Modification of the pelvic examination simulator for the developing world.

The clinical pelvic exam is a critical examination for external and internal inspection of female reproductive organs. A sensor enabled pelvic examination simulator was developed to provide immediate visual performance feedback. The simulator was modified for rural area usage, where electricity supply and PC display may not be available. We succeeded at replacing key components while maintaining functionality.

Validity of a Newly Developed Tri-axial Sensor for Clinical Breast Examination Skills Assessment.

The clinical breast examination is a critical exam for early detection of breast cancer. Assessment methods are needed to determine competency and skill mastery for experts and novices. The 3D sensor was developed to capture hand shear and normal forces conducted during an exam. Trials were conducted to record exploratory maneuvers used during the exam. The sensor system was found to be a reliable method for capturing exploratory maneuvers.

Use of simulation to understand the effects of task complexity and time away on clinical confidence.

In prior studies, mannequin-based simulation training has been used to help decrease student anxiety toward intimate clinical examinations. Using time away as an independent variable, the aim of this study was to assess decay of clinical confidence for four procedural tasks that vary in procedural complexity. Clinical confidence with intimate examinations, after a standardized mannequin-based simulation curriculum, decays over time. This decay is noted after two months of time away. Longer periods of time away did not show increased differences.

Simplifying touch data from tri-axial sensors using a new data visualization tool.

Quantification and evaluation of palpation is a growing field of research in medicine and engineering. A newly developed tri-axial touch sensor has been designed to capture a multi-dimensional profile of touch-loaded forces. We have developed a data visualization tool as a first step in simplifying interpretation of touch for assessing hands-on clinical performance.

Validity and reliability of a sensor-enabled intubation trainer: a focus on patient-centered data.

BACKGROUND: Prior work using simulation for assessing intubation skills has largely focused on the use of observer-generated performance measures in the form of checklists and global ratings scales. PURPOSE: The purpose of our work was to investigate whether patient-centered simulation data could be used to quantify learner's performance during direct laryngoscopy. METHODS: We designed a pretest/posttest prospective intervention study of residents' (n = 25) intubation skills. RESULTS: When assessing validity, all of the patient-centered simulation variables showed significant correlations with the previously validated observer-generated performance measures (r = 0.331-0.463, P ≤ 0.001). When assessing reliability, there were significant correlations between all of the sensor variables, confirming moderate to high inter-item reliability (r = 0.259-0.794, P ≤ 0.05). The observer-generated performance measures showed significant improvement in use of the Macintosh blade (T1 = 2.10/5.00, T2 = 3.64/5.00, P = 0.001). However, this was not the case for the Miller blade (T1 = 1.30/5.00, T2 = 1.75/5.00, P = 0.119). Overall, the patient-centered simulation variables provided a high level of detail regarding performance improvement areas. CONCLUSION: This study presents a multilevel analysis of sensor-generated simulation data. As the sensors provide sound, formative data regarding patient contact, the outputs may be used for specific criterion measures and detailed performance feedback.

Development and evaluation of a decision-based simulation for assessment of team skills.

BACKGROUND: There is a need to train and evaluate a wide variety of nontechnical surgical skills. The goal of this project was to develop and evaluate a decision-based simulation to assess team skills. METHODS: The decision-based exercise used our previously validated Laparoscopic Ventral Hernia simulator and a newly developed team evaluation survey. Five teams of 3 surgical residents (N = 15) were tasked with repairing a 10 × 10-cm right upper quadrant hernia. During the simulation, independent observers (N = 6) completed a 6-item survey assessing: (1) work quality; (2) communication; and (3) team effectiveness. After the simulation, team members self-rated their performance by using the same survey. RESULTS: Survey reliability revealed a Cronbach's alpha of r = .811. Significant differences were found when we compared team members' (T) and observers' (O) ratings for communication (T = 4.33/5.00 vs O = 3.00/5.00, P < .01) and work quality (T = 4.33/5.00 vs O = 3.33/5.00, P < .05). The team with the greatest survey ratings was the only group to successfully complete the task. CONCLUSION: The team evaluation survey had good reliability and correlated with task performance on the simulator. Our current and previous work provides strong evidence that nontechnical and team related skills can be assessed without simulating a crisis situation.

