- Email: [email protected]
Identifying Pitfalls in Chest Tube Insertion: Improving Teaching and Performance
ORIGINAL REPORTS
Identifying Pitfalls in Chest Tube Insertion: Improving Teaching and Performance James S. Davis, MD, George D. Garcia, MD, Jassin M. Jouria, MD, Mary M. Wyckoff, PhD, Salman Alsafran, MD, Jill M. Graygo, MPH, Kelly F. Withum, BS, and Carl I. Schulman, PhD Leonard M. Miller School of Medicine, Department of Surgery, University of Miami, Miami, Florida OBJECTIVE: Chest tube thoracostomies are common
surgical procedures, but little is known about how practitioners learn the skill. This study evaluates the frequency with which correctly performed tasks are executed by subjects during chest tube thoracostomies. DESIGN: In this prospective study, we developed a
mobile-learning module, containing stepwise multimedia guidance on chest tube insertion. Next, we developed and tested a 14-item checklist, modeled after key skills in the module. Participants, defined as ‘‘novice’’ (fewer than 10 chest tubes placed) or ‘‘expert’’ (10 or more placed), were assigned to either the video or control group. A trained clinician used the checklist to rate participants while they inserted a chest tube on a TraumaMan simulator.
p o 0.001) and clamp the distal end of the chest tube (42%, p o 0.001). Of all the steps, experts least frequently completed full finger sweeps (70%) and avoided the neurovascular bundle (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p ¼ not significant). CONCLUSIONS: Avoiding the neurovascular bundle,
controlled pleural entry, and finger sweeps are most often performed incorrectly among novices. This information can help instructors to emphasize key didactic steps, possibly C 2013 easing trainees’ learning curve. ( J Surg 70:334-339. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
SETTING: University of Miami, Miller School of Medi-
KEY WORDS: chest tube, thoracostomies, surgical educa-
cine, a tertiary care academic institution.
tion, simulation, instruction, procedure
PARTICIPANTS: Current medical students, residents, and
COMPETENCIES: Patient Care, Medical Knowledge,
the United States Army Forward Surgical Team members rotating through the institution. One hundred twenty-eight subjects entered and finished the study.
Practice-Based Learning and Improvement
RESULTS: One hundred twenty-eight subjects enrolled in the study; 86 (67%) were residents or US Army Forward Surgical Team members, 66 (77%) were novices, and 20 (23%) were experts. Novices most frequently connected the tube to suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). They least frequently completed full finger sweeps (33%), avoided the neurovascular bundle (35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to correctly perform a finger sweep (42%,
INTRODUCTION
Correspondence: Inquiries to Carl I. Schulman MD, PhD, MSPH, FACS, University of Miami—Miller School of Medicine, DeWitt Daughtry Family Department of Surgery, P.O. Box 016960 (D-40) Miami, FL 33101; fax: 305-326-7065; e-mail: [email protected] Sources of Support: DoD Grant W81XWH-10-2-0109. This manuscript was presented at the Annual Meeting of the American College of Surgeons, Chicago, Illinois, October 3, 2012.
334
The turn of the 20th century has borne witness to a fundamental paradigm shift in medical education. Resident work-hour restrictions,1,2 increasingly stringent rules regarding attending supervision,3-5 and exponential growth of medical technology have conspired to end the era of ‘see one, do one, teach one’. Today, Halstedian didactic paradigms have been replaced by more data-driven aspects of medical education.6 In many ways, the golden age of medical simulation has arrived.7 Simulation is particularly applicable to the hands-on aspects of medicine. Endoscopic and thoracoscopic surgeries, along with minor procedures like central lines, have all been taught and reinforced through simulation.8-10 Medical education through simulation frequently follows a general pattern: subjects who receive simulation training are subsequently evaluated based on a standardized checklist. Subject performance is compared either through
Journal of Surgical Education & 2013 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2012.12.005
pretest and posttests, or vis-a-vis a control group. In either case, outcomes are based solely on total-aggregate checklist score or specific outcome-related benchmarks. To date, no simulation study has focused on the individual, discrete procedural steps to improve future instruction. It would be beneficial to know, for example, that most residents learn the subclavian landmarks relatively easily, but struggle when actually cannulating the vein. Such information might affect how procedures are taught and reinforced. This descriptive study examines the manner in which novices and experts perform the steps of chest tube placement. Specifically, we evaluate their ability to correctly execute each step of chest tube placement. This information is potentially useful for subsequent teaching and testing of different learner groups. Our findings are then discussed in the context of learning theory, suggesting new avenues of inquiry and application in surgical education.
