Deliberate practice as an educational method for learning to interpret the prepubescent female genital examination.

BACKGROUND: Correct interpretation of the prepubescent female genital examination is a critical skill; however, physician skill in this area is limited. OBJECTIVE: To complement the bedside learning of this examination, we developed a learning platform for the visual diagnosis of the prepubescent female genital examination and examined the amount and rate of skill acquisition. PARTICIPANTS AND SETTING: Medical students, residents, and fellows and attendings participated in an on-line learning platform. METHODS: This was a multicenter prospective cross-sectional study. Study participants deliberately practiced 158 prepubescent female genital examination cases hosted on a computer-based learning and assessment platform. Participants assigned the case normal or abnormal; if abnormal, they identified the location of the abnormality and the specific diagnosis. Participants received feedback after every case. RESULTS: We enrolled 107 participants (26 students, 31 residents, 24 fellows and 26 attendings). Accuracy (95 % CI) increased by 10.3 % (7.8, 12.8), Cohen's d-effect size of 1.17 (1.14, 1.19). The change in specificity was +16.8 (14.1, 19.5) and sensitivity +2.4 (-0.9, 5.6). It took a mean (SD) 46.3 (32.2) minutes to complete cases. There was no difference between learner types with respect to initial (p = 0.2) or final accuracy (p = 0.4) scores. CONCLUSIONS: This study's learning intervention led to effective and feasible skill improvement. However, while participants improved significantly with normal cases, which has relevance in reducing unnecessary referrals to child protection teams, learning gains were not as evident in abnormal cases. All levels of learners demonstrated a similar performance, emphasizing the need for this education even among experienced clinicians.

Factors influencing medical student attrition and their implications in a large multi-center randomized education trial.

Participant attrition may be a significant threat to the generalizability of the results of educational research studies if participants who do not persist in a study differ from those who do in ways that can affect the experimental outcomes. A multi-center trial of the efficacy of different computer-based instructional strategies gave us the opportunity to observe institutional and student factors linked to attrition from a study and the ways in which they altered the participation profile. The data is from a randomized controlled trial conducted at seven US medical schools investigating the educational impact of different instructional designs for computer-based learning modules for surgical clerks. All students undertaking their surgical clerkships at the participating schools were invited participate and those that consented were asked to complete five study measures during their surgery clerkship. Variations in study attrition rates were explored by institution and by participants' self-regulation, self-efficacy, perception of task value, and mastery goal orientation measured on entry to the study. Of the 1,363 invited participants 995 (73 %) consented to participate and provided baseline data. There was a significant drop in the rate of participation at each of the five study milestones with 902 (94 %) completing at least one of two module post-test, 799 (61 %) both module post-tests, 539 (36 %) the mid-rotation evaluation and 252 (25 %) the final evaluation. Attrition varied between institutions on survival analysis (p < 0.001). Small but statistically significant differences in self-regulation (p = 0.01), self-efficacy (p = 0.02) and task value (p = 0.04) were observed but not in mastery or performance goal orientation measures (p = NS). Study attrition was correlated with lower achievement on the National Board of Medical Examiners subject exam. The results of education trials should be interpreted with the understanding that students who persist may be somewhat more self-regulated, self-efficacious and higher achievers than their peers who drop out and as such do not represent the class as a whole.

Effect of a clinical pathway on the hospitalisation rates of children with asthma: a prospective study.

AIM: To determine the effect of implementing a clinical pathway, using evidence-based clinical practice guidelines, for the emergency care of children and adolescents with asthma. METHODS: A prospective, before-after, controlled trial was conducted, which included patients aged 1-18 years who had acute exacerbations of asthma treated in a tertiary care paediatric emergency department. Data were collected for identical 2-month seasonal periods before and after implementation of the clinical pathway to determine hospitalisation rate and other outcomes. For 2 weeks after emergency visits, the rate at which patients returned to emergency care for worsening asthma was evaluated. A multidisciplinary panel, using national guidelines and a systematic review, developed the pathway. RESULTS: 267 patients were studied. The rate of hospitalisation was significantly lower in the post-implementation group (10/74; 13.5%) than in the pre-implementation control group (53/193; 27.5%; p = 0.02; number needed to treat 7.1). All reduction in hospitalisation occurred in children with moderate to severe asthma exacerbation. After implementation of the clinical pathway, the rate of administration of oral corticosteroids to patients with moderate or severe exacerbations increased from 71% to 92% (p = 0.01), and significantly more patients received beta2-agonists in the first hour (p = 0.02). No significant change in relapse to acute care occurred within 2 weeks (p = 0.19). CONCLUSIONS: An evidence-based clinical pathway for children and adolescents with moderate to severe exacerbations of acute asthma markedly decreases their rate of hospitalisation without increased return to emergency care.

