Physical Diagnosis Skills of Physicians in Training: A Focused Assessment

Objective: To assess the proficiency of emergency medicine (EM) trainees in the recognition of physical findings pertinent to the care of the critically ill patient.
Methods: Fourteen medical students, 63 internal medicine (IM) residents, and 47 EM residents from three university-affiliated programs in Philadelphia were tested. Proficiency in physical diagnosis was assessed by a multimedia questionnaire targeting findings useful in emergencies or related to diseases frequently encountered in the ED. Attitudes toward diagnosis not based on technology, teaching practices of physical examination during EM training, and self-motivated learning of physical diagnosis also were assessed for all the EM trainees.
Results: With the exception of ophthalmology, the EM trainees were never significantly better than the senior students or the IM residents. They were less proficient than the IM residents in cardiology, and not significantly different from the IM residents in all other areas. For no organ system tested, however, did they achieve less than a 42.9% error rate (range: 42.9–72.3%, median = 54.8%). There was no significant improvement in proficiency over the three years of customary EM training. The EM residents who had received supervised teaching in physical diagnosis during training achieved a significantly higher cumulative score. The EM residents attributed great clinical importance to physical diagnosis and wished for more time devoted to its teaching.
Conclusions: These data confirm the recently reported deficiencies of physical diagnosis skills among physicians in training. The results are particularly disturbing because they relate to EM trainees and concern skills useful in the ED. Physical diagnosis should gain more attention in both medical schools and residency programs.     

Evaluation of Emergency Medicine Resident Death Notification Skills by Direct Observation

Emergency physicians commonly perform death notifications. Physician training in death notification has been limited. Resident physicians are rarely evaluated in their performance of death notifications. OBJECTIVE: To evaluate death notification skills by direct observation of actual notifications performed by trained emergency medicine (EM) residents. METHODS: This was a prospective, observational study of EM resident death notification performance. EM residents received training and then were directly observed and evaluated by trained evaluators during actual death notifications in a 64,000-visit community teaching hospital emergency department. RESULTS: There were 327 evaluations of 70 different EM residents. Overall performance evaluations were 55% excellent, 40% satisfactory, and 5% unsatisfactory. Third-year EM residents and female EM residents were more likely to be rated excellent. CONCLUSIONS: Death notification is a skill that can be evaluated like other EM skills. Trained EM residents performed well in actual death notifications when directly observed and evaluated. Senior residents and female residents were more likely to be rated excellent.     

Assessment of musculoskeletal examination skills: physiatry residents as evaluators and models

OBJECTIVE: To evaluate the musculoskeletal examination (MSKE) skills of junior (postgraduate year [PGY] 2) physical medicine and rehabilitation (PM&R) residents and self-confidence with these skills, and to demonstrate changes in self-confidence in the MSKE skills of senior (PGY3 and PGY4) residents, who served as evaluators and models. DESIGN: Forty-one PGY2-4 residents participated in this retrospective cohort study, which was conducted within a residency program affiliated with two medical schools. Senior residents attended an instructional session in performing and evaluating MSKE skills, taught by a musculoskeletal physiatrist. The following week, junior residents were tested on their MSKE skills; nine seniors served as models, and another nine served as evaluators. Six seniors attended the instructional session only and did not participate in the evaluation. Juniors received a posttest teaching session on MSKE skills, before an unannounced repeat evaluation 5 mos later. All residents completed a survey regarding self-confidence in MSKE skills pre- and posttest teaching sessions. Performance of MSKE skills (based on PASSOR guidelines) and application of ACGME core competencies (medical knowledge, professionalism, interpersonal skills) were measured, and a survey was administered regarding self-confidence in MSKE skills. RESULTS: Posttest results showed a significant improvement of MSKE skills among juniors in the shoulder, lumbar spine, and knee examinations (P < 0.008), with the most robust improvement in the shoulder exam (P < 0.0001). Self-confidence of juniors in their MSKE skills increased significantly (P < 0.005). There was significant improvement (P < 0.008) in self-confidence in the MSKE skills of seniors who served as models and evaluators, but not in those who only attended the instructional session (P = 0.06). CONCLUSIONS: This evaluation and instructional method resulted in a significant improvement of MSKE skills of junior residents on formal testing. Using senior residents as evaluators and models improved their confidence in their own MSKE skills.     

Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents

OBJECTIVE: We aimed to determine internal medicine residents' perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal. DESIGN: Cross-sectional postal survey. SETTING: Canadian internal medicine training programs. PARTICIPANTS: Internal medicine residents attending Canadian English-speaking medical schools. INTERVENTIONS: A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools. MEASUREMENTS AND MAIN RESULTS: Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r(2) = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence. CONCLUSIONS: The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.     

A curricular initiative for internal medicine residents to enhance proficiency in internal jugular central venous line placement

OBJECTIVE: To determine the feasibility, efficacy, and outcomes of teaching Internal Jugular (IJ) central venous line placement (CVLP) to internal medicine residents in a hands-on training experience with adult patients. SUBJECTS AND METHODS: Data were obtained from 47 residents during their 3-year residency program through questionnaires and a proprietary system that tracks resident procedures. Twenty-five postgraduate year (PGY) 2 residents at the Mayo Clinic in Rochester, Minn, were assigned to IJ-CVLP training in the cardiac catheterization laboratory from January 2001 to June 2001. Their experience, analyzed immediately after training and at completion of residency, was compared with that of 22 PGY-2 residents in the same class who were not assigned to IJ-CVLP training. RESULTS: The median Likert scores of the residents' self-reported perception of independence in IJ-CVLP increased from 3.0 (mean +/- SD score, 2.8+/-1.4) before the intervention to 5.0 (4.4+/-0.9) after the intervention (P<.001, signed rank test). At graduation, trained residents had performed more IJ-CVLPs than the control residents (mean +/- SD, 17.8+/-8.4 vs 9.8+/-6.3, respectively; P<.001). Residents who received IJ-CVLP training, compared with those who did not, showed a significant increase in the mean percentage of IJ-CVLPs performed independently between PGY-1 (2.2%) and PGY-3 (31.2%) (P=.008). CONCLUSIONS: Training internal medicine residents to perform IJ-CVLP is feasible in the cardiac catheterization laboratory with supervision from an attending cardiologist. Trained residents performed significantly more IJ-CVLPs independently during their third year compared with their first year of training. We believe this initiative may be implemented successfully in graduate medical education curriculums.     

Resident Perception of Academic Skills Training and Impact on Academic Career Choice

OBJECTIVES: 1) To evaluate residents' perceptions of the quality of training in basic academic skills and the availability and quality of research resources during residency; 2) to evaluate the association between these attitudes and choice of an academic career; and 3) to assess residents' attitudes toward the importance of postgraduate fellowship training for success in an academic career. METHODS: A 15-item survey was administered to all U.S. emergency medicine (EM) residents in conjunction with the February 1997 American Board of Emergency Medicine (ABEM) In-service Examination. The survey assessed resident interest in a career in academic EM, and resident perception of the general quality of training in academic (research and teaching) skills. Residents were also asked to rate the quality of their training in the following specific academic skills: medical and grant writing, bedside teaching, lecturing, the use of computers, study design, statistics, and the use of audiovisual aids. Resident perceptions of the availability of the following resources were also assessed: teaching and research role models, data collection and analysis support, laboratory facilities, financial support of research, research fundamentals lectures, and computers. RESULTS: The response rate was 93%. Forty-four percent of the respondents were interested in academic EM, 36.6% were undecided, and 19.6% were not interested in an academic career. On a scale of 1 (unprepared) to 5 (well prepared), the residents rated their overall preparedness for an academic career fairly high (3.97 [0.86]). In contrast, they perceived the quality of their training in the specific academic skill areas assessed and research resource availability to be only fair. Despite resident perception of relatively inadequate training in basic academic skills, only 24% of the respondents indicated that they believed fellowship training was important for success in an academic career. Logistic regression analyses demonstrated that participation in a research project in medical school, the length of the training program (4- vs 3-year), being a first-year resident, and a better perception of one's overall academic skill preparation were factors independently associated with having a greater interest in an academic career. CONCLUSIONS: A relatively high percentage of residents initially express an interest in an academic career, but this interest wanes as residency progresses. A minority of residents believe that their training provides them with the specific skills needed to succeed in academics, or with adequate exposure to research resources or mentors. Emergency medicine may be able to increase the number of qualified academic faculty by recruiting medical students with prior research experience, and providing residents with better research training and role models.     