METHODS This study was conducted as part of a larger undertaking regarding the University of Miami Miller School of Medicine’s Trauma and Critical Care Mobile-Learning Curriculum, part of which has been evaluated and presented elsewhere.11,12 A 14-item skills checklist, modeled after key steps in chest tube insertion highlighted in the video, was developed by the Director of Clinical Education and pilot tested with PGY4 surgical residents who had inserted over 20 chest tubes previously (Appendix 1). The skills checklist went through several iterations before the final version was completed. Figure 1 is a screenshot from the chest tube module. Participants for this study were medical students, residents, and the United States Army Forward Surgical Team (FST) members rotating through the Army Trauma Training Center . FSTs consist of discrete 10-20 person
units, who train at the Army Trauma Training Center prior to their deployment.13 At minimum, FSTs consist of a general surgeon, nurses, and paramedics, all of whom are considered capable of placing a chest tube in the field. Recruitment took place from July to December, 2011. All participants filled out a standardized questionnaire regarding prior experience in placing and learning about chest tubes. Consenting participants were assigned to either the intervention group, which viewed the mobile-learning module on an Apple iPod Touch (Cupertino, CA), or the control group, which did not view the mobile-learning module or receive any other instruction. Those in the intervention group were monitored to ascertain that they watched the module and did not share it with controls or other bystanders. All subjects received explicit instruction not to share information regarding the chest tube procedure or study with their peers. Participants were presented with a standardized patient scenario and asked to place a chest tube on the TraumaMan task simulator (SIMULAB Corporation, Seattle, WA). Two surgical residents with training in the correct placement of chest tubes observed the participants insert a chest tube using the skills checklist to assess performance. The evaluators used the content of the modules to determine what constituted accepted thresholds for adequate technique. For the purpose of analysis, participants were defined as ‘‘novice’’ (fewer than 10 chest tubes placed) or ‘‘expert’’ (10 or more chest tubes placed) based on the participants’ questionnaire responses. This threshold was selected because the American College of Chest Physicians practice guidelines state that medical professionals must perform a minimum of 10 tube thoracostomies to achieve competence.14 Medical students were considered as a discrete group because of their complete lack of skill and experience in placing chest tubes. Descriptive statistics were calculated for each step using SPSS 19.0 (Chicago, IL), and each group was analyzed using a student t-test with significance level set at p r 0.05. The research was approved by the Institutional Review Boards at both the University and the United States Department of Defense.
RESULTS
FIGURE 1. Screen shot from one mobile learning module. The figure depicts a heavy curved forceps entering the pleural cavity above the rib during a chest tube placement procedure.
A total of 128 subjects were enrolled in the study, of whom, 44 (34%) were residents, 42 (33%) participants were members of the FST, and 42 (33%) were medical students. Among residents and FSTs, 66 (77%) were novices and 20 (23%) were experts. The results of the novice group are recorded in Table 1. In general, they most frequently connected the tube to wall suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). However, novices least frequently completed intrapleural finger sweeps for adhesions (33%), avoided the neurovascular bundle
Journal of Surgical Education Volume 70/Number 3 May/June 2013
335
TABLE 1. Novice Performance on Discrete Steps of Chest Tube Insertion (n ¼ 66) Steps Most Frequently Performed 2. Sterile preparation 3. Anesthetize area 5. Blunt dissection 14. Connect chest tube to wall suction
Percentage 80 80 82 91
Steps Least Frequently Performed 8. Avoid neurovascular bundle 9. Enter pleura in a controlled fashion 12. Place finger inside pleura to check for adhesions
35 39 33
Largest Percent Differences (Video vs No Video) 1. Identify insertion site 4. Transverse incision 12. Place finger inside pleura to check for adhesions 13. Clamp the distal end
27 27 42 42
*p o 0.05.
