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Introduction Health professionals in rural settings encounter a wide range of medical conditions requiring broad knowledge for their clinical practice. This creates the need for ongoing continuing professional development (CPD). In this study, we explored the barriers that health professionals in a rural healthcare context faced participating in CPD activities and their preferences regarding educational strategies to overcome these challenges. Methods This mixed-methods (exploratory sequential) study in a community hospital in rural Mexico includes 22 interviews, 3 focus groups, 40 observational hours, and a questionnaire of healthcare staff. Results Despite low engagement with CPD activities (67% not motivated), all participants expressed interest and acknowledged the importance of learning for their practice. Barriers to participating include a disparity between strategies used (lecture-based) and their desire for practical learning, institutional barriers (poor leadership engagement, procedural flaws, and lack of resources), and collaboration barriers (adverse interprofessional education environment, ineffective teamwork, and poor communication). Additional barriers identified were inconvenient scheduling of sessions (75%), inadequate classrooms (65%), high workload (60%), ineffective speakers (60%), and boring sessions (55%). Participants’ preferred learning strategies highlighted activities relevant to their daily clinical activities (practical workshops, simulations, and case analysis). The questionnaire had an 18% response rate. Discussion The barriers to CPD in this rural setting are multifactorial and diverse. A strong interest to engage in context-specific active learning strategies highlighted the need for leadership to prioritize interprofessional education, teamwork, and communication to enhance CPD and patient care. Thes

How can we design engaging and effective online learning in healthcare? How can we perform tele-simulation? How can we make digital learning authentic and not over-produced? How can we apply gamification strategies to enhance online cooperation? Tele-simulation and online cooperation are essential today in healthcare education and training, first of all for medical simulation: The e-REAL® online platform for healthcare simulation, aimed at fostering effective teamwork, knowledge sharing, and cooperation, is a solution that we designed to work within a highly immersive setting where learners and simulation instructors may interact all together in real time among themselves, as well as with virtual objects and avatars. This solution allows simulations in a virtual environment that display challenging situations; unlike other VR and AR solutions, e-REAL allows users to experience full immersion without the need for glasses or goggles, providing a memorable experience with a robust learning outcome. e-REAL is user-centric and easy to use: an Internet connection and a browser are the only requirements.

The e-REAL voice and speech analysis app helps medical simulation instructors to track learners individually with a focus on multiple factors such as tone of voice and spoken words, volume, rhythm, and other relevant aspects that are essential to provide a semantic and pragmatic overview of the interpersonal communication that is happening within a simulation setting. Functions and visual outputs include the following: 1. An integral transcript or a dialogue which can be visualized — audio clips, automatically divided phrase by phrase, are also available. 2. A word counter shows the number of spoken words per minute. 3. An internal search engine enables keyword search, highlighting the words in the transcript. 4. A word cloud tool visually summarizes the most spoken words. 5. A Voice Analysis tool is available in order to measure and visualize waveform (Decibel), perceived loudness (Hertz), and pitch.

Escape rooms are a great way for teams to work together to practice quickly solving problems under pressure and time constraints — all while simultaneously having fun. This article is about an online escape room designed to require cooperation and conflict, rational choice, decision making, truth-functional logic, causality, hypothesis testing, problem solving, cognitive and metacognitive challenges, teamworking and interpersonal communication under time pressure and stress, and organizing a strategic response that can later translate to the efficient and effective facilitation of real-world actions — all within a totally digitalized environment called e-REAL®. Cognitive biases, fixation errors, and other obstacles to overcome are assured, but evitable thanks to the effective learning experience are also assured. This escape room is designed to present lively, interactive activities aimed at understanding challenging scenarios like decision-making chains, as well as thrillers or cybercrime scenarios, Blockchain-based operations or digital and cryptocurrencies, but also data visualization and interpretation, preventative maintenance operations, and crisis management in healthcare or telemedicine.

