Kashiwagi, Deanne T.

Abstract Background: Medical education commonly utilizes the “see one, do one” two-step approach for teaching psychomotor skills; however, recent evidence suggests that Peyton’s four-step method leads to superior learning. The effect of Peyton’s four-step method on long term skill retention is less apparent and has never been assessed for Point-of-Care Ultrasound (POCUS). The purpose of this research project was to evaluate the effectiveness of Peyton’s four-step method on teaching the POCUS psychomotor skills of image acquisition to novice learners. Additionally, this research project assessed the influence of Peyton’s four-step method at three different points in time during the skill acquisition phase, in the setting of ongoing deliberate skill practice. Methods: A single-blinded, repeated measures interventional study based on experimental design was completed. PA students from one large academic medical center were randomized into a control group (using the two-step method) and intervention group (using Peyton’s four-step method). Students were taught POCUS of the aorta, bladder, heart, lungs, and kidneys. Students' POCUS skills were assessed during the immediate, intermediate, and delayed learning phases. At each assessment, an organ-specific score and a total score were obtained. Scores were compared using a Wilcoxon rank sum test. An ordinal logistic regression analysis was performed using a generalized linear mixed model with a multinomial distribution and cumulative logit link function to assess overall effect of Peyton's four-step method. Results: Students who were taught using Peyton’s method were found to have an increased likelihood of higher total scores compared to those taught using usual instruction (OR = 4.2, p = 0.003). Peyton’s method was found to have increased likelihood of higher scores for cardiac (OR = 2.3, p = 0.032), lung (OR = 2.5, p = 0.034), and kidney (OR = 3.0, p = 0.015). Student performance statistically improved with Peyton’s four-step method during the immediate (p = 0.031) and delayed (p = 0.011) skill acquisition phases, but not in the intermediate phase. Conclusion: Peyton’s four-step method improves overall psychomotor skill acquisition for POCUS. Peyton’s four-step method specifically improved psychomotor skills in the immediate skill acquisition phase and the delayed skill acquisition phase. The benefit of Peyton’s four-step method was more prominent in higher complexity POCUS applications.

Abstract Purpose : While it’s commonplace in medical education to train learners using simulated patient encounters, task trainers, or by practicing skills on healthy volunteers, little is known about how well learning and skills transfer to patient care. The purpose of this research is to quantify Point-of-Care Ultrasound (POCUS) skill transfer to patient care through performance assessment. Method : A quantitative analysis of aggregated data consisting of image quality of student-performed POCUS examinations from one midwestern Physician Assistant program was performed. Probabilities for scores of 1-2, 3, 4, and 5 were estimated using a multivariable cumulative logit model. Results : Forty-six PA students were included in the study. A total of 6,218 POCUS examinations were included; 4,506 on non-patients, and 1,712 on patients. When evaluating skill transfer from non-patients to patients, the probability of obtaining a high-quality examination decreases significantly, with a more substantial decrease in performance on more complex skills. The probability of a high-quality examination on the twenty-fifth examination was the highest when learning transfer happened earlier. Conclusion : While training medical providers using non-patient experiences is common, educators must understand the significant loss of quality upon skills transfer to patient care. More complex or higher risk skills likely require close monitoring at the point of skill transfer, to support the learner and ensure patient safety. Based on the findings of this research, earlier skill transfer is associated with worse immediate performance but better long-term re-learning outcomes. Increased deliberate practice prior to skill transfer is associated with better first-time performance on actual patients.

Abstract Background In the context of competency-based medical education, more research is needed to define point-of-care ultrasound (POCUS) competency and validate learner assessment. To address noted gaps in the currently validated assessment instruments, we developed the Observed Structured POCUS Readiness Examination (OSPRE). The purpose of this study is to demonstrate evidence of validity and reliability of the OSPRE in Physician Assistant (PA) students. Methods A prospective cohort study was designed to demonstrate evidence of validity and reliability for the OSPRE instrument at one PA program. Students completed a hands-on skills assessment utilizing a simulated patient scenario involving a traumatic injury. Student performance was assessed in real time by one reviewer and asynchronously by a second reviewer blinded to the scoring of the initial reviewer. Inter-rater reliability was calculated for overall score and for each criterion of the OSPRE. Results Intraclass correlation coefficient for the final percentage score between the independent reviewers utilizing the OSPRE instrument was noted to be 0.86 (95% CI 0.56–0.95, p < 0.001), demonstrating overall good reliability. Level of agreement for inter-rater reliability for the specific individual criterion ranged between fair and substantial. Conclusion The OSPRE instrument provides a valid and reliable assessment of POCUS skills in PA students. When compared to previously validated assessment instruments, scores on the OSPRE had a wider range, suggesting that the OSPRE might have a greater discriminatory value for POCUS skillset.

