A low-cost high-fidelity model for abscess simulation.

BACKGROUND: Treatment of a subcutaneous abscess is a commonly encountered scenario across multiple specialties. Prior simulation models for abscess incision and drainage have been limited by their cost and reproducibility. METHODS: We developed a realistic abscess model with commonly available materials that can be utilized in fresh cadaver labs at a cost of less than $1 USD per use. The model was evaluated for content validity with pre- and post-measures by 25 pre-clinical medical students. RESULTS: The model described herein successfully simulates commonly encountered subcutaneous abscesses. Pre and post-training surveys demonstrated a significant increase in all outcomes measures. CONCLUSIONS: The model presented in this manuscript can be easily incorporated into training programs that utilize a fresh cadaver lab for multi-procedural resident training. It provides a realistic abscess that can be placed in almost any anatomical location at a fraction of the cost, and significantly reduced preparation time compared to previously described models.

Students Teaching Students: A Novel Solution for Teaching Procedures via Instruction on the Corpse.

INTRODUCTION: Increased faculty and resident responsibilities have led to the decreased time available for teaching clinical skills to medical students. Numerous advances in education and simulation have attempted to obviate this problem; however, documented success is lacking. Our objective was to describe a novel fresh cadaver-based, student-driven procedural skills lab and to compare the educational effectiveness of student instructors to the senior instructor (SI). METHODS: This was a prospective study performed at an academic medical center. A pilot program, "Students Teaching Students," was introduced where four trained first-year medical students (TMS) instructed 41 other untrained first-year medical students in technical procedures. This study compared the teaching evaluations of the SI with the TMS teaching equivalent procedures. Paired t-test was used to determine statistically significant changes in procedural confidence between pre- and post-training. Utilizing a post-training questionnaire, average post-training confidence improvement values and objective post-training test scores of the participants were compared between TMS and SI, using a 2 sample t-test. Statistical significance was considered as a P-value<0.05. All statistical analyses were conducted in Stata 11 (StataCorp LP, College Station, TX, USA). RESULTS: Twenty-nine out of 39 (74%) students completed the questionnaire. Both groups demonstrated a statistically significant improvement in subjective confidence level in performing each procedure when pre- and post-training scores were compared, while there was no statistically significant difference found in cognitive knowledge between the groups (p=0.73). There was no statistically significant difference in the mean confidence improvement between the SI and TMS groups for chest tube insertion (2.06 versus 1.92 respectively, p=0.587), femoral line placement (2.00 versus 1.94 respectively, p=.734) or student test score (88% versus 85% respectively). CONCLUSION: Our results demonstrate that first-year medical students well-trained in technical skills, such as our TMS, may be a valuable additional teaching resource. The Students Teaching Students procedure lab employed in this study was effective at immediately increasing first-year medical students' confidence and technical skill. First-year medical students well-trained in technical skills, such as our TMS, may be a valuable additional teaching resource.

Pre-matriculation clinical experience positively correlates with Step 1 and Step 2 scores.

BACKGROUND: This study investigates whether students with pre-matriculation, formalized, clinical experience performed better in Step 1 and Step 2 of the United States Medical Licensing Exams (USMLE) compared to students without formal pre-matriculation clinical experience. METHODS: This research investigation was a retrospective cohort study conducted at the University of Arizona College of Medicine in Tucson, Arizona, USA, and analyzed students in the Class of 2017 and Class of 2018. Formal clinical experience was defined as registered nurses, physician assistants, nurse practitioners, paramedics, emergency medical technicians, or licensed practical nurses for any amount of time prior to matriculation, as well as scribing for at least 6 months prior to matriculation. Students with any amount of shadowing experience were not considered to have clinical experience. The authors performed multiple regression analyses to investigate the effects of formal clinical experience on USMLE exam performance. Statistical significance was defined as P<0.05. All statistical analyses were performed using SAS 9.4. RESULTS: Our study had a total of 227 students from the two classes, with 40 (17.6%) having formal pre-matriculation clinical experience, as already defined. Nine (3.96%) students were not assessed in USMLE Step 1 calculations, and 61 (26.9%) students were not assessed in USMLE Step 2 calculations due to an absence of recorded USMLE scores. Formal pre-matriculation clinical experience was a statistically significant positive predictor of USMLE Step 1 score (P=0.03) and USMLE Step 2 score (P<0.010). CONCLUSION: Formal pre-matriculation clinical experience, as defined previously, positively correlates with an increase in USMLE Step 1 and Step 2 scores.