Health professionals in rural settings encounter a wide range of medical conditions requiring broad knowledge for their clinical practice. This creates the need for ongoing continuing professional development (CPD). In this study, we explored the barriers that health professionals in a rural healthcare context faced participating in CPD activities and their preferences regarding educational strategies to overcome these challenges.This mixed-methods (exploratory sequential) study in a community hospital in rural Mexico includes 22 interviews, 3 focus groups, 40 observational hours, and a questionnaire of healthcare staff.Despite low engagement with CPD activities (67% not motivated), all participants expressed interest and acknowledged the importance of learning for their practice. Barriers to participating include a disparity between strategies used (lecture-based) and their desire for practical learning, institutional barriers (poor leadership engagement, procedural flaws, and lack of resources), and collaboration barriers (adverse interprofessional education environment, ineffective teamwork, and poor communication). Additional barriers identified were inconvenient scheduling of sessions (75%), inadequate classrooms (65%), high workload (60%), ineffective speakers (60%), and boring sessions (55%). Participants' preferred learning strategies highlighted activities relevant to their daily clinical activities (practical workshops, simulations, and case analysis). The questionnaire had an 18% response rate.The barriers to CPD in this rural setting are multifactorial and diverse. A strong interest to engage in context-specific active learning strategies highlighted the need for leadership to prioritize interprofessional education, teamwork, and communication to enhance CPD and patient care. These results could inform efforts to strengthen CPD in other rural contexts.

OBJECTIVE To compare malpractice claim rates before and after participation in simulation training, which focused on team training during a high-acuity clinical case. METHODS We performed a retrospective analysis comparing the claim rates before and after simulation training among 292 obstetrician-gynecologists, all of whom were insured by the same malpractice insurer, who attended one or more simulation training sessions from 2002 to 2019. The insurer provided malpractice claims data involving study physicians, along with durations of coverage, which we used to calculate claim rates, expressed as claims per 100 physician coverage years. We used three different time periods in our presimulation and postsimulation training claim rates comparisons: the entire study period, 2 years presimulation and postsimulation training, and 1 year presimulation and postsimulation training. Secondary outcomes included indemnity payment amounts, percent of claims paid, and injury severity. RESULTS Compared with presimulation training, malpractice claim rates were significantly lower postsimulation training for the full study period (11.2 vs 5.7 claims per 100 physician coverage years; P

Enhanced reality for immersive simulation (e-REAL®) is the merging of real and virtual worlds: a mixed reality environment for hybrid simulation where physical and digital objects co-exist and interact in real time, in a real place and not within a headset. The first part of this chapter discusses e-REAL: an advanced simulation within a multisensory scenario, based on challenging situations developed by visual storytelling techniques. The e-REAL immersive setting is fully interactive with both 2D and 3D visualizations, avatars, electronically writable surfaces and more: people can take notes, cluster key-concepts or fill questionnaires directly on the projected surfaces. The second part of this chapter summarizes an experiential coursework focused on learning and improving teamwork and event management during simulated obstetrical cases. Effective team management during a crisis is a core element of expert practice: for this purpose, e-REAL reproduces a variety of different emergent situations, enabling learners to interact with multimedia scenarios and practice using a mnemonic called Name-Claim-Aim. Learners rapidly cycle between deliberate practice and direct feedback within a simulation scenario until mastery is achieved. Early findings show that interactive immersive visualization allows for better neural processes related to learning and behavior change.

IntroductionTo achieve an expert performance of care teams, adequate simulation-based team training courses with an effective instructional design are essential. As the importance of the instructional design becomes ever more clear, an objective assessment tool would be valuable for educators and researchers. Therefore, we aimed to develop an evidence-based and objective assessment tool for the evaluation of the instructional design of simulation-based team training courses.MethodsA validation study in which we developed an assessment tool containing an evidence-based questionnaire with Visual Analogue Scale (VAS) and a visual chart directly translating the results of the questionnaire. Psychometric properties of the assessment tool were tested using five descriptions of simulation-based team training courses. An expert-opinion-based ranking from poor to excellent was obtained. Ten independent raters assessed the five training courses twice, by using the developed questionnaire with an interval of 2 weeks. Validity and reliability analyses were performed by using the scores from the raters and comparing them with the expert’s ranking. Usability was assessed by an 11-item survey.ResultsA 42-item questionnaire, using VAS, and a propeller chart were developed. The correlation between the expert-opinion-based ranking and the evaluators’ scores (Spearman correlation) was 0.95, and the variance due to subjectivity of raters was 3.5% (VTraining*Rater). The G-coefficient was 0.96. The inter-rater reliability (intraclass correlation coefficient (ICC)) was 0.91 (95% CI 0.77 to 0.99), and intra-rater reliability for the overall score (ICC) was ranging from 0.91 to 0.99.ConclusionsWe developed an evidence-based and reliable assessment tool for the evaluation of the instructional design of a simulation-based team training: the ID-SIM. The ID-SIM is available as a free mobile application.