Competence of New Emergency Medicine Residents in the Performance of Lumbar Punctures

Background: Medical students are taught some procedural skills during medical school, but there is no uniform set of procedures that all students learn before residency. Objective: To determine the level of competence in the performance of a lumbar puncture (LP) by new postgraduate year 1 (PGY1) emergency medicine (EM) residents. Methods: An observational study was conducted at three EM residencies with 42 PGY1 residents who recently graduated from 26 various medical schools. The LP procedure was divided into 26 major and 44 minor steps to create a scoring protocol. The model, procedure, and scoring protocol were validated by experienced emergency physicians. Subjects performed the procedure without interruption or feedback on an LP training model using a standard LP kit. A step was scored as “performed correctly” if two of the three evaluators concurred. Pre‐ and poststudy questionnaires assessed subjects' prior instruction and clinical experience with LP, self‐confidence, sense of relevance, motivation, and fatigue. Results: Subjects completed an average of 14.8 (57%; 95% confidence interval [95% CI] = 53% to 61%) of the major steps (range: 4–26) and 19.1 (43%; 95% CI = 42% to 45%) of the minor steps (range: 7–28) in 14.3 minutes (range: 3–22). Sixty‐nine percent failed to obtain cerebrospinal fluid from the model. Subjects' levels of confidence changed slightly on a five‐point scale from 2.8 (“little‐to‐some”) before the test to 2.5 after the test. Eighty‐three percent of the subjects previously performed LPs on patients during medical school (average attempts = 2.2; range: 0–10), but only 40% of those who did so were supervised by an attending during their first attempt. Conclusions: In the cohort studied, new PGY1 EM residents had not attained competence in performing LPs from training in medical school. Most new PGY1 residents probably require training, practice, and close, direct supervision of this procedure by attending physicians until the residents demonstrate competent performance.     

The first decade of the American Board of Internal Medicine certification in critical care medicine: an overview of examinees and certificate holders from 1987 through 1996

OVERVIEW: This study reviews the first decade of critical care medicine (CCM) certification by the American Board of Internal Medicine (1987-1996). Included are the characteristics of examinee and certificate-holder groups; examination performances from different underlying disciplines of internal medicine, with or without formal CCM training; and the influence of background and a training program as correlates of examination performance. DATA SOURCES: The CCM certification examination has been offered biennially since November 1987. Performance data on the American Board of Internal Medicine examinations in internal medicine and its subspecialties and added qualifications were available for candidates taking the CCM examinations. For examinees with formal CCM training, residency program director ratings, and information regarding the program characteristics of size and percentage of United States and Canadian medical graduates were also available. STUDY SELECTION: All examinees who ever attempted certification were included in this study. The study cohort for each of the five examination administrations consists of all first-time takers. CONCLUSIONS: Cohort sizes have decreased since formal training became an admission requirement in 1993. Percentages of International Medical Graduates and women attempting and achieving certification have increased steadily. Examination performance was positively associated with formal training, internal medicine examination performance, recent medical training, and pulmonary disease certification. For those with formal training, performance was also positively associated with training program director ratings of overall clinical competence and completion of a training program with a higher proportion of United States and Canadian medical graduates.     

Observation of Emergency Medicine Residents at the Bedside: How Often Does It Happen?

Objective: To determine how often trainees in emergency medicine (EM) are observed while performing a history, a physical examination, or specific procedures. Methods: The 26 members of the National Consensus Group on Clinical Skills in Emergency Medicine affiliated with an EM residency program were asked to circulate a survey to their residents during February and March 1994. Twenty-one programs participated. surveying a total of 514 residents. The residents were asked how many times they had been observed by an attending physician while they performed a history, a physical examination. endotracheal intubation. or central vein catheterization during training. The residents also were asked about observation of specific components of the physical examination. such as the heart. lung, and genitourinary systems. Results: Three hundred nineteen residents (62%) responded to the survey. Thirteen percent of the residents reported that they had never been observed taking a history during training. During their PGYI training, 19% of the residents reported that they had never been observed taking a history, 42% had been observed one to three times, 255% had been observed four to 12 times. and 13% had been observed >12 times. Six percent of the residents reported that they had never been observed doing a physical examination during training. During their PGYI training, 10% of the residents had never been observed performing a physical examination, 38% had been observed one to three times. 34% had been observed four to 12 times, and 18% had been observed >12 times. Conclusions: Many residents report that they are infrequently observed performing histories and physical examinations during their EM training. with a significant number of residents reporting that they were never observed performing basic bedside clinical skills. More direct observation with trained faculty observers may provide an opportunity for better evaluation and remediation of bedside clinical skills.     