"Flipped classroom" for academic and career advising: an innovative technique for medical student advising.

INTRODUCTION: Career advising for medical students can be challenging for both the student and the adviser. Our objective was to design, implement, and evaluate a "flipped classroom" style advising session. METHODS: We performed a single-center cross-sectional study at an academic medical center, where a novel flipped classroom style student advising model was implemented and evaluated. In this model, students were provided a document to review and fill out prior to their one-on-one advising session. RESULTS: Ninety-four percent (95% CI, 88%-100%) of the medical students surveyed felt that the advising session was more effective as a result of the outline provided and completed before the session and that the pre-advising document helped them gain a better understanding of the content to be discussed at the session. CONCLUSION: Utilization of the flipped classroom style advising document was an engaging advising technique that was well received by students at our institution.

Clinical skills temporal degradation assessment in undergraduate medical education.

INTRODUCTION: Medical students' ability to learn clinical procedures and competently apply these skills is an essential component of medical education. Complex skills with limited opportunity for practice have been shown to degrade without continued refresher training. To our knowledge there is no evidence that objectively evaluates temporal degradation of clinical skills in undergraduate medical education. The purpose of this study was to evaluate temporal retention of clinical skills among third year medical students. METHODS: This was a cross-sectional study conducted at four separate time intervals in the cadaver laboratory at a public medical school. Forty-five novice third year medical students were evaluated for retention of skills in the following three procedures: pigtail thoracostomy, femoral line placement, and endotracheal intubation. Prior to the start of third-year medical clerkships, medical students participated in a two-hour didactic session designed to teach clinically relevant materials including the procedures. Prior to the start of their respective surgery clerkships, students were asked to perform the same three procedures and were evaluated by trained emergency medicine and surgery faculty for retention rates, using three validated checklists. Students were then reassessed at six week intervals in four separate groups based on the start date of their respective surgical clerkships. We compared the evaluation results between students tested one week after training and those tested at three later dates for statistically significant differences in score distribution using a one-tailed Wilcoxon Mann-Whitney U-test for non-parametric rank-sum analysis. RESULTS: Retention rates were shown to have a statistically significant decline between six and 12 weeks for all three procedural skills. CONCLUSION: In the instruction of medical students, skill degradation should be considered when teaching complex technical skills. Based on the statistically significant decline in procedural skills noted in our investigation, instructors should consider administering a refresher course between six and twelve weeks from initial training.

Novel Use of Ultrasound to Teach Reproductive System Physical Examination Skills and Pelvic Anatomy.

OBJECTIVES: To determine whether integration of ultrasound (US) into a reproductive system examination clinical skills lab can increase confidence in palpating key reproductive structures during testicular and bimanual pelvic examinations, reduce anxiety about conducting testicular and bimanual pelvic examinations, and improve performance on multiple-choice questions based on structure identification using US images. METHODS: Second-year medical students enrolled in the Life Cycle preclinical course participated in this cross-sectional study. A single learning activity was developed to pair the teaching of the reproductive system physical examination with the use of US in the clinical skills lab. The evaluation of the teaching session consisted of a pre-post analysis of student self-reported knowledge, confidence, and anxiety. RESULTS: The response rate for the pre survey was 82% (n = 96), and the rate for the post survey was 79% (n = 93). Students' confidence in their ability to identify reproductive system structures on US images increased from pre to post survey. Their confidence in their ability to palpate the epididymis, uterus, and ovary during a physical examination improved, and their anxiety about conducting testicular and bimanual pelvic examinations decreased. Student satisfaction with the session was high. Students' performance on multiple-choice questions based on structure identification using US images was at 96% or higher. CONCLUSIONS: Our study findings support the integration of US into a reproductive system examination clinical skills lab. Medical students acquire competency and confidence in reproductive system physical examination skills with US integration.