OBJECTIVE To describe a simulation-based curriculum on twin vaginal delivery and evaluate its effects on trainee knowledge and comfort about twin vaginal birth. METHODS Trainees participated in a three-part simulation consisting of a patient counseling session, a twin delivery scenario, and a breech extraction skills station. Consenting trainees completed a 21-item presimulation survey and a 22-item postsimulation survey assessing knowledge, experience, attitudes, and comfort surrounding twin vaginal birth. Presimulation and postsimulation results were compared using univariate analysis. Our primary outcomes were change in knowledge and comfort before and after the simulation. RESULTS Twenty-four obstetrics and gynecology residents consented to participation with 18 postsimulation surveys available for comparison (75%). Trainees estimated their participation in 445 twin deliveries (median 19, range 0-52) with only 20.4% of these as vaginal births. Participants reported a need for more didactic or simulated training on this topic (64% and 88%, respectively). Knowledge about twin delivery improved after the simulation (33.3% compared with 58.3% questions correct, P

Debriefing is a lynchpin in the process of learning. As a post-experience analytic process, debriefing is a discussion and analysis of an experience, evaluating and integrating lessons learned into one's cognition and consciousness. Debriefing provides opportunities for exploring and making sense of what happened during an event or experience, discussing what went well and identifying what could be done to change, improve and do better next time. This manuscript serves as an introduction to debriefing, covering a range of topics that include a brief review of its origin, the structure and process of debriefing-specifically in the context of simulation-based medical education, and factors that facilitate effective, successful debriefing. An approach to debriefing immediately after real clinical events will be presented, as well as an evidence-based approach to evaluating debriefing skills of healthcare simulation instructors.

Background Opportunities for medical students to place intrauterine contraception (IUC) in patients are rare. Our objective was to determine whether participation in an IUC insertion and removal simulation exercise would increase medical students’ comfort level with, attitudes towards, and willingness to recommend IUC. Methods A prospective cohort study was undertaken in all students completing the obstetrics and gynecology clerkship at a major academic hospital during the 2010–2011 academic year. The exposure consisted of a 45-minute interactive didactic session and a 30-minute, hands-on practicum in IUC placement and removal using medical instruments and realistic pelvic models. Both levonorgestrel and Cu380A IUC devices were utilized. Participants completed a pre- and post-simulation survey instrument, designed to examine students’ IUC-specific knowledge, comfort, and attitudes. Pre- and post-simulation responses were compared by McNemar’s test for paired samples. Results Thirty-five paired pre- and post-simulation surveys were analyzed, representing a 78 % response rate. Composite IUC-related knowledge scores increased by a median of 3 out of 10 points after the intervention (p

Healthcare has come to appreciate the value of simulation and its role in education, training, evaluation and research. This article reviews simulator technology and the role of simulation in obstetrics. The scope and nature of the obstetric literature published between January 1950 and July 2007 were reviewed. A total of 84 out of the 305 articles identified met criteria for inclusion in this review, most (59/84) having been published since 2000. The field of obstetrical simulation has grown substantially over the past decade. Thus far, the literature supports simulation as an essential tool for practicing routine and critical events, and improving technical proficiency and teamwork. Simulation can serve as a strategy for improving procedural and behavioral skills, potentially mitigating adverse perinatal events. More research is needed to determine whether obstetrical simulation leads to a significant reduction in the risk of birth-related injury and improved birth outcomes.

Article-at-a-Glance Background Patient safety administrators, educators, and researchers are striving to understand how best to monitor and improve team skills and determine what approaches to monitoring best suit their organizations. A behavior-based tool, based on principles of crisis resource management (CRM) in nonmedical industries, was developed to quantitatively assess communication and team skills of health care providers in a variety of real and simulated clinical settings. The CATS Assessment The Communication and Teamwork Skills (CATS) Assessment has been developed through rapid-cycle improvement and piloted through observation of videotaped simulated clinical scenarios, real-time surgical procedures, and multidisciplinary rounds. Specific behavior markers are clustered into four categories—coordination, cooperation, situational awareness, and communication. Teams are scored in terms of the occurrence and quality of the behaviors. The CATS Assessment results enable clinicians to view a spectrum of scores—from the overall score for the categories to specific behaviors. Conclusion The CATS Assessment tool requires statistical validation and further study to determine if it reliably quantifies health care team performance. The patient safety community is invited to use and improve behavior-based observation measures to better evaluate their training programs, continue to research and improve observation methodology, and provide quantifiable, objective feedback to their clinicians and organizations.