Drug Alert Experience and Salience during Medical Residency at Two Healthcare Institutions

Background  Drug alerts are clinical decision support tools intended to prevent medication misadministration. In teaching hospitals, residents encounter the majority of the drug alerts while learning under variable workloads and responsibilities that may have an impact on drug-alert response rates. Objectives  This study was aimed to explore drug-alert experience and salience among postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2), and postgraduate year 3 (PGY-3) internal medicine resident physicians at two different institutions. Methods  Drug-alert information was queried from the electronic health record (EHR) for 47 internal medicine residents at the University of Pennsylvania Medical Center (UPMC) Pinnacle in Pennsylvania, and 79 internal medicine residents at the MetroHealth System (MHS) in Ohio from December 2018 through February 2019. Salience was defined as the percentage of drug alerts resulting in removal or modification of the triggering order. Comparisons were made across institutions, residency training year, and alert burden. Results  A total of 126 residents were exposed to 52,624 alerts over a 3-month period. UPMC Pinnacle had 15,574 alerts with 47 residents and MHS had 37,050 alerts with 79 residents. At MHS, salience was 8.6% which was lower than UPMC Pinnacle with 15%. The relatively lower salience (42% lower) at MHS corresponded to a greater number of alerts-per-resident (41% higher) compared with UPMC Pinnacle. Overall, salience was 11.6% for PGY-1, 10.5% for PGY-2, and 8.9% for PGY-3 residents. Conclusion  Our results are suggestive of long-term drug-alert desensitization during progressive residency training. A higher number of alerts-per-resident correlating with a lower salience suggests alert fatigue; however, other factors should also be considered including differences in workload and culture.     

Evaluation of general and traditional internal medicine residencies utilizing a medical records audit based on educational objectives

Residency programs in general internal medicine must ensure that skills relevant to the care of both ambulatory and hospitalized patients are taught effectively. The authors evaluated both a general and a traditional internal medicine training program at the same institution. They employed a medical records audit technique based on educational objectives that assessed the approach of residents in each program in dealing with five inpatient and five outpatient problems. Inpatient performance also was assessed by subjective faculty evaluations. Resident physicians in the general program more closely reflected the educational objectives in two of five outpatient audits. There were no differences between the programs for inpatient audits or subjective evaluations. These findings support the argument that the emphasis on teaching ambulatory medicine need not jeopardize inpatient training, and they demonstrate the feasibility of a medical records audit based on educational objectives for program evaluation.     

Focused Training of Emergency Medicine Residents in Goal-directed Echocardiography: A Prospective Study

OBJECTIVES: To determine if a focused transthoracic echocardiography (TTE) training course would improve the accuracy of completion and interpretation of a goal-directed TTE by emergency medicine residents. METHODS: This was a prospective, observational, educational study of the impact of a focused training course on the change in physician performance on pre- and postcourse examinations testing competency in goal-directed TTE defined by five criteria: 1). image orientation, 2). anatomy identification, 3). chamber size grading, 4). ventricular function estimation, and 5). pericardial effusion identification. Subjects included were emergency medicine residents with between ten and 20 hours of noncardiac ultrasound didactics and between 20 and >150 proctored noncardiac ultrasound examinations. All underwent five hours of focused echocardiography didactics and one hour of proctored practical echocardiography training designed and implemented by an emergency physician ultrasound director and a cardiologist. Before the start of the training course, participants completed two examinations: 1) written 23-question test on the above concepts and 2) performance of a TTE on a healthy subject testing 16 elements that define a properly performed examination. After the training course, participants again completed both examinations. RESULTS: A total of 21 emergency medicine residents qualified for and underwent standardized testing and training. The percentage correct on the precourse written examination was 54% (95% CI = 50% to 59%), and the postcourse examination score was 76% (95% CI = 71% to 80%) (p < 0.005, paired t-test). The percentage correct on the precourse practical examination was 56% (95% CI = 51% to 60%), and the postcourse examination score was 94% (95% CI = 91% to 96%) (p < 0.005). CONCLUSIONS: A focused six-hour echocardiography training course significantly improved emergency medicine residents' percentage scores on both written and practical examinations testing essential components required for correct goal-directed TTE performance and interpretation.     