(35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to perform an intrapleural finger sweep (42%, p o 0.001) and clamp the distal end of the chest tube prior to insertion (42%, p o 0.001). The results of the expert group are recorded in Table 2. Overall, experts least frequently performed finger sweeps (70%), avoided the neurovascular bundle (75%), and opened the hemostat widely to expand the pleural puncture (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p ¼ not significant). Medical students (Table 3) performed the most poorly overall; they least frequently used the hemostat to puncture the pleura (26%), entered the pleura in a controlled fashion (17%), and spread the hemostat widely (26%). In evaluating the medical student video group with the control group, the video group was significantly more likely to identify the insertion site (48%; p o 0.05), dissect over the rib (48%; p o 0.05), and clamp the distal end of the chest tube prior to insertion (52%; p o 0.05).
DISCUSSION Over the past decade, many technology-based surgical education tools have been created and tested. These tools foster both trainee knowledge and technical skill. In most cases, the evaluation process includes a standardized checklist of steps necessary for completing the procedure with all items weighted equally, producing an aggregate score.15,16 Some checklists involve a more complex scoring system that may require fulfillment of major and minor criteria.17 Also, completing a specific ‘critical step’ may be prerequisite to achieving competency. Checklists and stepwise learning of procedural tasks are directly rooted in learning theory. Learning theory asserts that humans learn procedures better when broken up into individual steps.18 Mayer’s cognitive theory of adaptive learning extended the concept to multimedia formats, which should also proceed in a segmented fashion.19 In the age of medical simulation and testing, learned procedural skills are tested in a stepwise format, as well.20 Nevertheless, it is incongruous to employ a stepwise checklist, as procedure-based studies often do, while
TABLE 2. Expert Performance on Discrete Steps of Chest Tube Insertion (n ¼ 20) Steps Most Frequently Performed 2. Sterile preparation 14. Connect chest tube to wall suction
336
Percentage 100 100
Steps Least Frequently Performed 8. Avoid the neurovascular bundle 10. Spread hemostat widely 12. Place finger inside pleura to check for adhesions
75 75 70
Largest Percent Differences (Video vs No Video) 4. Transverse incision 12. Place finger inside pleura to check for adhesions 13. Clamp the distal end
20 20 20
Journal of Surgical Education Volume 70/Number 3 May/June 2013
TABLE 3. Medical Student Performance on Discrete Steps of Chest Tube Insertion (n ¼ 42) Steps Most Frequently Performed 2. 3. 4. 5.
Percentage
Sterile preparation Anesthetize area Transverse incision Blunt dissection
79 79 81 74
Skills Least Frequently Performed 7. Use hemostat to puncture pleura 9. Enter pleura in a controlled fashion 10. Spread hemostat widely
26 17 26
Largest Percent Differences (Video vs No Video) 1. Identify insertion site 6. Dissect over the rib 13. Clamp the distal end
48 48 52
*p o 0.05.
