Assessing competency in spasticity management: a method of development and assessment

ABSTRACT: This project endeavored to create an educational module including methodology to instruct physical medicine and rehabilitation residents in the evaluation and appropriate treatment of patients with spasticity and other sequelae of the upper motor neuron syndrome. It further sought to verify acquired competencies in spasticity management through objective evaluation methodology. A physical medicine and rehabilitation board-certified physician with 10 yrs clinical experience in spasticity management trained 16 residents using a standardized competency-based module. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education. The 16 residents successfully demonstrated proficiency in every segment of the evaluation module by the end of the Postgraduate Year 3 spasticity management rotation. Objective measures compared resident scores on an institution-specific standardized test administered before and after training. Resident proficiency in the skills and knowledge pertaining to spasticity management was objectively verified after completion of the standardized educational module. Validation of the assessment tool is evidenced by significantly improved postrotational institution-specific standardized test scores (mean pretest score, 61.1%; mean posttest score, 95.4%) as well as oral testing. In addition, the clinical development tool was validated by residents being individually observed performing skills and deemed competent by a board-certified physical medicine and rehabilitation physician specializing in spasticity management. The standardized educational module and evaluation methodology provide a potential framework for the definition of baseline competency in the clinical skill area of spasticity management.     

Residency training in physical medicine and rehabilitation. I: Clinical and didactic experience

A survey was conducted to determine the type of clinical and didactic training experience that was provided to resident trainees in physical medicine and rehabilitation (PM&R) in the 1987-1988 academic year. Chief residents from 43 (61%) of the 70 PM&R programs accredited by the Accreditation Council for Graduate Medical Education responded. According to respondents, the programs averaged 12.6 residents. The residents spent an average of 18.5 months on an inpatient bedservice, 12.6 months on outpatient exposures, and the remainder of the time attending other clinical experiences and didactic training. Forty percent of those responding reported that their programs required in-house call in postgraduate years (PGYs) 2 through 4, and 53% of the programs required no in-house call during the same clinical years. Seven percent of the programs required in-house call in PGYs 2 and 3, but none in PGY 4. The average time spent in electrodiagnostic studies was 7.6 months (range = 2 to 19 months). Electromyography exposure by completion of PGY 4 also varied widely, from 40 to 500 studies. Resident trainee exposure to inpatient and outpatient spinal cord injury, closed head injury, pediatric rehabilitation, sports medicine, and geriatric medicine, and rehabilitation fellowship positions being offered through the responding PM&R residency training programs were also surveyed. Some instances of apparent program imbalances or inadequate training which could reduce the scope of a resident's educational experience were noted.     

Tracheostomy management skills competency in physical medicine and rehabilitation residents: a method for development and assessment

This educational unit was developed to instruct physical medicine and rehabilitation residents on tracheostomy management in non-ventilator-dependent patients and to implement an objective assessment format to measure the attainment of these skills. Thirty-one subjects participated in a 2-day didactic and hands-on workshop supervised by an attending physiatrist, certified speech pathologists, and registered nurses. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education. To test the success of the standardized educational module, data have been collected on an ongoing basis for a period of 6 yrs. A before-and-after multiple-choice written examination, as well as simulated patient encounters consisting of eight segments divided into four stations, was used to assess knowledge acquisition and skill achievement. Before instruction, none of the 31 participants were able to perform appropriate tracheostomy care. After the workshop, 31 of 31 (100%) successfully demonstrated clinical proficiency in every segment of the evaluation element of the educational module. Furthermore, a significant increase in knowledge was observed in the multiple-choice examination from pretest to posttest (pretest, 52.7%; posttest, 84.5%). Participation in this module resulted in substantial acquisition of knowledge and skills regarding tracheostomy management for physical medicine and rehabilitation residents.     

