Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5784_Библиотеки_им_академика_М_И_Перельмана.pdf
Highly Motivated Learners
Well-defined learning objectives that address knowledge or skills that matter clinically
9.
8.
7.
6.
5.
4.
3.
2.
1.
Advancement toward the next clinical task or unit
6 Continuing Education
Appropriate level of difficulty for medical learners
Focused, repetitive practice of the knowledge or skills
Rigorous measurements that yield reliable data
Informative feedback from educational sources (e.g., teachers, simulators)
Frequent monitoring, error correction, and more deliberate practice
Performance evaluation toward reaching a mastery standard
Fig. 6.1 Elements of deliberate practice (Adapted from McGaghie etal. [16])
use after initial training, for practicing physicians and continuing education, and has
been shown to be superior to traditional teaching methods, particularly when used
in a simulation environment [13–15].
While web-based educational modules combined with simulation create a strong
template for continuing education in a blended model, POC US education for practicing physicians requires special attention to the needs of advanced learners.
Integration of blended learning with the Deliberate Practice theory creates an excellent framework for continuing education of POC US.In fact, improved performance
has been found in learners who received simulator training using the elements of
Deliberate Practice [17].
An essential element of deliberate practice, and education in general is competency assessment. Physicians must master image acquisition, interpretation, and
be able to integrate these into their medical decision-making [18]. There are multiple methods available for POC US competency assessment, from the use of
checklists (e.g., Council of Residency Directors peer reviewed standardized
direct observational assessment tools [19]), to the use of management software,
online quizzes, and direct observation. Methods for competency assessment are
listed in Fig.6.2.
59
60
Checklists
Commercially Available Management Software
Simulation
Fig. 6.2 Methods for
competency assessment
M.E.W. Thiessen and R.E. Lewiss
http://emmilestones.pbworks.com
Quality Assurance Activities
Software Supported Image Review
In Person Image Review
Written/Web Based Examinations
Web-based online Examinations
http://www.emsono.com/acep/exam.html
http://www.ultrasoundninja.com
Direct Observation
Educational Goals
The ideal educational outcome for any continuing education-based activity range is
a positive perception of the learning experience on the part of the physician. This
changes behavior, and eventually benets patients. Kirkpatrick offers a way to
gauge effectiveness of an educational activity on the leaner. See Table6.1 [20].
For reference, a 2007 Agency for Healthcare Research and Quality (AHRQ)
review found that in terms of the various possible educational modalities for continuing education, print media is less effective than live lectures. Multimedia educational tools are more effective than any single media alone. Interactive modalities
are more effective than noninteractive modalities, and multiple exposures over time
are more effective than single exposures. Simulation was shown to be effective in
improving psychomotor skills [9].
6 Continuing Education
Table 6.1 Kirkpatrick’s adapted hierarchy of evaluating educational outcomes [20]
Level 1 Reaction Covers learners’ views on the learning experience, its
Level 2a Learning: change in
attitudes/perception
Level 2b Learning: modication
of knowledge or skills
Level 3 Behavior Documents the transfer of learning to the workplace or
Level 4a Results: change in the
professional practice
Level 4b Benets to patients Any improvement in the health and well-being of
organization, presentation, content, teaching methods,
and aspects of the instructional organization, materials,
quality of instruction
Modication of attitudes/perceptions—outcomes here
relate to changes in the reciprocal attitudes or
perceptions between participant groups toward
intervention/simulation
Modication of knowledge/skills—for knowledge, this
relates to the acquisition of concepts, procedures, and
principles; for skills, this relates to the acquisition of
thinking/problem-solving, psychomotor, and social
skills
willingness of learners to apply new knowledge and
skills
Change in organizational practice—wider changes in
the organizational delivery of care, attributable to an
educational program
patients/clients as a direct result of an educational
program
61
Blended Learning
Based on the ndings of the AHRQ, web-based instruction, simulation, and elements of Deliberate Practice in a blended learning format create an ideal framework
for POC US education. Blended learning has been shown to be an effective educational format and lends itself well to POC US [21, 22]. Blended learning integrates
multiple educational modalities to maximize knowledge acquisition and skill mastery on the part of the learner [18]. Modalities can include in-person lectures, online
educational modules or recorded lectures, hands-on scanning with live models or
simulators, and simulation time. The importance of integrating simulation and
hands-on teaching with faculty present cannot be overemphasized. Particularly for
POC US, the psychomotor skill of image acquisition and real-time interpretation
are essential. Learners who receive only web-based education do not perform as
well with hands-on skills [23, 24]. Additionally, blended learning provides skill
retention [25].