evaluating subjects solely based on their cumulative score. The specific stepwise responses possess inherent value in assessing individual and group performance. According to the principle of adaptive learning, a subject’s learning strengths and weaknesses may be used to direct future learning.21 Computerized adaptive testing applies the concept to testing: a subject’s answers to test questions are used to further refine the remainder of the examination.22,23 In either case, a feedback loop is established between the subject’s performance and future learning interactions. Our study on chest tube placement did not observe such a feedback loop to allow adaptive learning. Currently, the mobile-learning module does not contain that capability. However, as medical education embraces computerbased simulations, thoroughly researching and articulating
how computers can help trainees learn in simulated environments is imperative. Our results provide initial information that is prerequisite to applying adaptivelearning theory to mobile learning. In our study on chest tube placement, avoiding the neurovascular bundle, finger sweeps, and controlled pleural entry were most often performed incorrectly among novices. Interestingly, the first 2 actions also most often challenged experienced subjects as well. We attribute this to differences in significance and intuitiveness among the various procedural steps. Critical steps are steps without which successful execution of the procedure would be impossible. For example, a skin incision is necessary for placement of a chest tube. Other steps are intuitive to subjects with baseline medical knowledge as part of a standard medical approach. Prior to an invasive procedure, some form of anesthetic is frequently administered. These steps are more likely to be completed appropriately. In contrast, more advanced technical steps requiring detailed knowledge of anatomy and blind dissection are more challenging. Avoiding the neurovascular bundle and finger sweeps are steps that require more advanced knowledge of anatomic spatial relationships—it is these that novices and experts performed least well in our study. There are several limitations inherent to the nature of this study. As a pilot study, it is fundamentally limited by the small amount of data collected. However, the proliferation of medical simulation will only increase the volume of data available and allow for more accurate assessment and application of adaptive-learning principles. Secondly, data on subjects’ performance are somewhat dependent upon the educational tool being tested. A different educational intervention might lead to different postintervention results. As such, adaptive learning and testing technologies
TABLE A1. Checklist for Chest Tube Insertion
Critical Elements for Chest Tube Insertion
Criteria Met
Criteria Needs Review
1. Identify insertion site 5th intercostal anterior MAL on affected side or nipple line (not in females) 2. Sterile preparation of chest 3. Anesthetize skin and subcutaneous tissue and periostium of underlying rib and pleura just past the rib 4. 2-3 cm incision transverse incision parallel to the line of ribs at the predetermined site with a 11 scalpel 5. Bluntly dissect the subcutaneous tissue with a hemostat or scissors 6. Dissect over the top of the underlying rib to the next highest intercostal space 7. With the tip of the hemostat puncture the parietal pleura while pushing at the top border of the rib 8. Enter pleural space over the top of the rib to avoid damaging the neural vascular bundle 9. Enter in a control fashion to avoid laceration to the lung 10. Once inside the pleura spread the hemostat widely and withdraw while still open 11. Create a sufficient opening in the pleura for the chest tube 12. Place finger inside whole of pleura and move finger 360 degrees to confirm correct location and assure no impediment and adhesions 13. Clamp distal end of the chest tube (proximal optional) 14. Connect to an underwater seal collection chamber Journal of Surgical Education Volume 70/Number 3 May/June 2013
337
may need to be specific to the intervention, rather than being specific to the procedure tested. Medical education should derive its techniques from an accepted, research-based theory of learning.19 Such derivations have been slow to arrive to medical simulation. This study is the first to evaluate the pretest knowledge and relative improvement on individual steps of chest tube insertion, both among novices and experts. This information provides the initial step towards applying adaptive learning to medical simulation technology. Further inquiries will be necessary to ascertain how adaptive learning can integrate into simulation, procedural instruction, and just-in-time learning.
8. Barsuk JH, McGaghie WC, Cohen ER, et al. Use of
simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4:397-403. 9. Solomon B, Bizekis C, Dellis SL, et al. Simulating
video-assisted thoracoscopic lobectomy: a virtual reality cognitive task simulation. J Thorac Cardiovasc Surg. 2011;141:249-255. 10. Walsh CM, Sherlock ME, Ling SC, Carnahan H.
Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy. Cochrane Database Syst Rev. 2012;6:CD008237. 11. Davis JS, Garcia GD, Wyckoff MM, et al. Use of
APPENDIX 1 CHECKLIST FOR CHEST TUBE INSERTION
mobile learning module improves skills in chest tube insertion. J Surg Res. 2012;177:21-26. 12. Schulman CI, Garcia GD, Wyckoff MM, et al.
TABLE A1.
Mobile learning module improves knowledge of medical shock for forward surgical team members. Mil Med. 2012;177(11):1316-1321.
REFERENCES 1. Accreditation Council for Graduate Medical Education.