Use of mannequin-based simulation to decrease student anxiety prior to interacting with male teaching associates.

BACKGROUND: Previous studies have compared the usefulness of teaching associates versus mannequin trainers for learning physical exam skills. Little work has been done to assess the usefulness of mannequin trainers prior to students' interaction with teaching associates. PURPOSE: We studied the effects of mannequin-based simulators on student comfort levels toward learning the male genitourinary examination. METHODS: First-year medical students (N = 346) were surveyed before and after a mannequin-based curriculum to assess their comfort levels toward learning the male genitourinary examination. RESULTS: The mannequin-based curriculum significantly increased (p < .001) student comfort levels toward the male genitourinary exam. However, the pre-post improvements were small, and on average students only progressed from being "very uncomfortable" to "somewhat comfortable." The intimate nature of the examination was the top cause of anxiety toward learning the male genitourinary exam. Students were least comfortable with the digital rectal examination at the beginning of class. CONCLUSIONS: We suggest that mannequin-based simulators be used prior to students' experience with male teaching associates when learning the male genitourinary exam.

Moving past normal force: capturing and classifying shear motion using 3D sensors.

In our previous research, we used clinical breast examination models instrumented with direct (normal) force sensors for training and assessment. A weakness of the normal force sensors is the ability to delineate, in detail, all of the performance measures we wish to understand. This study incorporated the use of newly developed shear force sensors to extend a framework for quantifying hands-on performance.

Modification of commercially available simulators to elicit decision making behavior.

In recent years, simulation training has emerged as an innovative method for decreasing error and teaching complex procedures. Simulation has also been a valuable tool for evaluating investigatory and analytic thinking. By adding a specific, clinically oriented modification to a commercially available simulator, we were able to elicit first-year emergency medicine resident perceptions, actions, and decisions.

Introducing simulation technology to new faculty: do not let them play.

As part of our simulation-based curriculum design process, we require faculty instructors to formally examine and test the simulators prior to instructional use. This requirement is invaluable when using commercially available, mannequin-based simulations. Our study shows that, when teaching a clinical examination using simulation, the clinical presentation of a commercial simulator should be defined based on the consensus of experienced clinicians instead of the commercial label.

Clinical examination simulation: getting to real.

Verschuren and Hartog's six-stage methodology for design-oriented research is a process that is ideally suited to the development of artifacts that meet a desired outcome. We discuss the methodology and its relevance to simulation development for establishing a wide variety of realistic clinical breast examination models that can be used for assessment.

Expanding the use of simulators as assessment tools: the new pop quiz.

This study introduces a novel way to implement simulation in medical education. We investigated the feasibility of integrating a newly developed breast examination simulator into a breast exam technique lecture while also collecting detailed data on medical students' breast exam skills. Results indicate that it is feasible to integrate simulation technology into the classroom environment and collect detailed performance data that can be analyzed and used for skills assessment.

Are commercially available simulators durable enough for classroom use?

Our efforts show that commercially available simulators can be modified to affect realism and durability.

Use of sensor technology to explore the science of touch.

Two, world-renown researchers in the science of touch (Klatzky and Lederman) have shown that there are a set of reproducible and subconscious maneuvers that humans use to explore objects. Force measuring sensors may be used to electronically identify and quantify these maneuvers. Two sensored silicone breast models were configured to represent two different clinical presentations. One-hundred clinicians attending a local breast cancer meeting performed clinical breast examinations on the models, and their performance was captured using sensor-based data acquisition technology. We have found that Klatzy and Lederman's previously defined touch maneuvers are used during the clinical breast examination and can be identified and quantified for the first time using sensor technology.

Toward a simulation and assessment method for the practice of camera-guided rigid bronchoscopy.