Cadaver-based Necrotizing Fasciitis Model for Medical Training.

Necrotizing fasciitis is a devastating infectious disease process that is characterized by extensive soft tissue necrosis along deep fascial planes, systemic toxicity, and high mortality. Ultrasound imaging is a rapid and non-invasive tool that can be used to help make the diagnosis of necrotizing fasciitis by identifying several distinctive sonographic findings. The purpose of this study is to describe the construction of a realistic diagnostic training model for necrotizing fasciitis using fresh frozen cadavers and common, affordable materials. Presently, fresh non-embalmed cadavers have been used at medical institutions for various educational sessions including cadaver-based ultrasound training sessions. Details for the preparation and construction of a necrotizing fasciitis cadaver model are presented here. This paper shows that the images obtained from the cadaver model closely imitate the ultrasound appearance of fluid and gas seen in actual clinical cases of necrotizing fasciitis. Therefore, it can be concluded that this cadaver-based model produces high-quality sonographic images that simulate those found in true cases of necrotizing fasciitis and is ideal for demonstrating the sonographic findings of necrotizing fasciitis.

A Fresh Cadaver Model for the Instruction of Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules.

Objective The aim of our study is to determine if a fresh cadaver model (FCM) for the instruction of ultrasound (US)-guided fine-needle aspiration (FNA) of thyroid nodules is a practical method for instruction. Study Design Pre- and postinstruction assessment of medical students' ability to perform US-guided FNA of artificially created thyroid nodules placed adjacent to the thyroid gland of a fresh cadaver. Setting University-based fresh cadaver laboratory. Subjects and Methods Study participants included a total of 17 first- and second-year medical students with minimal US training. Technical skills were assessed using a 10-item checklist. In addition, a cognitive assessment regarding the indications, contraindications, and complications of the procedure was completed. A postinstruction assessment was provided for participants 5 weeks after their initial assessment. Differences between pre- and postinstruction assessment scores of technical skills were analyzed using McNemar's test. The mean cognitive knowledge gain was analyzed using a paired 2-sample t test. Results Eight of 10 items on the skills checklist were statistically significant between pre- and postinstruction skills assessment ( P < .05). There was a statistically significant change in cognitive knowledge gain regarding the contraindications of the procedure ( P = .001), but not for indications or complications ( P = .104 and P = .111, respectively). Conclusion US-guided FNA continues to be an important diagnostic procedure in the workup of thyroid nodules, making it an essential skill to integrate into surgical skills lab. Our FCM for the instruction of US-guided FNA is the first of its kind, and this pilot study shows this is a viable method for instruction.

Cadaver-based abscess model for medical training.

Ultrasound imaging is a rapid and noninvasive tool ideal for the imaging of soft tissue infections and is associated with a change of clinician management plans in 50% of cases. We developed a realistic skin abscess diagnostic and therapeutic training model using fresh frozen cadavers and common, affordable materials. Details for construction of the model and suggested variations are presented. This cadaver-based abscess model produces high-quality sonographic images with internal echogenicity similar to a true clinical abscess, and is ideal for teaching sonographic diagnostic skills in addition to the technical skills of incision and drainage or needle aspiration.

A novel fresh cadaver model for education and assessment of joint aspiration.

OBJECTIVES: The objective of this study was to describe a novel cadaver model and to determine the utility of this model for teaching and assessing students in performing knee, elbow, and wrist arthrocentesis. METHODS: Third year medical students were evaluated while performing arthrocentesis during a fresh cadaver training sessions. RESULTS: Sixty-three participants were included in this analysis. There was statistically significant improvement between the pre- and post-test analysis in all aspects assessed in our study of elbow, knee and wrist arthrocentesis. CONCLUSIONS: The use of fresh cadavers for the education and assessment of arthrocenteses is an effective training model.