Current level of training,experience and perceptions of emergency physicians as expert witnesses: A pilot study

The objective of the present study was to determine emergency physicians' training, experience and perceptions as expert witnesses. Emergency physicians of an adult tertiary referral and teaching hospital participated in a pilot survey regarding their experiences in report writing and in court as expert witnesses. The 28‐item survey also examined the amount of formalized forensic medical teaching that emergency physicians had received during their training. Of the participants, 41% (95% CI 21.6–64.1; 7/17) had never received any undergraduate or postgraduate training in forensic medicine, 11/17 (65%, 95% CI 41.2–82.8) had provided a written expert opinion for court, and 12/17 (71%, 95% CI 46.6–87.0) had attended court as an expert witness. All participants considered themselves ‘skilled in attending an emergency resuscitation’, whereas 3/13 (23%, 95% CI 7.5–50.9) considered themselves ‘skilled in attending a courtroom trial’. Nearly 90% (95% CI 64.7–98.0; 15/17) thought that medical evidence training should be a requirement of emergency speciality training. The most commonly preferred forms of medical evidence training were mock court sessions (76%, 95% CI 52.2–91.0; 13/17) and forensic workshops (76%, 95% CI 52.2–91.0; 13/17). From 10 non‐technical skills required of an EP, ‘appearing in court as an expert witness’ was perceived to be the second most difficult skill by most respondents. Emergency physicians in this pilot study have limited training for the role of expert witness and see it as one of the most difficult non‐technical skills they have to perform. Further research is required regarding the current and future scope of forensic training.     

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric

Purpose

The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing.

Integrating simulation into a busy residency program.

A mandatory program of computer-driven simulation training was instituted in a medium-sized surgical training program in order to achieve the goal of increased resident performance outside the setting of direct patient care. Postgraduate year (PGY) 1-5 residents received mentored instruction on a virtual reality (VR) laparoscopic surgical trainer in performance of specific tasks appropriate to training level. Training for PGY 1-2 residents consisted of basic manipulative VR tasks. Training for PGY 3-5 residents consisted of VR suturing and intracorporeal knot-tying tasks. Each resident received two to four mentored one-hour sessions, and was instructed to return for self-directed practice during blocked and unscheduled time. PGY 3-5 residents had laparoscopic suturing and knot-tying skills evaluated in an animal model prior to onset of VR training and two to four months after start of training. After seven months of availability of training, PGY 1-2 residents had undertaken significantly more training sessions than PGY 3-5 residents (18+/-3 vs. 9+/-2; p<0.01). All PGY 1-2 residents demonstrated improved task performance, and six achieved expert performance relative to experienced laparoscopic surgeons. The suturing task in the animal lab was accomplished faster post-training (91+/-9 seconds vs. 154+/-16 seconds; p<0.01). Early results suggest that broadly applied VR training is of significant benefit in increasing resident technical skills. Based on early success, a broader program of computer-based simulation has been implemented, using more advanced devices for technical skills training, and a human patient simulator for training critical decision-making skills.     

Modernising medical careers: educational implications for the emergency department

Modernising Medical Careers (MMC) is a project designed to reconfigure postgraduate medical education throughout the United Kingdom. It is proposed that all UK medical school graduates undertake a 2 year foundation programme to build basic professional skills to which specialist training can be added. Implicit in these proposals is that career choices need to be made at a relatively early phase of training. In the case of emergency medicine, a common stem of training in emergency and critical care is being proposed which would be suitable early training for potential specialists in emergency medicine, anaesthesia, intensive care, and acute medicine. In both foundation training and higher specialist training, the trainee should have the skills of a self directing, reflective learner and the trainer the skills required to produce a good learning environment with a supportive and open atmosphere and learning structured to maximise the opportunities for experiential learning in the workplace.     

The Environment of Care Model: a paradigm shift in comprehensive breast care

Abstract

Knowing one’s own role is a key collaboration competency for postgraduate trainees in the Canadian competency framework (CanMEDS®). To explore methods to teach collaborative competency to internal medicine postgraduate trainees, baseline role knowledge of the trainees was explored. The perceptions of roles (self and others) at patient discharge from an acute care internal medicine teaching unit amongst 69 participants, 34 physicians (25 internal medicine postgraduate trainees and 9 faculty physicians) and 35 health care professionals from different professions were assessed using an adapted previously validated survey (Jenkins et al., 2001). Internal medicine postgraduate trainees agreed on 8/13 (62%) discharge roles, but for 5/13 (38%), there was a substantial disagreement. Other professions had similar lack of clarity about the postgraduate internal medicine residents’ roles at discharge. The lack of interprofessional and intraprofessional clarity about roles needs to be explored to develop methods to enhance collaborative competence in internal medicine postgraduate trainees.     