Abstract Background Geographic cohorting (GCh) is a popular model of care that localizes physician teams to a single hospital unit. Objectives We conducted a scoping review identifying the aims, implementation strategies, study methods, and measured outcomes of GCh. Methods We searched the medical literature analysis and retrieval system online, Embase, and Scopus databases. Eligible citations included English language reports of interventions including GCh in adult patients. Included studies were screened for their aim, GCh implementation strategy, study method, and outcomes measured. Results Of 1863 identified citations, 30 met inclusion criteria, representing 27 interventions. Implementation aims varied from specific goals measured by a single metric to multiple outcomes intended to capture wide‐ranging effects of GCh. A majority of studies ( n = 13, 48.1%) used a pre‐post cohort design. GCh was implemented in one of four ways: (1) as a stand‐alone intervention, (2) bundled with accountable care unit elements, (3) bundled with care components that did not include all ACU elements, (4) GCh bundled with ACU elements and additional components (“enhanced” ACU). The measured outcomes sorted to eight different categories: patient outcomes, patient safety, patient experience, work flow, workload, clinician experience, communication/team work, and cost. Conclusions The current literature on GCh describes implementation as both a stand‐alone intervention and bundled with other care elements. Current research has not delineated whether the degree to which GCh is implemented matters, nor what impact it has as part of a bundled care intervention. Future work would benefit from a prospective design that clarifies these questions, facilitating care models tailored to the needs of the practice ecosystem.

Abstract Background “Decision Fatigue” (DF) describes the impaired ability to make decisions because of repeated acts of decision‐making. Objectives We conducted a scoping review to describe DF in inpatient settings. Methods To be included, studies should have explored a clinical decision, included a mechanism to account for the order of decision making, and be published in English in or after the year 2000. Six databases were searched. Retrieved citations were screened and retained studies were reviewed against the inclusion criteria. References of included studies were manually searched, and forward citation searches were conducted to capture relevant sources. Results The search retrieved 12,781 citations, of which 41 were retained following screening. Following review, 16 studies met the inclusion criteria. Half were conference abstracts and none examined hospitalists. Emergency medicine and intensive care settings were the most frequently studied clinical environments ( n = 13, 81%). All studies were observational. The most frequently examined decisions were about resource utilization ( n = 8, 50%), however only half of these examined downstream clinical outcomes. Decision quality against prespecified standards was examined in four (25%) studies. Work environment and patient attributes were often described but not consistently accounted for in analyses. Clinician attributes were described in four (25%) investigations. Findings were inconsistent: both supporting and refuting DF's role in the outcome studied. Conclusions The role of clinician, patient, and work environment attributes in mediating DF is understudied. Similarly, the context surrounding the decision under study require further explication and when assessing resource use and decision quality, adjudication should be made against prespecified standards.

Objectives Use of point‐of‐care ultrasound (POCUS) in clinical medicine and inclusion in medical training is increasing. Some professional societies recommend that 25–50 POCUS examinations be completed for each application learned; however, the amount of practice required is not well studied. As such, a better understanding of the learning curves of POCUS psychomotor skills is needed. This systematic review characterizes the learning curves for POCUS psychomotor skill acquisition. Methods With the assistance of a research librarian, the available literature through August 28, 2023, was identified. The titles and abstracts, and then the full text were reviewed by two reviewers to screen for inclusion. All studies included after full‐text review then underwent data extraction and analysis. Results The search identified 893 unique studies. Forty‐five studies underwent full‐text review, with 17 meeting full inclusion criteria. Substantial heterogeneity was noted in study design, duration of education, number and type of learners, and methods for statistical analysis. Clear and validated definitions for learning endpoints, such as plateau points or competency, are lacking. Learning curves and endpoints differ for different applications of POCUS. Conclusion The results are overall supportive of the recommendations to complete 25–50 examinations per application of POCUS learned. However, specific applications require more practice than others. Certain applications, such as cardiac and the Focused Assessment with Sonography in Trauma (FAST) exams, are closer to 50; while others, such as soft tissue, airway, and eye require no more than 25.

Inspired by the ABIM Foundation's Choosing Wisely® campaign, the “Things We Do for No Reason™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.