Physical Medicine and Rehabilitation: Trends in Graduate Medical Education and Subspecialization Amid Changing Demographics.

With an aging and growing US population, American healthcare faces an impending physician shortage. This is important for the field of physical medicine and rehabilitation, because physiatrists' skills in managing chronic conditions and functional outcomes are especially relevant to an older population. The present study was designed to better understand the future physical medicine and rehabilitation workforce, by recording and analyzing the quantities of Accreditation Council of Graduate Medical Education-accredited physical medicine and rehabilitation graduate medical education programs and positions between 2001-2002 and 2017-2018. Results indicated that physical medicine and rehabilitation graduate medical education has grown since 2001-2002, especially in subspecialties such as pediatric rehabilitation and sports medicine. However, the growth in physical medicine and rehabilitation residency positions has been three-fold lower than that of total graduate medical education. In addition, subspecialization has become increasingly prevalent, and residency positions have declined relative to the population of older adults. The future identity of physical medicine and rehabilitation will continue to develop as professional and demographic trends shape this important medical specialty.

Improvement of Spatial and Non-verbal General Reasoning Abilities in Female Veterinary Medical Students Over the First 64 Weeks of an Integrated Curriculum.

Spatial visualization ability is defined as the ability to mentally rotate two- and three-dimensional figures. Visual reasoning is the ability to manipulate mental images of an object to reach a certain conclusion and has been linked to spatial ability. There is currently limited information about how entry-level spatial and visual reasoning abilities may be enhanced with progression through the rigorous veterinary medical curriculum. The present study made use of two tests that measure spatial ability and one test that measures non-verbal general reasoning ability in female veterinary students: Guay's Visualization of Views Test, Adapted Version (VVT), Mental Rotations Test (MRT), and Raven's Advanced Progressive Matrices Test, short form (APMT). Tests were given immediately before commencing the integrated veterinary medical curriculum (T0), at week 32 (T1), and at week 64 (T2) into the program. Results showed improved spatial visualization ability as measured by VVT and MRT and improved non-verbal general reasoning ability as measured by APMT at both 32 and 64 weeks. The spatial ability scores measured by VVT and MRT showed a positive correlation with non-verbal general reasoning ability scores (APMT), supporting the idea that these abilities are linked.

Violins, medicine, and the art of listening.

A violinist enters into the clinic and through the encounter, teaches providers important lessons on empathy and listening within the healthcare setting. How might we better understand communication within the provider-patient interaction? How might we improve medical education to reflect the provision of holistic patient-centered care?

Transvaginal ultrasound guided trigone and bladder injection: A cadaveric feasibility study for a novel route of intradetrusor chemodenervation.

PURPOSE: OnabotulinumtoxinA (BTX) detrusor chemodenervation is an efficacious third-line treatment for overactive bladder. Despite high clinical efficacy rates for BTX injection, many patients refuse initial or repeat treatment due to the invasiveness of the cystoscopic route of delivery. We assess the feasibility of injecting the trigone and posterior bladder wall via a transvaginal route under ultrasound guidance using a human cadaveric model. MATERIALS AND METHODS: Eight de-identified anonymous fresh female deceased donor cadaver pelvises were placed in supine split leg position. A transvaginal ultrasound probe guided injections of India ink into the trigone in 3 sites and the posterior wall in 2 sites. Full thickness bladder biopsies were then obtained and histologic analysis was performed to confirm presence of India ink in the detrusor layer. RESULTS: The mean time from day of death was 11.0 days (range, 4.0-23.0 days). Three to five bladder biopsies were obtained per cadaver, for a total of 34 specimens (20 trigone, 14 posterior wall). Histologic analysis revealed presence of India ink within the detrusor layer in 8/8 (100.0%) of cadavers. The surgeon's perception of appropriate targeting under ultrasound guidance was confirmed in 8/8 cadavers (100.0%) involving the bladder trigone, and 7/8 (87.5%) involving the posterior wall. Of injections that were believed to have appropriately targeted the detrusor layer, 22/34 specimens (64.7%) demonstrated the presence of India ink under histologic analysis. CONCLUSIONS: Intradetrusor injection of the bladder trigone and posterior wall under transvaginal ultrasound guidance is feasible and has acceptable accuracy.

Entry-Level Spatial and General Non-verbal Reasoning: Can These Abilities be Used as a Predictor for Anatomy Performance in Veterinary Medical Students?