62
Blogs
Social media including Twitter
o
M.E.W. Thiessen and R.E. Lewiss
Web-Based Instruction
Web-based learning appeals specically to the continuing education audience
because it allows for individualized learning, exible scheduling, novel instructional methods, and distance learning. It also insures consistent content, and means
of assessment [26]. It is an effective tool for POC US as part of a blended educational experience [27, 28].
Web-based learning may consist of online modules to read, lectures to view,
interactive scenarios, social media communication, online discussion groups, multiple choice examinations, and others. Online discussions and novel ideas are especially appealing to engage experienced learners [29]. Figure6.3 lists examples of
online education tools. One paper has suggested that the nancial cost of a webbased or blended curriculum may be similar to that of a traditional ultrasound
course. Arguably, the number of hours dedicated to preparation is signicantly less
for web-based education [27]. Even when used as adjunct educational tools, webbased educational resources have improved outcomes over the traditional method
for teaching ultrasound skills [30].
Studies demonstrate that web-based learning for continuing education improves
knowledge, attitude, and even skills, albeit to a lesser extent. For POC US specically,
web-based education is best utilized in a blended curriculum that includes a hands-on
scanning and/or simulation component to assist in motor skill acquisition [31–33].
Web-based education, in which participants complete multiple online modules over
time, benets learners with repeated exposure [34].
A completely web-based curriculum has limitations: social isolation, deindividualized instruction, lack of timely or in-person feedback. However, there is
Fig. 6.3 Web-based online
educational tools
Competency Lists
Google Hangout Discussions
Narrated lectures
Videos including YouTube and Vime
Organizational Websites
Podcasts
Question Banks
Text Documents
1. Match Instruction Difficulty to Your Learners’ Developmental Level
10.
12. Engage in Quality Monitoring and Improvement
11. Identify and Mitigate Issues that may Diminish the Effectiveness of Web-Based Instruction
6 Continuing Education
2. Minimize Extraneoues Features that Inhibit Learning
3. Balance Interactivity with Cognitive Load
4. Provide Rich Feedback and Guidance
5. Maximize Learner Control
6. Use Web-Based Instruction to Enhance Learning Around and Within It
7. Clearly Define and Communicate the Reasons for Using Web-Based Instruction
8. Integrate Space and Time for the Web-Based Instruction into the Curriculum
9. Be Explicit About How Using Web-Based Instruction Relates to Assessment
Address Faculty Motives and Perceptions
Fig. 6.4 Twelve tips for effective web-based instruction (adapted from Yavner etal. [35])
evidence to support that when utilized wisely and appropriately, a blended curriculum including web-based elements leads to education success [26].
There are several essential steps to ensure an effective learning experience for
POC US web-based education as part of a blended curriculum. First and foremost,
the educator must assess the learners in order to tailor the content appropriately.
Additional tips for creating effective web-based educational tools can be seen in
Fig.6.4 [35]. Web-based instruction should contain a minimum of extraneous material. It should be interactive enough to maintain the attention of the learner, but not
so interactive that it is distracting. Ideally, the program would allow the learner to
tailor the educational module or curriculum to their preferred style of learning. This
is particularly important for POC US education as studies have shown that simulation and hands-on education are necessary to improve psychomotor skills. If a
schedule and curriculum are utilized, time to work on the web-based content should
be allotted. Educators should elucidate the purpose of the web-based instruction is
being used, as well as how it will be used for assessment. Finally, educators should
solicit feedback from stakeholders and learners to continue to improve the webbased instruction content and effectiveness [35].
63
Simulation andHands-On Education
Simulation entails the use of low- or high-delity US trainers either in a simulated
clinical environment. Live human models can be used. Table6.2 describes characteristics of high- and low-delity ultrasound simulators [18]. Simulation allows for
64
M.E.W. Thiessen and R.E. Lewiss
reproducible clinical scenarios, ease of performance evaluation, and the ability to
learn outside of the patient care environment [36, 37]. Simulation has been widely
used in graduate medical education [37–39], and more recently in continuing education (See Chap. 11 – Simulation) [20].
Use of simulation and hands-on training for POC US skills has met with great
success, usually as a part of a blended educational experience [11, 25, 40–44]. With
respect to continuing education, simulation has been shown to be positively received
by learners, as well as impart a perceived improvement in condence and clinical
preparedness. It has also been shown to improve knowledge and long-term retention
of skills. Most educators feel that while current evidence supporting the implementation of simulation education in POC US is limited, use of this educational format
is necessary as the evidence moves forward [20].