A prospective randomized trial comparing a virtual reality simulator to bedside teaching for training in sigmoidoscopy

BACKGROUND AND STUDY AIMS: Clinical investigation using endoscopy simulators is now possible due to recent advances in virtual reality technology. A prospective randomized trial was conducted to compare the exclusive use of a virtual reality endoscopy simulator with bedside teaching for training in sigmoidoscopy. MATERIALS AND METHODS: Internal medicine residents were randomly assigned to training exclusively using a virtual reality simulator (group 1) or via bedside teaching (group 2). Residents were then observed performing five sigmoidoscopic procedures in asymptomatic patients referred for colorectal cancer screening. Endoscopic examinations were evaluated for procedure duration, completion, ability to perform retroflexion, and level of patient comfort/discomfort. Each examination was scored from 1 (inability to insert the endoscope beyond the rectum) to 5 (able to complete the entire examination independently in less than 20 min). RESULTS: Sixty-six sigmoidoscopic examinations were completed by nine residents in group 1 (simulator-trained group) and seven residents in group 2 (traditional teaching group). Participants in group 1 had more difficulty with initial endoscope insertion and negotiation of the rectosigmoid junction (mean score +/- SEM 2.9 +/- 0.2) than those in group 2 (3.8 +/- 0.2) ( P < 0.001). The splenic flexure was reached independently in 10 of 34 examinations (29 %) in group 1, compared with 23 of 32 examinations (72 %) in group 2 ( P = 0.001). Retroflexion was successfully performed by 19 of 34 (56 %) in group 1 compared to 27 of 32 (84 %) in group 2 ( P = 0.02). The average procedure time, patient satisfaction, and discomfort associated with the procedure did not differ statistically between the two groups. CONCLUSIONS: The use of a state-of-the-art virtual reality-based endoscopy simulator is inferior to traditional bedside teaching techniques when used exclusively for training medical residents to perform sigmoidoscopy.     

Emergency Medicine Residents Do Not Document Detailed Neurologic Examinations

Objectives: Physical examinations performed by residents in many specialties are often incomplete and inaccurate. This report assessed the documentation of the neurologic examination performed by emergency medicine (EM) residents when examining patients with potential psychiatric or neurologic chief complaints. Methods: A retrospective chart review of neurologic examinations documented by EM residents was performed. An eight‐item neurologic examination score was created and analyzed by resident postgraduate year. A linear mixed model was used to determine if differences in neurologic examination scores existed between resident year, type of complaint, and resident year and type of complaint. A one‐point difference in scores was considered clinically important. Results: A total of 384 charts were reviewed. An average of 4.26 items (95% confidence interval [CI] = 3.91 to 4.62) out of a possible eight were documented that did not vary by resident year of training (p = 0.08). An effect was found for type of complaint. Documentation was lower for psychiatric than for neurologic complaints: mean score for psychiatric complaints 3.97 vs. mean score for neurologic complaints 4.55 (difference –0.58, 95% CI = –1.02 to –0.14). No interaction was found for type of complaint and resident year. A clustering effect was identified for individual residents. Conclusions: Emergency medicine residents do not document detailed neurologic examinations on patients with neurologic or psychiatric complaints. Individual resident variation contributes to this documentation.     

Integrating simulation into a busy residency program

A mandatory program of computer‐driven simulation training was instituted in a medium‐sized surgical training program in order to achieve the goal of increased resident performance outside the setting of direct patient care. Postgraduate year (PGY) 1–5 residents received mentored instruction on a virtual reality (VR) laparoscopic surgical trainer in performance of specific tasks appropriate to training level. Training for PGY 1–2 residents consisted of basic manipulative VR tasks. Training for PGY 3–5 residents consisted of VR suturing and intracorporeal knot‐tying tasks. Each resident received two to four mentored one‐hour sessions, and was instructed to return for self‐directed practice during blocked and unscheduled time. PGY 3–5 residents had laparoscopic suturing and knot‐tying skills evaluated in an animal model prior to onset of VR training and two to four months after start of training. After seven months of availability of training, PGY 1–2 residents had undertaken significantly more training sessions than PGY 3–5 residents (18±3 vs. 9±2; p<0.01). All PGY 1–2 residents demonstrated improved task performance, and six achieved expert performance relative to experienced laparoscopic surgeons. The suturing task in the animal lab was accomplished faster post‐training (91±9 seconds vs. 154±16 seconds; p<0.01). Early results suggest that broadly applied VR training is of significant benefit in increasing resident technical skills. Based on early success, a broader program of computer‐based simulation has been implemented, using more advanced devices for technical skills training, and a human patient simulator for training critical decision‐making skills.