Context Few data exist on the relationships between experienced physicians' work hours and sleep, and patient safety. Objective To determine if sleep opportunities for attending surgeons and obstetricians/gynecologists are associated with the risk of complications. Design, setting, and patients Matched retrospective cohort study of procedures performed from January 1999 through June 2008 by attending physicians (86 surgeons and 134 obstetricians/gynecologists) who had been in the hospital performing another procedure involving adult patients for at least part of the preceding night (12 am-6 am, postnighttime procedures). Sleep opportunity was calculated as the time between end of the overnight procedure and start of the first procedure the following day. Matched control procedures included as many as 5 procedures of the same type performed by the same physician on days without preceding overnight procedures. Complications were identified and classified by a blinded 3-step process that included administrative screening, medical record reviews, and clinician ratings. Main outcome measures Rates of complications in postnighttime procedures as compared with controls; rates of complications in postnighttime procedures among physicians with more than 6-hour sleep opportunities vs those with sleep opportunities of 6 hours or less. Results A total of 919 surgical and 957 obstetrical postnighttime procedures were matched with 3552 and 3945 control procedures, respectively. Complications occurred in 101 postnighttime procedures (5.4%) and 365 control procedures (4.9%) (odds ratio, 1.09; 95% confidence interval [CI], 0.84-1.41). Complications occurred in 82 of 1317 postnighttime procedures with sleep opportunities of 6 hours or less (6.2%) vs 19 of 559 postnighttime procedures with sleep opportunities of more than 6 hours (3.4%) (odds ratio, 1.72; 95% CI, 1.02-2.89). Postnighttime procedures completed after working more than 12 hours (n = 958) compared with 12 hours or less (n = 918) had nonsignificantly higher complication rates (6.5% vs 4.3%; odds ratio, 1.47; 95% CI, 0.96-2.27). Conclusion Overall, procedures performed the day after attending physicians worked overnight were not associated with significantly increased complication rates, although there was an increased rate of complications among postnighttime surgical procedures performed by physicians with sleep opportunities of less than 6 hours.

Introduction: Despite published recommended best practices for full disclosure and apology to patients and families after adverse medical events, actual practice can be inadequate. The use of ‘‘cognitive aids’’ to help practitioners manage complex critical events has been successful in a variety of fields and healthcare. We wished to extend this concept to disclosure and apology events. The aim of this study was to test if a brief opportunity to review a best practice guideline for disclosure and apology would improve communication performance. Methods: Thirty pairs of experienced obstetricians and labor nurses participated in a 3-part exercise with mixed-realism simulation. The first part used a standardized actor patient to meet the obstetrical team. The second part used a high-fidelity simulation leading to an adverse medical event (retained sponge), and the third part used standardized actors, patient, and husband, who systematically move through stages of grief response. The participants were randomized into 2 groups, one was provided with a cognitive aid in the form of a best practice guideline for disclosure and apology and the other was only given time to plan. Four blinded raters working in pairs scored subjects on a 7-point scale using a previously developed assessment instrument modified for this study. Results: Pooled ratings of the disclosure and apology discussion for the intervention group (n = 167, mean = 4.9, SD = 0.92) were higher than those from the control group (n = 167, mean = 4.3, SD = 1.21) (P G0.0001). One specific element was rated higher for the intervention group than the control group; posture toward the patient (n = 27, mean = 5.1, SD = 0.82 versus n = 28, mean = 4.3, SD = 1.33) (P = 0.020). The elements of dealing with anger, dealing with depression, dealing with denial, bargaining, and acceptance were not different. Conclusions: Experienced practitioners performed better in a simulated disclosure and apology conversation after reviewing a cognitive aid in the form of a best practice guideline than a control group that was only given time to prepare.

Objective To identify the potential impact that different definitions of live births and practice patterns have on infant mortality rates in England and Wales, France, Japan, and the United States. Methods United States data were obtained from the 1986 linked national birth-infant death cohort, and those for the other countries came from either published sources or directly from the Ministries of Health. Results In 1986 in the United States, infants weighing less than 1 kg accounted for 36% of deaths (32% white and 46% black); 32% resulted from fatal congenital anomalies. These rates were much higher in both categories than in England and Wales in 1990 (24 and 22%, respectively), France in 1990 (15 and 25%, respectively), and Japan in 1991 (9% for infants weighing less than 1 kg, percentage of fatal congenital anomalies unknown). These cases are more likely to be excluded from infant mortality statistics in their countries than in the United States. Conclusions In 1990, the United States infant mortality rate was 9.2 per 1000 live births, ranking the United States 19th internationally. However, infant mortality provides a poor comparative measure of reproductive outcome because there are enormous regional and international differences in clinical practices and in the way live births are classified. Future international and state comparisons of reproductive health should standardize the definition of a live birth and fatal congenital anomaly, and use weight-specific fetal-infant mortality ratios and perinatal statistics.