Critics of simulation-based POC US education question if certain skills
transfer from the simulated to the patient care environment [45]. Simulation
provided with faculty presence has been found to be superior to self-guided
simulation [46]. Others worry that learned skills will decay without continued
practice [47]. While the literature on simulation for continuing medical education and POC US is still limited, most educators agree it is an essential element
of training [18].
The features of effective simulation education are listed in Fig.6.5 [13–15].
Feedback has been found to be the most important element of simulation education.
Additional important factors include repetetive practice, the ability to tailor the simulation to the learner in a high-delity, reproducible scenario and active participation.
As with any educational activity, clearly stated learning objectives and learner
expectations result in better learning [48]. Simulation has the benet of providing
the opportunity for practice and competency evaluations. Checklists can be utilized
for this element [49]. CORD recommends that competency assessment on POC US
technique, image acquisition, and image interpretation be demonstrated by practicing clinicians [50].
Table 6.2 Characteristics of ultrasound simulators (from Lewiss etal. [18])
Characteristic Low-delity simulators High-delity simulators
Condition Static Static or dynamic
Availability Handmade or commercial Commercial
Skill tested 1 Skill 1 Skill or multiple skills
Separate ultrasound
machine required
Tissue motion No Yes
Ultrasound transducer Required and needs to be
Real-time
2-dimensional images
Real-time haptic
feedback
Cost Inexpensive Expensive
Yes No
connected to actual machine
Yes Yes
Possible Yes
Mock probe with position sensor or
patient dummy with position sensor
1. Provide feedback during the learning experience with the simulator.
Clearly define outcomes and benchmarks for the learners to achieve using the simulator.
10. Ensure the simulator is a valid learning tool.
6 Continuing Education
2. Learners should repetitively practice skills on the simulator.
3. Integrate simulators into the overall curriculum.
4. Learners should practice with increasing levels of difficulty.
5. Adapt the simulator to complement multiple learning strategies.
6. Ensure the simulator provides for clinical variation.
7. Learning on the simulator should occur in a controlled environment.
8. Provide individualized (in addition to team) learning on the simulator.
9.
Fig. 6.5 Features of effective simulation education (Adapted from Issenberg [48])
Pitfalls
65
1. Failure to assess the learner prior to the educational activity.
2. Not providing specic goals and objectives for the learning activity.
3. Lack of preparation prior to the activity will detract from the educational value.
4. Inadequate assessment of the learners and the educational activity will limit
improvement.
Key Recommendations
1. Utilize a blended approach to continuing education
2. Utilize an ideal education workow (Figure 5.1)
3. Know your learner
References
1. ACGME [Internet]. www.acgme.org/acWebsite/RRC-110/110_guidelines.asp.
2. Cohen N. The critical care anesthesiology milestone project [Internet]. 2014. https://www.
acgme.org/acgmeweb/Portals/0/PDFs/Milestones/CriticalCareMedicine.pdf.
3. Malangoni M.The surgical critical care milestone project [Internet]. http://www.acgme.org/
acgmeweb/portals/0/pdfs/milestones/surgicalcriticalcaremilestones.pdf.
66
4. Expert Round Table on Ultrasound in ICU.International expert statement on training stan-
dards for critical care ultrasonography. Intensive Care Med. 2011;37(7):1077–83.
5. Hoppmann RA, Rao VV, Poston MB, Howe DB, Hunt PS, Fowler SD, etal. An integrated
ultrasound curriculum (iUSC) for medical students: 4-year experience. Crit Ultrasound
J.2011;3(1):1–12.
6. American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg
Med. 2009;53(4):550–70.
7. Quinones MA, et al. American College of Cardiology/American Heart Association Clinical
Competence Statement on Echocardiography: a report of the American College of Cardiology/
American Heart Association/American College of Physicians—American Society of Internal
Medicine Task Force on Clinical Competence. Circulation. 2003;107(7):1068–89.
8. Price DW, Miller EK, Rahm AK, Brace NE, Larson RS.Assessment of barriers to changing
practice as CME outcomes. JContin Educ Heal Prof. 2010;30(4):237–45.
9. Marinopoulos SS, Dorman T, Ratanawongsa N, Wilson LM, Ashar BH, Magaziner JL, etal.
Effectiveness of continuing medical education. Evid Rep Technol Assess. 2007;149:1–69.