E-mail amplification of a mock code teaching round.

To determine whether e-mail could be used to supplement a teaching round, we implemented the following educational intervention: each Monday, a mock code was presented. Two e-mails were then sent the same day to all residents. One summarized the main teaching points whereas the second solicited discussion. Each Friday, a third e-mail was sent that summarized the discussion. We collected all e-mails and surveyed the residents. Fifteen of 18 residents completed the questionnaire; two were not participants in the e-round. Forty percent (7/15) of the residents attended fewer than half of the mock codes but most participants (10/13) reported reading >95% of the e-mails. A majority reported storing (11/13), printing (7/13), and reading e-mails a second time (12/13). Seven of 13 reported learning as much or more from the e-mails as from the mock code itself. We conclude that e-mail can increase learning from a traditional mock code teaching round.

Ipratropium bromide added to asthma treatment in the pediatric emergency department.

OBJECTIVE: To determine if the addition of ipratropium bromide to the emergency department (ED) treatment of childhood asthma reduces time to discharge, number of nebulizer treatments before discharge, and the rate of hospitalization. METHODS: Patients >12 months of age were eligible if they were to be treated according to a standardized ED protocol for acute asthma with nebulized albuterol (2.5 mg/dose if weight <30 kg, otherwise 5 mg/dose) and oral prednisone or prednisolone (2 mg/kg up to 80 mg). Subjects were randomized to receive either ipratropium (250 microg/dose) or normal saline (1 mL/dose) with each of the first three nebulized albuterol doses. Further treatment after the first hour was determined by physicians blinded to subject group assignment. Records were reviewed to determine the length of time to discharge home from the ED, number of doses of albuterol given before discharge, and the number of patients admitted to the hospital. RESULTS: Four hundred twenty-seven patients were randomized to ipratropium or control groups; these groups were similar in all baseline measures. Among patients discharged from the ED, ipratropium group subjects had 13% shorter treatment time (mean, 185 minutes, vs control, 213 minutes) and fewer total albuterol doses (median, three, vs control, four). Admission rates did not differ significantly (18%, vs control, 22%). CONCLUSIONS: The addition of three doses of ipratropium to an ED treatment protocol for acute asthma was associated with reductions in duration and amount of treatment before discharge.

Pediatric residents: are they ready to use computer-aided instruction?

OBJECTIVE: To assess pediatric residents' readiness to use computer-aided instruction (CAI). DESIGN: Survey. SETTING: Pediatric residency program based in a tertiary care children's hospital. PARTICIPANTS: Four pediatric residency classes. ASSESSMENT INSTRUMENT: Self-administered questionnaire. MAIN OUTCOME MEASURES: Residents' access to computers and the Internet, experience with CD-ROM and World Wide Web computer tutorials, and attitudes toward CAI. Responses were stratified by age, training level, sex, and previous computer education. RESULTS: Fifty-one (69%) of the residents owned a computer. Men were more likely than women to own a computer (20 [87%] of 23 men vs 31 [61%] of 51 women; P=.02). Medical education software was used by 18 (28%) of 65, but only 2 (4%) of 74 had ever purchased CAI. Twenty-seven (36%) of 74 regularly accessed medical education World Wide Web sites. Nineteen (26%) of 74 had never accessed the Internet. Of those who had, 50 (91%) of 55 continued to do so at least weekly. Eighteen (95%) of the 19 residents who had never accessed the Internet were female (P=.005). Men were twice as likely to have Internet access at home (P=.01) and were more likely to regularly visit medical education World Wide Web sites (P=.02). Attitudes toward CAI were positive. Most respondents would be willing to use CAI developed at their institution. Most residents ranked CAI ahead of printed teaching materials but behind personal teaching by a pediatrician. Attitudes did not differ by sex. CONCLUSION: Despite positive attitudes toward CAI, pediatric residents are not yet universally ready to use CAI.