Musculoskeletal education in physical medicine and rehabilitation residency programs: graduating resident perspective

OBJECTIVES: To characterize graduating physical medicine and rehabilitation (PM&R) residents physicians' perceptions of their current musculoskeletal (MSK) training, to identify barriers perceived by resident physicians to improving MSK education experiences, and to compare the views of resident physicians with those of PM&R residency program directors. DESIGN: Fourth-year PM&R residents graduating in 2004 whose program directors attended the 2004 Association of Academic Physiatrists annual meeting were asked to complete an MSK education survey developed by the authors. Data were compared with a previous MSK education survey that had been completed by PM&R residency program directors. RESULTS: Ninety-three of 156 (61%) fourth-year PM&R residents responded after multiple contacts. According to residents, the most frequently used MSK education formats during residency were MSK lecture series, MSK journal clubs, and MSK workshops. Potential barriers to improved MSK education during residency included staff, money, and time. If given unlimited resources, most residents would greatly increase the use of visiting lecturers, MSK workshops, and MSK lecture series. CONCLUSION: Graduating PM&R residents as well as residency program directors indicated a strong interest in expanding resident MSK education through the use of visiting lecturers. Differences were noted with respect to the use of hands-on learning (i.e., MSK workshops [residents]) vs. passive learning (i.e., CD ROMS/DVDs and videos [program directors]). Both groups described how limited resources including staff, money, and time are barriers to resident MSK education.     

Criteria for selection of physical medicine and rehabilitation residents. A survey of current practices and suggested changes

The growing number of medical graduates seeking residency training in Physical Medicine and Rehabilitation (PM&R) has made the resident selection process increasingly difficult. This circumstance has prompted a search for more efficient selection criteria. Forty-one PM&R residency program directors in the United States and Puerto Rico completed a survey on the way they selected their residents. The results indicate that personal applicant characteristics, as determined by interview, were more important than academic criteria in ranking residency candidates. Of the academic variables presented, participation in a PM&R elective at the program director's hospital and the Dean's letter were rated highest. The interview experience has a major influence on the ranking of an applicant for acceptance into a PM&R training program. Academic criteria should have more influence on applicant selection than they do at present. In addition, early identification and vigorous recruitment of resident candidates with an interest in research is essential for increasing the number of academic physiatrists within our specialty.     

Reliability of a 360-degree evaluation to assess resident competence

OBJECTIVE: To determine the feasibility and psychometric qualities of a 360-degree evaluation of physical medicine and rehabilitation (PM&R) residents' competence. DESIGN: Nurses, allied health staff, and medical students completed a 12-item questionnaire after each PM&R resident rotation from January 2002 to December 2004. The items were derived from five of the six competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). RESULTS: Nine hundred thirty evaluations of 56 residents were completed. The alpha reliability coefficient for the instrument was 0.89. Ratings did not vary significantly by resident gender. Senior residents had higher ratings than junior residents. A reliability of >0.8 could be achieved by ratings from just five nurses or allied health staff, compared with 23 ratings from medical students. Factor analysis revealed all items clustered on one factor, accounting for 84% of the variance. In a subgroup of residents with low scores, raters were able to differentiate among skills. CONCLUSION: Resident assessment tools should be valid, reliable, and feasible. This Web-based 360-degree evaluation tool is a feasible way to obtain reliable ratings from rehabilitation staff about resident behaviors. The assignment of higher ratings for senior residents than junior residents is evidence for the general validity of this 360-degree evaluation tool in the assessment of resident performance. Different rater groups may need distinct instruments based on the exposure of rater groups to various resident activities and behaviors.     

An internship for college students in physical medicine and rehabilitation: effects on awareness, career choice, and disability perceptions

OBJECTIVE: To show the impact that an internship program in Physical Medicine and Rehabilitation (PM&R) for college students has on their knowledge about the field, career choice, and perceptions about people with disabilities. DESIGN: Twelve students were selected to participate in the study. Students observed patient therapies and followed faculty and physiatry resident physicians. Students also participated in research studies in rehabilitation research. Group discussions regarding specific projects, research methods, career choice, and perceptions about disability were part of a didactic curriculum. Surveys about PM&R knowledge, attitudes toward people with disabilities, demographics, and course evaluations were administered. RESULTS: Results showed that the program increased knowledge about PM&R (P < 0.008). Premedical students missed significantly fewer questions (8.2 vs. 11.7; P = 0.04) on this survey than did other participants. Results also showed that this program affected their attitudes toward people with disabilities and student choice to pursue a career in health care. CONCLUSIONS: This type of internship experience provides an educational environment for college students to become acquainted with PM&R, interact positively with people with disabilities, and influence career choice in the allied health professions.     