Development of a fresh cadaver model for instruction of ultrasound-guided breast biopsy during the surgery clerkship: pre-test and post-test results among third-year medical students.

BACKGROUND: The aim of our study was to determine if a fresh cadaver model is a viable method for teaching ultrasound (US)-guided breast biopsy of palpable breast lesions. METHODS: Third-year medical students were assessed both preinstruction and postinstruction on their ability to perform US-guided needle aspiration or biopsy of artificially created masses using a 10-item checklist. RESULTS: Forty-one third-year medical students completed the cadaver laboratory as part of the surgery clerkship. Eight items on the checklist were found to be significantly different between pre-testing and post-testing. The mean preinstruction score was 2.4, whereas the mean postinstruction score was 7.10 (P < .001). CONCLUSIONS: Fresh cadaver models have been widely used in medical education. However, there are few fresh cadaver models that provide instruction on procedures done in the outpatient setting. Our model was found to be an effective method for the instruction of US-guided breast biopsy among medical students.

Introducing a Fresh Cadaver Model for Ultrasound-guided Central Venous Access Training in Undergraduate Medical Education.

INTRODUCTION: Over the past decade, medical students have witnessed a decline in the opportunities to perform technical skills during their clinical years. Ultrasound-guided central venous access (USG-CVA) is a critical procedure commonly performed by emergency medicine, anesthesia, and general surgery residents, often during their first month of residency. However, the acquisition of skills required to safely perform this procedure is often deficient upon graduation from medical school. To ameliorate this lack of technical proficiency, ultrasound simulation models have been introduced into undergraduate medical education to train venous access skills. Criticisms of simulation models are the innate lack of realistic tactile qualities, as well as the lack of anatomical variances when compared to living patients. The purpose of our investigation was to design and evaluate a life-like and reproducible training model for USG-CVA using a fresh cadaver. METHODS: This was a cross-sectional study at an urban academic medical center. An 18-point procedural knowledge tool and an 18-point procedural skill evaluation tool were administered during a cadaver lab at the beginning and end of the surgical clerkship. During the fresh cadaver lab, procedure naïve third-year medical students were trained on how to perform ultrasound-guided central venous access of the femoral and internal jugular vessels. Preparation of the fresh cadaver model involved placement of a thin-walled latex tubing in the anatomic location of the femoral and internal jugular vein respectively. RESULTS: Fifty-six third-year medical students participated in this study during their surgical clerkship. The fresh cadaver model provided high quality and lifelike ultrasound images despite numerous cannulation attempts. Technical skill scores improved from an average score of 3 to 12 (p<0.001) and procedural knowledge scores improved from an average score of 4 to 8 (p<0.001). CONCLUSION: The use of this novel cadaver model prevented extravasation of fluid, maintained ultrasound-imaging quality, and proved to be an effective educational model allowing third-year medical students to improve and maintain their technical skills.

Ultrasound-guided procedures in medical education: a fresh look at cadavers.

Demand for bedside ultrasound in medicine has created a need for earlier exposure to ultrasound education during the clinical years of undergraduate medical education. Although bedside ultrasound is often used for invasive medical procedures, there is no standardized educational model for procedural skills that can provide the learner a real-life simulated experience. The objective of our study was to describe a unique fresh cadaver preparation model, and to determine the impact of a procedure-focused ultrasound training session. This study was a cross-sectional study at an urban academic medical center. A sixteen-item questionnaire was administered at the beginning and end of the session. Fifty-five third year medical students participated in this 1-day event during their surgical clerkship. Students were trained to perform the following ultrasound-guided procedures: internal jugular vein cannulation, femoral vein cannulation femoral artery cannulation and pericardiocentesis. Preparation of the fresh cadaver is easily replicated and requires minor manipulation of cadaver vessels and pericardial space. Fifty-five medical students in their third year participated in this study. All of the medical students agreed that US could help increase their confidence in performing procedures in the future. Eighty percent (95 % CI 70-91 %) of students felt that there was a benefit of learning ultrasound-based anatomy in addition to traditional methods. Student confidence was self-rated on a five-point Likert scale. Student confidence increased with statistical significance in all of the skills taught. The most dramatic increase was noted in central venous line placement, which improved from 1.95 (SD = 0.11) to 4.2 (SD = 0.09) (p < 0.001). The use of fresh cadavers for procedure-focused US education is a realistic method that improves the confidence of third year medical students in performing complex but critical procedures.