10. Hofer M, Kamper L, Miese F, Kröpil P, Naujoks C, Handschel J, et al. Quality indicators
for the development and didactics of ultrasound courses in continuing medical education.
Ultraschall Med. 2012;33(1):68–75.
11. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB.Does simulation-based med-
ical education with deliberate practice yield better results than traditional clinical education? A
meta-analytic comparative review of the evidence. Acad Med. 2011;86(6):706–11.
12. Duvivier RJ, van Dalen J, Muijtjens AM, Moulaert VRMP, van der Vleuten CPM, Scherpbier
AJJA.The role of deliberate practice in the acquisition of clinical skills. BMC Med Educ.
2011;11:101.
13. Ericsson KA.Deliberate practice and the acquisition and maintenance of expert performance
in medicine and related domains. Acad Med. 2004;79(10 Suppl):S70–81.
14. Ericsson KA.Deliberate practice and acquisition of expert performance: a general overview.
Acad Emerg Med. 2008;15(11):988–94.
15. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, etal. Technology-enhanced
simulation for health professions education: a systematic review and meta-analysis. JAMA.
2011;306(9):978–88.
16. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB.Medical education featuring
mastery learning with deliberate practice can lead to better health for individuals and populations. Acad Med. 2011;86(11):e8–9.
17. Ericsson KA.An expert-performance perspective of research on medical expertise: the study
of clinical performance. Med Educ. 2007;41(12):1124–30.
18. Lewiss RE, Hoffmann B, Beaulieu Y, Phelan MB. Point-of-care ultrasound education: the
increasing role of simulation and multimedia resources. JUltrasound Med. 2014;33(1):27–32.
19. Lewiss RE, Pearl M, Nomura JT, Baty G, Bengiamin R, Duprey K, etal. CORD-AEUS: con-
sensus document for the emergency ultrasound milestone project. 2013.
20. Khanduja PK, Bould MD, Naik VN, Hladkowicz E, Boet S.The role of simulation in con-
tinuing medical education for acute care physicians: a systematic review. Crit Care Med.
2015;43(1):186–93.
21. Kempinska AY, Bhanji F, Larouche S, Dubrovsky AS. A novel simulation-based pro-
gram for ultrasound-guided fracture reductions: program evaluation. Am J Emerg Med.
2014;32(12):1547–9.
22. Mitchell JD, Mahmood F, Wong V, Bose R, Nicolai DA, Wang A, etal. Teaching concepts
of transesophageal echocardiography via web-based modules. J Cardiothorac Vasc Anesth.
2015;29(2):402–9.
23. Filippucci E, Meenagh G, Ciapetti A, Iagnocco A, Taggart A, Grassi W.E-learning in ultraso-
nography: a web-based approach. Ann Rheum Dis. 2007;66(7):962–5.
24. Woodworth GE, Chen EM, Horn J-LE, Aziz MF.Efcacy of computer-based video and simu-
lation in ultrasound-guided regional anesthesia training. JClin Anesth. 2014;26(3):212–21.
M.E.W. Thiessen and R.E. Lewiss
6 Continuing Education
25. Laack TA, Dong Y, Goyal DG, Sadosty AT, Suri HS, Dunn WF. Short-term and long-term
impact of the central line workshop on resident clinical performance during simulated central
line placement. Simul Healthc. 2014;9(4):228–33.
26. Cook DA.Web-based learning: pros, cons and controversies. Clin Med (Lond). 2007;7(1):37–42.
27. Kang TL, Berona K, Elkhunovich MA, Medero-Colon R, Seif D, Chilstrom ML, etal. Web-
based teaching in point-of-care ultrasound: an alternative to the classroom? Adv Med Educ
Pract. 2015;6:171–5.
28. Chenkin J, Lee S, Huynh T, Bandiera G.Procedures can be learned on the web: a randomized
study of ultrasound-guided vascular access training. Acad Emerg Med. 2008;15(10):949–54.
29. Chan TM, Thoma B, Lin M. Creating, curating, and sharing online faculty development
resources: the medical education in cases series experience. Acad Med. 2015;90(6):785–9.
30. Arroyo-Morales M, Cantarero-Villanueva I, Fernández-Lao C, Guirao-Piñeyro M, Castro-
Martín E, Díaz-Rodríguez L.A blended learning approach to palpation and ultrasound imaging
skills through supplementation of traditional classroom teaching with an e-learning package.
Man Ther. 2012;17(5):474–8.
31. Curran VR, Fleet L.A review of evaluation outcomes of web-based continuing medical educa-
tion. Med Educ. 2005;39(6):561–7.