督导教学联合PAL教学法在超声医学专业技能培训中的应用

目的探讨督导教学联合同伴互助学习（PAL）教学法在超声医学专业技能培训教学中的应用价值。 方法选取2020年6月至2022年6月浙江大学医学院附属第二医院超声医学科2018级、2019级住院医师共34人。采用督导教学联合PAL教学法,对2018级、2019级住院医师进行各系统操作切面带教培训与讲解、互助组学习以及带教老师督导教学。每周进行一次系统切面考核（过程考核）,按专业技能考试评分表,80分为合格。培训结束后进行结业技能考试（结业考试）。统计结业技能考试通过率,以及采用Likert 5级评分法调查住院医师对该课程的满意程度,以评估该教学方法的有效性。 结果应用督导教学联合PAL教学法后,超声医学科2018级、2019级住院医师每周进行的专业技能操作考核（过程考核）成绩均合格（≥80分）,考试平均分分别为（88.29±2.78）、（87.49±4.51）分;住院医师结业技能考试（结业考试）通过率为100%。收回满意度调查问卷34份,结果表明,住院医师均对该教学方法和内容安排满意或非常满意,均认为督导教学联合PAL教学法有助于掌握专业操作技能,提高学习效率,促进与老师的交流。 结论督导教学联合同伴PAL教学法在住院医师规范化培训超声专业技能培训中应用效果较好,可为超声专业技能培训教学提供新的思路。     

临床病例解析培训对提高麻醉住院医师临床思维的作用分析

目的通过比较麻醉住院医师临床技能考核结果,说明麻醉临床病例解析评估的重要性,为进一步提高麻醉住院医师培训质量提供思路和手段。方法选取2011年至2013年北京友谊医院和北京天坛医院麻醉专业住院医师轮转培训25人,以临床病例解析分析要点为考核点,对其专业临床技能进行考核评分,对比不同培训时段的考核结果。结果第一年住院医师的得分比第二年第三年住院医师均低,不合格率也高于第二年第三年住院医师。住院医师参加的临床病例解析培训次数越多,成绩优良率也越高。结论住院医师的临床思维麻醉病例解析培训有利于提高住院医师的临床思维和技能,使学科培训更加高效化、系统化、规范化。     

Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial

Background: Internal medicine residents must be competent in Advanced Cardiac Life Support (ACLS) for board certification. Purpose: The purpose was to use a medical simulator to assess baseline proficiency in ACLS and determine the impact of an intervention on skill development. Method: This was a randomized trial with wait-list controls. After baseline evaluation in all residents, the intervention group received 4 education sessions using a medical simulator. All residents were then retested. After crossover, the wait-list group received the intervention, and residents were tested again. Performance was assessed by comparison to American Heart Association guidelines for treatment of ACLS conditions with interrater and internal consistency reliability estimates. Results: Performance improved significantly after simulator training. No improvement was detected as a function of clinical experience alone. The educational program was rated highly.     

The Educational Intervention "GRIEV_ING" Improves the Death Notification Skills of Residents

Background: Death notification is a common, difficult, and emotionally laden communication for emergency physicians. Teaching emergency medicine residents the skills for success in this communication is an important focus for educators. To accomplish this task, educators need practical, proven teaching and assessment tools focused on death notification skills. Objectives: To test the hypothesis that a teaching module, based on the mnemonic "GRIEV_ING," could improve resident confidence, competency, and communication skills when delivering a death notification. Methods: The GRIEV_ING intervention consisted of a two-hour educational session composed of small-group, role-play, and didactic experiences. The authors used a pre–post–retention repeated-measures design to test their hypothesis immediately following and three months after training. For each assessment cycle, three quantitative measures were collected: self-confidence, relationship–communication, and competency. Relationship–communication and competency scores were collected during simulated survivor encounters. Results: Complete data for 20 residents were obtained. Significant improvements were noted in resident confidence scores at the pre–post (F = 16.7, p <0.0001) and pre–retention (F = 14.0, p = 0.001) comparisons. Likewise, significant improvements were noted in resident competence scores at the pre–post (F = 4.7, p = 0.04) and pre–retention (F = 8.8, p = 0.008) comparisons. Resident relationship–communication scores were uniformly high, and there was no significant change in this score across study intervals. Conclusions: This study demonstrates that a defined educational intervention focused on the GRIEV_ING mnemonic can improve physician confidence and competence in death notification.     