We have developed a way to measure performance during a camera-guided rigid bronchoscopy using manikin-based simulation. In an effort to measure contact pressures within the airway during a rigid bronchoscopy, we instrumented pressure sensors in a commercially available bronchoscopy task trainer. Participants were divided into two groups based on self-reported levels of expertise: novice (none to minimal experience in rigid bronchoscopy) and experts (moderate to extensive experience). There was no significant difference between experts and novices in the time taken to complete the rigid bronchoscopy. However, novices touched a greater number of areas than experts, showing that novices induce a higher number of unnecessary soft-tissue contact compared to experts. Moreover, our results show that experts exert significantly less soft tissue pressure compared to novices.

Lost in translation: unfolding medical students' misconceptions of how to perform a clinical digital rectal examination.

BACKGROUND: Digital rectal examination (DRE) skills are difficult to teach and assess. This study sought to assess the construct validity of newly developed DRE simulators, which were then used to evaluate DRE palpation techniques and accuracy based on experience. METHODS: Medical students (n = 30), residents (n = 24), and experienced clinicians (n = 24) performed clinical DREs on the simulators and documented their findings. During the examinations, computer-generated quantitative performance data were collected. RESULTS: Students focused more on pronating and supinating their examining finger in the rectum. In addition, students were less accurate when assessing the prostate gland compared with experienced clinicians and residents (students = 33%, residents = 64%, and clinicians = 76%; P <.05. CONCLUSIONS: The DRE simulators were useful in defining specific differences in clinical DRE palpation techniques based on experience. We believe the observed differences are largely caused by students' misconceptions about how to perform the DRE.

A simulation-based assessment of clinical breast examination technique: do patient and clinician factors affect clinician approach?

BACKGROUND: Recent publications describing widely accepted clinical breast examination (CBE) techniques have sparked interest in setting standards for CBE. In support of CBE training and assessment, the purpose of our study was to quantify CBE palpation techniques using simulation technology and assess the affects of clinical presentation and clinician background on CBE techniques. METHODS: Three sensored silicone breast models were configured to represent 3 different clinical presentations. The models were examined by 102 clinicians at a local breast cancer meeting, and their performance was captured by using sensored based data acquisition technology. RESULTS: Clinicians had significantly longer examination times on the fatty breast with no masses compared with the breast with a dominant mass and the breast with fibrocystic changes (66.37 seconds, 40.50 seconds, and 42.28 seconds, P < .05). In addition, on average, female clinicians had significantly greater examination times (females = 56.66 seconds, males = 42.09 seconds, P < .05) and touched more sensors (females = 7.97, males = 6.30, P < .05) with greater pressures (females = 5.21, males = 4.82, P < .05) than their male counterparts. CONCLUSIONS: Clinical presentation and clinician background may affect CBE technique yet does not appear to negatively affect clinician accuracy. Additional research quantifying the range of CBE techniques used in medical practice may inform CBE standardization and competency testing.

Fear of missing a lesion: use of simulated breast models to decrease student anxiety when learning clinical breast examinations.

BACKGROUND: Medical students experience a considerable amount of discomfort during their training. The purpose of the current study was to identify sources of student anxiety when learning clinical breast examinations (CBEs) and to evaluate the effects of simulated breast models on student comfort. METHODS: Simulated breast models were introduced into the curriculum for 175 second-year medical students. Using surveys, students identified sources of anxiety and rated their comfort levels when learning CBE skills. RESULTS: "Fear of missing a lesion" and the "Intimate/personal nature of the exam" accounted for 73.8% of student anxiety when learning CBEs. In addition, there were significant improvements (P < .05) in student comfort levels when using simulated breast models to learn CBE skills. CONCLUSIONS: We have identified 2 of the top causes of anxiety for second-year medical students learning CBE. In addition, we found simulated breast models to be effective in increasing student comfort levels when learning CBEs.

Developing performance criteria for the e-Pelvis simulator using visual analysis.

The e-Pelvis is an inanimate simulator for clinical uterine examination. Data from the e-Pelvis has been studied extensively yet the clinical characteristics of palpation remain elusive. We describe our use of visual representation of the data that enabled expert physician/investigators to discover patterns of palpation.