Introduction Organizational behavior and management fields have long realized the importance of teamwork and team-building skills, but only recently has health care training focused on these critical elements. Communication styles and strategies are a common focus of team training but have not yet been consistently applied to medicine. We sought to determine whether such communication strategies, specifically "advocacy" and "inquiry," were used de novo by medical professionals in a simulation-based teamwork and crisis resource management course. Explicit expression of a jointly managed clinical plan between providers, a strategy shown to improve patient safety, was also evaluated. Methods Forty-four of 54 videotaped performances of an ongoing team-building skills course were viewed and analyzed for presence of advocacy and/or inquiry that related to information or a plan; inclusion criteria were participation of a nonconfederate obstetrician and an anesthesiologist. Verbal statement of a jointly managed clinical plan was also recorded. Results Anesthesiologists advocated information in 100% of cases and advocated their plans in 93% of cases but inquired information in 30% of cases and inquired about the obstetricians' plans in 11% of cases. Obstetricians advocated information in 73% of cases, advocated their plans in 73% of cases, inquired information in 75% of cases, and inquired about the anesthesiologists' plans in 59% of cases. An explicitly stated joint team plan was formed in 45% of cases. Conclusions Anesthesiologists advocated more frequently than obstetricians, while obstetricians inquired and advocated in more balanced proportions. However, fewer than half of the teams explicitly agreed on a joint plan. Increasing awareness of communication styles, and possibly incorporating these skills into medical training, may help teams arrive more efficiently at jointly managed clinical plans in crisis situations.

Patient safety initiatives aimed at reducing medical errors and adverse events are being implemented in Obstetrics. The Controlled Risk Insurance Company (CRICO), Risk Management Foundation (RMF) of the Harvard Medical Institutions pursued simulation as an anesthesia risk control strategy. Encouraged by their success, CRICO/RMF promoted simulation-based team training as a risk control strategy for obstetrical providers. We describe the development, implementation, and evaluation of an obstetric simulation-based team training course grounded in crisis resource management (CRM) principles.We pursued systematic design of course development, implementation, and evaluation in 3 phases, including a 1-year or more posttraining follow-up with self-assessment questionnaires.The course was highly rated overall by participants immediately after the course and 1-year or more after the course. Most survey responders reported having experienced a critical clinical event since the course and that various aspects of their teamwork had significantly or somewhat improved as a result of the course. Most (86%) reported CRM principles as useful for obstetric faculty and most (59%) recommended repeating the simulation course every 2 years.A simulation-based team-training course for obstetric clinicians was developed and is a central component of CRICO/RMF's obstetric risk management incentive program that provides a 10% reduction in annual obstetrical malpractice premiums. The course was highly regarded immediately and 1 year or more after completing the course. Most survey responders reported improved teamwork and communication in managing a critical obstetric event in the interval since taking the course. Simulation-based CRM training can serve as a strategy for mitigating adverse perinatal events.

Across health care, teamwork is a critical element for effective patient care. Yet, numerous well-intentioned training programs may fail to achieve the desired outcomes in team performance. Hope for the improvement of teamwork in health care is provided by the success of the aviation and military communities in utilizing simulation-based training (SBT) for training and evaluating teams. This consensus paper 1) proposes a scientifically based methodology for SBT design and evaluation, 2) reviews existing team performance metrics in health care along with recommendations, and 3) focuses on leadership as a target for SBT because it has a high likelihood to improve many team processes and ultimately performance. It is hoped that this discussion will assist those in emergency medicine (EM) and the larger health care field in the design and delivery of SBT for training and evaluating teamwork.

Simulation is a practical and safe approach to the acquisition and maintenance of task-oriented and behavioral skills across the spectrum of medical specialties, including obstetrics and gynecology. Since the 1990s, the profession of obstetrics and gynecology has come to appreciate the value of simulation and major steps are being taken toward incorporating this technique into specialty-specific training, evaluation, and credentialing programs. This article provides an overview of simulators and simulation in health care and describes the scope of their current use and anticipated applications in the field of obstetrics and gynecology.

This article reviews the physiology and pathophysiology of selected endocrine glands. The common presenting clinical signs and symptoms are reviewed, and the initial laboratory tests that may establish the diagnosis are recommended. Diagnosis and management of hypothyroidism, hyperthyroidism, hyperparathyroidism, hypoparathyroidism, pituitary disorders, diabetes mellitus (types I and II), hypoglycemia, and disorders of the adrenal cortex are discussed. The clinical management of the most commonly encountered endocrine disorders seen in the primary care setting is described, and pharmacologic considerations are underscored.