There is currently limited available information, but growing interest, in possible relationships between spatial visualization skills in medical students and their academic performance in select areas of the curriculum such as radiographic interpretation and anatomy. There is very limited comparable information on how entry-level spatial visualization skills may correlate with macroscopic anatomy performance in veterinary medical students exposed to an integrated curriculum. The present study made use of a battery of two short tests that measure spatial ability: Guay's visualization of views test (VVT) and mental rotation test (MRT) and, one test that measures general non-verbal reasoning abilities: Raven's Advanced Progressive Matrices Test, short form (APMT). Tests were given to 1st-year veterinary medical students (n = 124) immediately before commencing the integrated veterinary medical curriculum. Results show there is a positive correlation between entry-level spatial ability and non-verbal general reasoning scores confirming these abilities are linked (r: +0.22 and +0.3 for VVT/APMT and MRT/APMT respectively). The dispersion and inconsistency of significant positive correlation between anatomy practical exams grade and spatial and general reasoning scores suggest these abilities either do not correlate with anatomy practical exams grade or, are overcome with progression through the anatomy courses. Males scored higher than females in the spatial ability tests: 16.59 vs. 12.06 for VVT (p = 0.01) and 19.0 vs. 14.68 for MRT (p = 0.01). Scores for APMT did not show a significant difference by gender.

Photogrammetry of Human Specimens: An Innovation in Anatomy Education.

Cadaver-based anatomical education is supplemented by a wide range of pedagogical tools-from artistic diagrams, to photographs and videos, to 3-dimensional (3D) models. However, many of these supplements either simplify the true anatomy or are limited in their use and distribution. Photogrammetry, which overlaps 2-dimensional (2D) photographs to create digital 3D models, addresses such shortcomings by creating interactive, authentic digital models of cadaveric specimens. In this exploratory pilot study, we used a photogrammetric setup and rendering software developed by an outside group to produce digital 3D models of 8 dissected specimens of regional anatomy. The photogrammetrically produced anatomical models authentically and precisely represented their original specimens. These interactive models were deemed accurate and teachable by faculty at the Stanford University Division of Clinical Anatomy. Photogrammetry is, according to these results, another possible method for rendering cadaveric materials into interactive 3D models, which can be used for anatomical education. These models are more detailed than many computer-generated versions and provide more visuospatial information than 2D images. Future researchers and educators could use such technology to create institutional libraries of digital 3D anatomy for medical education.

Evaluation of an E-Learning Course for Clubfoot Treatment in Tanzania: A Multicenter Study.

In total, 80% of clubfoot cases occur in low- and middle-income countries, where lack of clinical knowledge of the Ponseti method of treatment presents as a major barrier to treatment. This study aims to determine the effectiveness of an electronic learning course to teach clinicians in Tanzania Ponseti method theory. A total of 30 clinicians were recruited from clinics with high referral rates for clubfoot patients and invited to 1 of 3 training sites: Mbeya (n = 15), Zanzibar (n = 10), and Mwanza (n = 5). Baseline knowledge, measured through a pretest, was compared to performance on a posttest after e-learning course completion. Scores for Mbeya and Zanzibar participants improved from 44 ± 12.5 to 69.8 ± 16.5 (P < .0001) and 44.3 ± 14.0 to 67.9 ± 21.4 (P = .01), respectively. Our results suggest that an e-learning course may be an effective method of disseminating Ponseti method theory in Tanzania. Successful implementation requires an understanding of the device availability and technology literacy of the users.

Trends in Geriatrics Graduate Medical Education Programs and Positions, 2001 to 2018.

It is no secret that the average age of the U.S. population is increasing, and this has special significance for the U.S. health care system. The number of individuals above 65 years old is predicted to increase 55% by 2030, and all the while, there is a looming physician shortage, one especially relevant for Geriatricians. Therefore, current Geriatricians must have objective information to assess the past, present, and future state of this important specialty. However, little literature exists regarding the recent changes in Geriatrics-related graduate medical education programs. In the present study, we use data from the Accreditation Council of Graduate Medical Education, to characterize quantitative trends in Geriatrics graduate medical education between academic years 2001-2002 and 2017-2018. We find that, when Hospice/Palliative Care is excluded, Geriatrics-related graduate medical education programs have grown by just 1.1% when adjusting for population growth. There are 58 fewer total filled Geriatrics and Geriatric Psychiatry positions in 2017-2018 than there were in 2001-2002, a population-adjusted decline of 23.3%. Our results confirm the growing notion that the Geriatrics specialty may need to alter its approach toward professional supply, if it is to meet the growing health care demands of an aging U.S.