Musculoskeletal injection skills competency in physical medicine and rehabilitation residents: a method for development and assessment

An educational module was developed in attempt to satisfy two main objectives: to develop and implement a methodology for instruction of generally encountered injection techniques in the practice of physical medicine and rehabilitation and to implement an objective assessment format to measure attainment of these skills. Guidelines for this module were developed in consideration of Accreditation Council for Graduate Medical Education (ACGME) physical medicine and rehabilitation residency program requirements and ACGME Outcome Project. Eleven physical medicine and rehabilitation residents participated in a 1-day didactic/laboratory workshop covering injection education and techniques, followed by a supervised 2-wk practice session. Knowledge acquisition and skill attainment were measured via before and after multiple-choice written examination and simulated patient encounters utilizing anatomic models. An increase in knowledge was observed on the multiple-choice examination from pretest to posttest (pretest, 59.3%; posttest, 90.6%). Before instruction, 0 of 11 residents were able to perform any of the injection techniques (14 injection techniques and one sterile technique). At completion of the module, 7 of 11 residents (64%) competently performed 15 of 15 techniques (100%), 3 of 11 (26%) competently performed 14 of 15 techniques (93%), and 1 of 11 (9%) competently performed 11 of 15 techniques (73%). Participation in this module resulted in substantial acquisition of knowledge and skills regarding musculoskeletal injections for physical medicine and rehabilitation residents. This workshop provided a framework for the definition of baseline competency in this clinical skill area.     

Assessing physicians' interpersonal skills: do patients and physicians see eye-to-eye?

OBJECTIVE: To determine the level of agreement between standardized patient ratings and resident physician self-ratings of physician interpersonal skills and the level of agreement between faculty observer and standardized patient ratings of resident physicians' interpersonal skills. DESIGN: Structured clinical evaluation. A total of 25 resident physicians in physical medicine and rehabilitation conducted a 10-min interview of a standardized patient to obtain a history. A resident physician, a standardized patient, and a faculty observer rated the resident physician's interpersonal skills immediately after the interview. The main outcome measure was a modification of the patient assessment measure from the American Board of Internal Medicine, a 9-item rating scale assessing communication (score range, 9-45). RESULTS: There was a low level of agreement between standardized patient ratings and the resident physicians' self-ratings of interpersonal skills (Lin's concordance coefficient, rc = 0.11, P = 0.58). Conversely, there was a statistically significant degree of agreement between the standardized patient and faculty observer ratings of resident physician interpersonal skills (rc = 0.50, P = 0.006). CONCLUSIONS: Some resident physicians have significant difficulty accurately assessing how well they communicate with patients. Physicians in training rarely get feedback regarding their interpersonal skills and may have difficulty using social comparison. Conversely, standardized patients and faculty observers may have insight into interpersonal skills about which resident physicians are unaware.     

Integrating physical medicine and rehabilitation into the curriculum of Iranian medical students

Purpose. To evaluate the attitude of interns toward Physical Medicine and Rehabilitation (PM&R) and design a PM&R curriculum for medical students with continued medical education programmes and workshops based on the needs and interest of Iranian medical community.

Method. Eighty questionnaires were distributed to the medical interns on the last day after attendance in the PM&R ward after participating in a one-month outpatient and inpatient course including 12 lectures.

Results. Out of 80 participants, 34 (42.5%) were female and 46 (57.5%) were male. All the participants believed

participating in a rehabilitation course was necessary; 52 (65%) believed that participating in a separate course of PM&R was necessary, and 28 (35%) believed that rehabilitation of each field of medicine should be presented in its course. A significant percentage (31.4%) of the participants were interested in continuing their education in PM&R specialty.

Conclusion. The enthusiasm of the medical students towards PM&R is a promising sign toward progress of PM&R in Iran which must be directed through a strong effort of physiatrists through setting up appropriate educational programmes for medical students and continued medical education programme s in the universities.     