Introduction of a fresh cadaver laboratory during the surgery clerkship improves emergency technical skills.

BACKGROUND: Student acquisition of technical skills during the clinical years of medical school has been steadily declining. To address this issue, the authors instituted a fresh cadaver-based Emergency Surgical Skills Laboratory (ESSL). METHODS: Sixty-three medical students rotating through the third-year surgery clerkship participated in a 2-hour, fresh cadaver-based ESSL conducted during the first 2 days of the clerkship. The authors evaluated students utilizing both surgical skills and written examination before the ESSL and at 4 weeks post ESSL. RESULTS: Students demonstrated a mean improvement of 64% (±11) (P < .001) and 38% (±17) (P < .001) in technical skills and clinical knowledge, respectively. When technical skills were compared between cohorts, there were no differences observed in both pre- and post-testing (P = .08). CONCLUSIONS: A fresh cadaver laboratory is an effective method to provide proficiency in emergency technical skills not acquired during the clinical years of medical school.

A comparison of unguided vs guided case-based instruction on the surgery clerkship.

BACKGROUND: Guided case-based instruction is an effective and efficient means of learning for third year medical students on the surgery clerkship. Compared with an unguided format for teaching biliary disease, we observed greater student satisfaction as well as a more efficient utilization of student as well as faculty time with the guided instruction. OBJECTIVE: While case-based instruction (CBI) has become an extremely popular teaching modality during the first 2 years of medical school, there has been little published regarding its utilization during the clinical years of medical school. The purpose of our study was to compare guided CBI (G-CBI) to unguided CBI (UG-CBI) during the surgery clerkship. DESIGN: From July 2007 to July 2008, we utilized a UG-CBI format to teach biliary disease, formerly taught by a standard lecture. The unguided style is used by our institution for the first 2 years of medical school education, where the role of the facilitator is minimal. From July 2008 to December 2010, we changed to a G-CBI format where 5 different clinical scenarios were presented that all dealt with some form of biliary disease. A Likert-like scale was used to analyze student opinion comparing guided to the traditional unguided format. Questions regarding biliary disease contained in the National Board of Medical Examiners (NBME) shelf examination, given to all students at the end of the rotation, were also compared between the 2 groups. Cohen's d statistic was used to assess effect size. SETTING: The study took place at the University of Arizona College of Medicine. PARTICIPANTS: There were 88 students in the UG-CBI group and 146 in the G-CBI group. RESULTS: Ninety-six percent of the students preferred G-CBI over the unguided format utilized during the basic science years. Eighty-two percent felt that the guided format sessions were a more efficient method of instruction and 91% of students agreed or strongly agreed that time was more efficiently utilized in preparing for the case discussion during the guided format. Shelf examination scores analyzing biliary disease questions (2-4 per examination) showed a moderate size effect favoring the G-CBI, although the numbers were too small to draw definite conclusions in this regard. CONCLUSIONS: G-CBI is more suited for the surgery clerkship than the UG-CBI utilized during the first 2 years of medical school. Lack of a clinical knowledge base among the students rotating on the surgery clerkship as well as time limitations for both the student and clinical faculty favor this more efficient means of learning.

Assessment of alcohol withdrawal in Native American patients utilizing the Clinical Institute Withdrawal Assessment of Alcohol Revised Scale.