32. Fordis M, King JE, Ballantyne CM, Jones PH, Schneider KH, Spann SJ, etal. Comparison
of the instructional efcacy of internet-based CME with live interactive CME workshops: a
randomized controlled trial. JAMA. 2005;294(9):1043–51.
33. Wutoh R, Boren SA, Balas EA. eLearning: a review of internet-based continuing medical
education. JContin Educ Heal Prof. 2004;24(1):20–30.
34. Shaw T, Long A, Chopra S, Kerfoot BP.Impact on clinical behavior of face-to-face continu-
ing medical education blended with online spaced education: a randomized controlled trial.
JContin Educ Heal Prof. 2011;31(2):103–8.
35. Yavner SD, Pusic MV, Kalet AL, Song HS, Hopkins MA, Nick MW, et al. Twelve tips for
improving the effectiveness of web-based multimedia instruction for clinical learners. Med
Teach. 2015;37(3):239–44.
36. Gordon JA.As accessible as a book on a library shelf: the imperative of routine simulation in
modern health care. Chest. 2012;141(1):12–6.
37. McLaughlin S, Fitch MT, Goyal DG, Hayden E, Kauh CY, Laack TA, etal. Simulation in graduate
medical education 2008: a review for emergency medicine. Acad Emerg Med. 2008;15(11):1117–29.
38. Schroedl CJ, Corbridge TC, Cohen ER, Fakhran SS, Schimmel D, McGaghie WC, etal. Use
of simulation-based education to improve resident learning and patient care in the medical
intensive care unit: a randomized trial. JCrit Care. 2012;27(2):219.e7–13.
39. Okuda Y, Bond W, Bonfante G, McLaughlin S, Spillane L, Wang E, etal. National growth in
simulation training within emergency medicine residency programs, 2003–2008. Acad Emerg
Med. 2008;15(11):1113–6.
40. Mendiratta-Lala M, Williams T, de Quadros N, Bonnett J, Mendiratta V.The use of a simula-
tion center to improve resident prociency in performing ultrasound-guided procedures. Acad
Radiol. 2010;17(4):535–40.
41. Ahmad R, Alhashmi G, Ajlan A, Eldeek B.Impact of high-delity transvaginal ultrasound simu-
lation for radiology on residents’ performance and satisfaction. Acad Radiol. 2015;22(2):234–9.
42. Girzadas DVJ, Antonis MS, Zerth H, Lambert M, Clay L, Bose S, etal. Hybrid simulation
combining a high delity scenario with a pelvic ultrasound task trainer enhances the training
and evaluation of endovaginal ultrasound skills. Acad Emerg Med. 2009;16(5):429–35.
43. Knudson MM, Sisley AC.Training residents using simulation technology: experience with
ultrasound for trauma. JTrauma. 2000;48(4):659–65.
44. Evans LV, Dodge KL, Shah TD, Kaplan LJ, Siegel MD, Moore CL, etal. Simulation training
in central venous catheter insertion: improved performance in clinical practice. Acad Med.
2010;85(9):1462–9.
45. Sidhu HS, Olubaniyi BO, Bhatnagar G, Shuen V, Dubbins P.Role of simulation-based educa-
tion in ultrasound practice training. JUltrasound Med. 2012;31(5):785–91.
67
68
46. Alba GA, Kelmenson DA, Noble VE, Murray AF, Currier PF.Faculty staff-guided versus self-
guided ultrasound training for internal medicine residents. Med Educ. 2013;47(11):1099–108.
47. Wang EE, Quinones J, Fitch MT, Dooley-Hash S, Griswold-Theodorson S, Medzon R, etal.
Developing technical expertise in emergency medicine—the role of simulation in procedural
skill acquisition. Acad Emerg Med. 2008;15(11):1046–57.
48. Issenberg SB. The scope of simulation-based healthcare education. Simul Healthc.
2006;1(4):203–8.
49. Dong Y, Suri HS, Cook DA, Kashani KB, Mullon JJ, Enders FT, etal. Simulation-based objec-
tive assessment discerns clinical prociency in central line placement: a construct validation.
Chest. 2010;137(5):1050–6.
50. Akhtar S, Theodoro D, Gaspari R, Tayal V, Sierzenski P, Lamantia J, etal. Resident training
in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency
Medicine Residency Directors Conference. Acad Emerg Med. 2009;16(Suppl 2):S32–6.
M.E.W. Thiessen and R.E. Lewiss