An augmented reality tool for learning spatial anatomy on mobile devices.

Augmented Realty (AR) offers a novel method of blending virtual and real anatomy for intuitive spatial learning. Our first aim in the study was to create a prototype AR tool for mobile devices. Our second aim was to complete a technical evaluation of our prototype AR tool focused on measuring the system's ability to accurately render digital content in the real world. We imported Computed Tomography (CT) data derived virtual surface models into a 3D Unity engine environment and implemented an AR algorithm to display these on mobile devices. We investigated the accuracy of the virtual renderings by comparing a physical cube with an identical virtual cube for dimensional accuracy. Our comparative study confirms that our AR tool renders 3D virtual objects with a high level of accuracy as evidenced by the degree of similarity between measurements of the dimensions of a virtual object (a cube) and the corresponding physical object. We developed an inexpensive and user-friendly prototype AR tool for mobile devices that creates highly accurate renderings. This prototype demonstrates an intuitive, portable, and integrated interface for spatial interaction with virtual anatomical specimens. Integrating this AR tool with a library of CT derived surface models provides a platform for spatial learning in the anatomy curriculum. The segmentation methodology implemented to optimize human CT data for mobile viewing can be extended to include anatomical variations and pathologies. The ability of this inexpensive educational platform to deliver a library of interactive, 3D models to students worldwide demonstrates its utility as a supplemental teaching tool that could greatly benefit anatomical instruction. Clin. Anat. 30:736-741, 2017. © 2017Wiley Periodicals, Inc.

Spatial and Visual Reasoning: Do These Abilities Improve in First-Year Veterinary Medical Students Exposed to an Integrated Curriculum?

Spatial visualization ability refers to the human cognitive ability to form, retrieve, and manipulate mental models of spatial nature. Visual reasoning ability has been linked to spatial ability. There is currently limited information about how entry-level spatial and visual reasoning abilities may predict veterinary anatomy performance or may be enhanced with progression through the veterinary anatomy content in an integrated curriculum. The present study made use of two tests that measure spatial ability and one test that measures visual reasoning ability in veterinary students: Guay's Visualization of Views Test, adapted version (GVVT), the Mental Rotations Test (MRT), and Raven's Advanced Progressive Matrices Test, short form (RavenT). The tests were given to the entering class of veterinary students during their orientation week and at week 32 in the veterinary medical curriculum. Mean score on the MRT significantly increased from 15.2 to 20.1, and on the RavenT significantly increased from 7.5 to 8.8. When females only were evaluated, results were similar to the total class outcome; however, all three tests showed significant increases in mean scores. A positive correlation between the pre- and post-test scores was found for all three tests. The present results should be considered preliminary at best for associating anatomic learning in an integrated curriculum with spatial and visual reasoning abilities. Other components of the curriculum, for instance histology or physiology, could also influence the improved spatial visualization and visual reasoning test scores at week 32.

Design, development, and evaluation of an online virtual emergency department for training trauma teams.

BACKGROUND: Training interdisciplinary trauma teams to work effectively together using simulation technology has led to a reduction in medical errors in emergency department, operating room, and delivery room contexts. High-fidelity patient simulators (PSs)-the predominant method for training healthcare teams-are expensive to develop and implement and require that trainees be present in the same place at the same time. In contrast, online computer-based simulators are more cost effective and allow simultaneous participation by students in different locations and time zones. In this pilot study, the researchers created an online virtual emergency department (Virtual ED) for team training in crisis management, and compared the effectiveness of the Virtual ED with the PS. We hypothesized that there would be no difference in learning outcomes for graduating medical students trained with each method. METHODS: In this pilot study, we used a pretest-posttest control group, experimental design in which 30 subjects were randomly assigned to either the Virtual ED or the PS system. In the Virtual ED each subject logged into the online environment and took the role of a team member. Four-person teams worked together in the Virtual ED, communicating in real time with live voice over Internet protocol, to manage computer-controlled patients who exhibited signs and symptoms of physical trauma. Each subject had the opportunity to be the team leader. The subjects' leadership behavior as demonstrated in both a pretest case and a posttest case was assessed by 3 raters, using a behaviorally anchored scale. In the PS environment, 4-person teams followed the same research protocol, using the same clinical scenarios in a Simulation Center. Guided by the Emergency Medicine Crisis Resource Management curriculum, both the Virtual ED and the PS groups applied the basic principles of team leadership and trauma management (Advanced Trauma Life Support) to manage 6 trauma cases-a pretest case, 4 training cases, and a posttest case. The subjects in each group were assessed individually with the same simulation method that they used for the training cases. RESULTS: Subjects who used either the Virtual ED or the PS showed significant improvement in performance between pretest and posttest cases (P < 0.05). In addition, there was no significant difference in subjects' performance between the 2 types of simulation, suggesting that the online Virtual ED may be as effective for learning team skills as the PS, the method widely used in Simulation Centers. Data on usability and attitudes toward both simulation methods as learning tools were equally positive. DISCUSSION: This study shows the potential value of using virtual learning environments for developing medical students' and resident physicians' team leadership and crisis management skills.