BACKGROUND: The Clinical Institute Withdrawal Assessment of Alcohol Revised (CIWA-Ar) is a commonly used scale for assessing the severity of alcohol withdrawal syndrome in the acute setting. Despite validation of this scale in the general population, the effect of ethnicity on CIWA-Ar scoring does not appear in the literature. The purpose of our study was to investigate the validity of the CIWA-Ar scale among Native American patients evaluated for acute alcohol detoxification. METHODS: A case series of all patients seen for alcohol withdrawal at an Acute Drug and Alcohol Detoxification facility was conducted from June 1, 2011, until April 1, 2012. The CIWA-Ar scores were recorded by trained nursing staff on presentation to Triage Department and every 2 hours thereafter. At our institution, a score of 10 or greater indicates the need for inpatient hospital admission and treatment. Ethnicity was self-reported. Age, sex, blood alcohol concentration, blood pressure, and pulse were recorded on presentation and vital signs repeated every 2 hours. Patients were excluded from the study if other drug use was noted by history or initial urine drug screen. A multivariate logistic regression model was utilized to identify statistically significant variables associated with admission to the inpatient unit and treatment. The relationship of CIWA-Ar scores and ethnicity was compared using analysis of variance. RESULTS: A total of 115 whites, 45 Hispanics, and 47 Native Americans were included in the analysis. Native Americans had consistently lower CIWA-Ar scores at 0, 2, 4, and 6 hours than the other 2 ethnic groups (P = 0.002). In addition, Native Americans were admitted to the hospital less often than the other 2 groups for withdrawal (P < 0.001). CONCLUSIONS: The CIWA-Ar scale may underestimate the severity of alcohol withdrawal syndrome in certain ethnic group such as Native Americans. Further prospective studies should be undertaken to determine the validity of the CIWA-Ar scale in assessing alcohol withdrawal across different ethnic populations.

Utilization of a non-preserved cadaver to address deficiencies in technical skills during the third year of medical school: a cadaver model for teaching technical skills.

BACKGROUND: Emergency technical procedures performed by medical students have decreased in the last decade. An Emergency Surgical Skills Laboratory (ESSL) using a non-preserved cadaver was developed in response to address this deficiency. METHODS: A total of 232 students rotating through a 6-week surgery clerkship participated in the ESSL from 1 July 2008 to 1 July 2011. Two four-hour sessions using case-based trauma scenarios in the ESSL served as a model for procedural instruction. Skills taught included basic suturing, intubation, cricothyrotomy, chest tube placement, thoracentesis, venous access, central line, and radial arterial line placement. RESULTS: Students noted that technical proficiency in suturing was obtained during the ESSL sessions in comparison to the emergency department or operating room (p < 0.001) during the 6-week clerkship. During the 6-week rotation only 12 % of students participated in chest tube insertion, 5 % central venous line placement, and 14 % femoral vein blood draw. Finally, 90 % of respondents reported increased understanding and comfort in regard to trauma resuscitation following the ESSL. CONCLUSIONS: Technical procedural proficiency has become increasingly difficult to obtain in medical school due to multifactorial limitations. The ESSL provides an opportunity for developing technical skills needed for emergency situations not otherwise provided during the surgical clerkship.

Postoperative pain assessment and analgesic administration in Native American patients undergoing laparoscopic cholecystectomy.

Ethnic disparities in pain assessment and analgesic administration following surgery have received little attention in the surgery literature. We noted that our Native American patients were less likely than others to complain of pain. A retrospective chart review of 21 Native American patients and a control group who underwent outpatient, elective laparoscopic cholecystectomy was performed. Native American patients had a statistically lower numeric pain score (mean, 6.5; 95% CI, 3.6-9.4) than non-Native American patients (mean, 8.1; 95% CI, 6.3-9.9; t38 = 2.63; P < .05). Native American patients also received less postsurgical analgesic (mean, 7.4; 95% CI, 4.0-10.8) than non-Native American patients (mean, 11.2; 95% CI, 7.2-15.2; t38 = 3.07; P < .01). Medical staff attending Native American patients should be aware that response to some scales to assess pain may not reflect accurately the degree of pain experienced.