Objectives to direct the training of emergency medicine residents on off-service rotations: hand surgery

This is the fifth article in a continuing series on objectives to direct the training of emergency medicine residents. The emergency physician frequently must deal with hand injuries. Often these may appear innocuous; recognition of these injuries requires certain technical skills and a working knowledge of these entities. Specific objectives presented provide guidance for the didactic content as well as skill mastery for the resident experience.     

Medical school effect on student selection of physical medicine and rehabilitation as a specialty

Of the several roads that lead to practice in the specialty of physical medicine and rehabilitation (PM&R), the most common is from a US medical school to a PM&R residency to specialty practice. To reduce the predicted shortage of PM&R physicians, more medical students must be attracted to the specialty. Past studies have failed to show success of various mechanisms, designed to expose students to the field, to attract to the residency programs. The current study was designed to further explore the medical school factors contributing to choice of the PM&R residency. The number of PM&R residents produced by each of the US medical schools was related to various characteristics of these schools: size, presence of a PM&R department, presence of a PM&R residency program. Only school size was found to explain the sizable observed variation in number of residents. Additional research incorporating quality and quantity of curricular exposure to PM&R is suggested.     

Use of Geriatrics At Your Fingertips, a pocket guide, to educate physiatrists in geriatric care

OBJECTIVE: To determine whether a geriatric pocket guide, Geriatrics At Your Fingertips, may be a useful tool in educating physiatrists about the care of their older patients. DESIGN: Geriatrics At Your Fingertips was distributed through the American Academy of Physical Medicine and Rehabilitation (AAPM&R) to physical medicine and rehabilitation (PM&R) residents and practicing physiatrists. Two questionnaires evaluated guide use. SETTING: Two academic PM&R departments and physiatrists in the United States. PARTICIPANTS: Two PM&R residency programs, members of AAPM&R's Geriatric Rehabilitation Special Interest Group (GR-SIG), and AAPM&R's membership. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Identification of clinically useful information by residents and GR-SIG members and frequency of guide use among AAPM&R membership. RESULTS: Forty-five PM&R residents and 17 GR-SIG members reported examples of useful information. Geriatrics At Your Fingertips was requested by 483 AAPM&R members. Forty-six percent returned questionnaires (N=223). Seventy percent had used the guide at least once and 49% 4 or more times. CONCLUSIONS: Geriatrics At Your Fingertips is a useful tool with which to educate PM&R residents and physiatrists about geriatric care.     

A model of standardized training in basic life support skills of emergency medicine residents

This intervention study was designed to determine the current level of basic life support knowledge and skills of residents in a university-based emergency medicine residency program, and to investigate the potential benefit derived by these residents from a standardized theoretical and practical training session. All residents underwent tests before and after the training session. The residents were asked to perform basic life support on a recording cardiopulmonary resuscitation mannequin. Assessments were made using a 10-item checklist, with the highest score being 17. Each step performed by the resident was scored by an emergency physician for accuracy and effectiveness. Twenty-eight residents participated in the study. According to the modified Berden scale, the pretest and posttest scores were 11.2±2.9 and 15.6±1.0, respectively, and the mean difference was 4.36±2.9 (t test, P < .001). Only 11 residents (39.3%) were rated as “good” or “very good” in the pretest, whereas the corresponding figure in the posttest was 27 (96.4%) (P < .001). Skills, such as checking the airway patency (P < .001), checking breathing (P < .001), appropriate compression rate (P < .003), and delivering 2 effective breaths (P < .001), improved significantly. Depth of chest compression (P < .023) was improved significantly only in residents with fewer than 2 years of experience. The training process should comprise standardized courses to facilitate acquisition of the desired skills.     

Physical medicine in medical curricula: training primary care physicians and students

The demonstrated need for the education of primary care physicians in the principles of Physical Medicine & Rehabilitation (PM&R) is not matched by the curricula of medical schools and primary care residency programs. This anomaly of medical education is discussed from the standpoint of the hindrances inherent in the medical professional as a whole and more specifically in PM&R itself. Several concepts are suggested to stimulate thought about how PM&R may change perceptions of the specialty. Increased general medical knowledge is an important element of the PM&R learning experience. The emphasis of medical education should be on the students' needs rather than those of the specialty.