Virtual worlds for teaching the new CPR to high school students.

In this study we created a virtual 3D world for learning to manage medical emergencies and evaluated it with 24 high school students in the USA and Sweden. We found that students in both groups felt immersed and found the online simulation easy to use. Scores for flow and self-assessed flow were significantly higher for the RHS group as compared to the HG group (p=.001 and .023 respectively; Mann Whitney U test). Self-efficacy scores for the HG group were significantly higher after training (p=.016 Mann Whitney U test). Males in the RHS group scored significantly higher on flow and self assessed flow than females (p=.006 and p=.023 respectively; Mann Whitney U test). This study demonstrates the potential value of using MMOS for learning to respond to medical emergencies.

Collaborative learning using Internet2 and remote collections of stereo dissection images.

We have investigated collaborative learning of anatomy over Internet2, using an application called remote stereo viewer (RSV). This application offers a unique method of teaching anatomy, using high-resolution stereoscopic images, in a client-server architecture. Rotated sequences of stereo image pairs were produced by volumetric rendering of the Visible female and by dissecting and photographing a cadaveric hand. A client-server application (RSV) was created to provide access to these image sets, using a highly interactive interface. The RSV system was used to provide a "virtual anatomy" session for students in the Stanford Medical School Gross Anatomy course. The RSV application allows both independent and collaborative modes of viewing. The most appealing aspects of the RSV application were the capacity for stereoscopic viewing and the potential to access the content remotely within a flexible temporal framework. The RSV technology, used over Internet2, thus serves as an effective complement to traditional methods of teaching gross anatomy.

The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability.

This study evaluates the relative roles of the radial collateral ligament, the lateral ulnar collateral ligament, and the overlying musculature in posterolateral rotatory instability of the elbow. Fourteen cadaveric upper limbs underwent sequential arthroscopic sectioning of the lateral collateral ligament complex. After sectioning, arthroscopic and fluoroscopic evaluation of a lateral pivot shift test was done. Minimal instability was noted after the first section, but no difference between radial collateral or lateral ulnar collateral ligament sectioning was found. A greater degree of instability was seen between the first and second cut ( P = .0001), but no significant difference was seen between sectioning the 2 groups ( P = .61). Complete instability occurred only after sectioning the overlying musculature. On the basis of this study, injury to both the radial collateral and lateral ulnar collateral ligaments is necessary to cause significant posterolateral rotatory instability of the elbow. Furthermore, the overlying musculature plays an important role in overall stability.

Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance.

BACKGROUND: Several studies have investigated the transfer of surgical trainees' skills acquired on surgical simulators to the operating room setting. The purpose of this study was to compare the effectiveness of two laparoscopic surgery simulators by assessing the transfer of skills learned on simulators to closely matched surgical tasks in the animal laboratory. STUDY DESIGN: In this post-test-only Control group study design, 46 surgically naive medical student volunteers were randomly assigned to one of three groups: Tower Trainer group (n = 16), LapSim group (n = 17), and Control group (n = 13). Outcomes measures included both time and accuracy scores on three laparoscopic tasks (Task 1: Grasp and Place; Task 2: Run the Bowel; Task 3: Clip and Cut) performed on live anesthetized pigs, and a global rating of overall performance as judged by four experienced surgeons. RESULTS: The Tower Trainer group performed significantly better than the Control group on 1 of 7 outcomes measures-Task 3: Time (p < 0.032), although the LapSim group performed significantly better than the Control group on 2 of 7 measures-Task 3: Time (p < 0.008) and Global score (p < 0.005). In comparing the two simulators, the LapSim group performed significantly better than the Tower Trainer group on 3 of 7 outcomes measures-Task 2: Time (p < 0.032), Task 2: Accuracy (p < 0.030) and Global score (p < 0.005), although the Tower Trainer group did not perform significantly better than the LapSim group on any measure. CONCLUSIONS: This study demonstrated that naive subjects trained on a virtual-reality part-task trainer performed better on live surgical tasks in a porcine model as compared with those trained with a traditional box trainer. These findings could aid in selection of appropriate training methodologies.

