinations with ten short essay questions to complete on the initial day. After the elective, students completed the other examination in a crossover design. SETTING: Five surgical intensive care units (ICUs) in a tertiary care university teaching hospital. PARTICIPANTS: Fourth-year medical students enrolled in the critical care medicine elective. INTERVENTIONS: All students were enrolled in a critical care medicine elective consisting of an orientation, interactive conferences, technical skills laboratories, daily rounds, and patient-care experience. These components were designed to encourage problem-solving, improve analytical skills, and minimize the deterrents to education in the ICU. MEASUREMENTS: The primary outcome measure was the difference in examination scores before and after the rotation. Examinations were designed to test the student's skills in application, analysis, synthesis and evaluation. Specific questions concerning hemodynamic assessment were compared. MAIN RESULTS: The students' mean pre-elective scores were 58.8 +/- 10.8%, compared with 85.5 +/- 9.4% after the elective (p < .0001). CONCLUSION: Students can learn cognitive components of patient management skills using a format that encourages judgment, decision-making, and analytical skills, despite the liabilities inherent to education in an ICU.

Objective evaluation of clinical performance and correlation with knowledge.

In certifying competence of anesthesiologists who have finished residency training, knowledge and judgment are evaluated objectively using written and oral examinations. Clinical motor skills, however, are not routinely assessed by objective techniques. This implicitly assumes that knowledge and judgment correlate with performance of motor skills. This study was designed to evaluate whether performance of a particular motor skill correlates with performance on a knowledge test related to that skill. To do this, we developed a criterion-referenced Spinal Anesthesia Skill Test and a knowledge test using multiple-choice questions related to spinal anesthesia. Both the skill and knowledge tests were administered to 44 residents at various levels of training at five major anesthesia teaching programs. Scores on the skill test were significantly higher than in the knowledge test, suggesting that proficiency in this essential motor skill is achieved earlier in training. There was no correlation between scores on the skill test and knowledge test. There were institution-linked differences in the scores on the skill test, suggesting that teaching of motor skills is not uniform. The advantages of developing criteria of performance of motor skills is discussed.

Performance evaluation: continuous lumbar epidural anesthesia skill test.

The evaluation of skills in anesthesiology residents is usually subjective and lacks demonstrable reliability. Therefore, an objective criterion-referenced skill test for measuring performance of continuous lumbar epidural anesthesia was developed. For such a test to be useful, it is necessary to demonstrate agreement among rater-observers. Eight performances of continuous lumbar epidural anesthesia were recorded on video tape and simultaneously rated by nine anesthesiology faculty observers to determine inter-rater reliability. Inter-rater agreement was analyzed by determining coefficient kappa for each item and the entire test. Coefficient kappa for the entire test was 0.82 indicating a high degree of agreement between raters on the performance or nonperformance of various items. Development and utility of skill tests are discussed.