LUCY: a 3-D pelvic model for surgical simulation.

Development of 3-D models of human anatomy for use in virtual reality simulators is anticipated to enhance surgical training. These models may be a valuable resource for gaining mastery of minimal-access procedures. The pelvis portion (hip to upper-thigh) of a 32-year-old female cadaver was frozen and sectioned axially in approximately 2-mm increments as the first step in producing an accurately representative 3-D model of the human female pelvis. Photographic exposures of the entire series of 95 sections were then converted to digital format. Adobe PhotoShop masks for each structure were created and converted into wire-frame and surface-textured models; this aggregate model set was named "LUCY." To date, 3-D representations of 40 pelvic structures (over 2200 individual masks) have been modeled In conjunction with haptic technology, these virtual anatomic models will enable users to practice fundamental surgical manipulations and procedures such as tubal ligation and ovariectomy. The deployment of surgical-simulation models such as LUCY may facilitate technical-performance aspects of surgical training, particularly those associated with minimal-access procedures. Manipulations and procedures can be practiced over the Internet, providing a host of flexible options to enhance the surgical curricula.

Initial evaluation of a shoulder arthroscopy simulator: establishing construct validity.

Formal evaluation of surgical simulators is essential before their introduction into training programs. We report our assessment of the Mentice Corp Procedicus shoulder arthroscopy simulator. This study tests the hypothesis of construct validity that experienced surgeons will score better on the simulator than individuals with minimal to no experience with the technique. Thirty-five subjects were stratified into three groups (novice, intermediate, and expert) based on their past 5 years' experience with shoulder arthroscopies. Each subject had an identical session on the simulator and completed anatomic identification, hook manipulations, and scope navigation exercises. We found statistically significant differences among the three groups in hook manipulation and scope navigation exercises, with the expert group performing the exercises more quickly (P =.013) and more accurately (P =.002) than the other two groups. No statistically significant differences were found among the groups in the identification of anatomic landmarks. Experts rated the simulator as an effective teaching tool, giving it a mean score of 4.22 and 4.44 (maximum, 5) for teaching instrument control and triangulation, respectively.

Arthroscopic evaluation of scaphoid waist fracture stability and the role of the radioscaphocapitate ligament.

PURPOSE: The purpose of this article is to arthroscopically evaluate the effect of forearm rotation on scaphoid fracture displacement and the impact of intra-articular ligament sectioning. TYPE OF STUDY: Controlled laboratory study. METHODS: Scaphoid fracture stability is studied arthroscopically in 10 cadaveric upper limbs. Displacement of the osteotomized scaphoid with and without forearm rotation is arthroscopically evaluated before and after radioscaphocapitate (RSC) ligament sectioning. RESULTS: No rotation at the fracture site was identified in full pronation and full supination with the wrist immobilized. With the RSC ligament intact, no immobilization, and the wrist fully pronated, 25% of scaphoid fractures rotated less than 1 mm, 62.5% rotated 1 to 2 mm, and 12.5% rotated more than 2 mm. After sectioning the RSC ligament, the fully pronated wrist resulted in rotation of less than 1 mm in 75% and 1 to 2 mm in 25%. No rotation at the fracture site was seen with supination, with or without immobilization. No difference was found between loaded and unloaded trials. CONCLUSIONS: Based on this observational data, it appears safe to use a below-elbow thumb spica cast in the treatment of minimally displaced scaphoid waist fractures. Sectioning of the RSC ligament resulted in reduced amount of rotation at the scaphoid waist fracture; thus the RSC ligament may be a deforming force rather than a stabilizing force in scaphoid waist fractures. Arthroscopy may be a valuable tool in the study of the effect of ligament sectioning on fracture stability.

The fundamental manipulations of surgery: a structured vocabulary for designing surgical curricula and simulators.

A structured vocabulary is proposed for supporting the design and development of advanced surgical simulators. Nine fundamental surgical instrument-tissue actions or manipulations are defined and common synonyms provided. The vocabulary focuses on "target skills" that are familiar to surgeons, in comparison with "enabling skills" from the lexicon of instructional designers and psychometricians. The adoption of this vocabulary can facilitate communication among surgeons and bioengineers developing "high-fidelity" surgical simulators.