Resident duty hours in the learning and work environment: comparison of 2003 and 2011 standards. Available at: http://acgme-2010standards.org/ pdf/dh-ComparisonTable2003v2011.pdf. Accessed 09.10.12. 2. Fields RC, Bowman MC, Freeman BD, Klingensmith
ME. Implementation of an after hours resident educational program in a general surgery residency: a paradigm for increasing formal didactic training outside of the hospital setting in the era of the 80-hour workweek. J Surg Educ. 2009;66:340-343. 3. Ulmer C, Wolman DM, Johns MM, eds. Institute of
Medicine resident duty hours: enhancing sleep, supervision and safety. 1st ed. Washington, DC: National Academies Press; 2009. 4. Philibert I, Amis S, eds. The ACGME 2011 duty hour
standards: enhancing quality of care, supervision, and resident professional development. Chicago: Accreditation Council for Graduate Medical Education; 2011. 5. Accreditation Council for Graduate Medical Education.
13. Pereira BM, Ryan ML, Ogilvie MP, et al. Predeploy-
ment mass casualty and clinical trauma training for US army forward surgical teams. J Craniofac Surg. 2010;21:982-986. 14. Ernst A, Silvestri GA, Johnston D. Interventional
pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123:1693-1717. 15. Lenchus J, Issenberg SB, Murphy D, et al. A blended
approach to invasive bedside procedural instruction. Med Teach. 2011;33:116-123. 16. Hutton IA, Kenealy H, Wong C. Using simulation
models to teach junior doctors how to insert chest tubes: a brief and effective teaching module. Intern Med J. 2008;38:887-891. 17. Huang GC, Newman LR, Schwartzstein RM, et al.
Procedural competence in internal medicine residents: validity of a central venous catheter insertion assessment instrument. Acad Med. 2009;84:1127-1134. 18. Clark RC. Developing technical training. 1st ed. Silver
Spring, MD: International Society for Performance Improvement; 1999: 59–80.
Common program requirements. Available at: /http://acgme-2010standards.org/pdf/Common_Pro gram_Requirements_07012011.pdfS; Accessed 09.10.12.
19. Mayer RE. Applying the science of learning to
6. Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond
see one, do one, teach one: toward a different training paradigm. Postgrad Med J. 2009;85:244-249.
Cognitive task analysis for teaching technical skills in an inanimate surgical skills laboratory. Am J Surg. 2004;187:114-119.
7. Satava RM. Emerging technologies for surgery in the
21. Paramythis A, Loidl-Reisinger S. Adaptive learn-
21st century. Arch Surg. 1999;134:1197-1202. 338
medical education. Med Educ. 2010;44:543-549. 20. Velhamos GC, Toutouzas KG, Sillin LF, et al.
ing
environments
and
e-learning
standards.
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Electronic Journal of eLearning 2004;2:181-194. Available at: /http://web.archive.org/web/20100331 014042/; Available at: http://www.ejel.org/volume-2/ vol2-issue1/issue1-art11-paramythis.pdfS; Accessed 09.10.12. 22. Parshall CG, Davey T, Pashley PJ. Innovative item
types for computerized testing. In: Van der Linden
WJ, Glas CAW, eds. Computerized adaptive testing: theory and practice. 1st ed. Dordrecht, the Netherlands: Kluwer Academic Publishers; 1992:129–148. 23. Van der Linden WJ, Glas CAW, eds. Computerized
adaptive testing theory and practice. 1st ed. Dordrecht, the Netherlands: Kluwer Academic Publishers; 1992: Preface and Chapter 1.
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Identifying Pitfalls in Chest Tube Insertion: Improving Teaching and Performance James S. Davis, MD, George D. Garcia, MD, Jassin M. Jouria, MD, Mary M. Wyckoff, PhD, Salman Alsafran, MD, Jill M. Graygo, MPH, Kelly F. Withum, BS, and Carl I. Schulman, PhD Leonard M. Miller School of Medicine, Department of Surgery, University of Miami, Miami, Florida OBJECTIVE: Chest tube thoracostomies are common
surgical procedures, but little is known about how practitioners learn the skill. This study evaluates the frequency with which correctly performed tasks are executed by subjects during chest tube thoracostomies. DESIGN: In this prospective study, we developed a
mobile-learning module, containing stepwise multimedia guidance on chest tube insertion. Next, we developed and tested a 14-item checklist, modeled after key skills in the module. Participants, defined as ‘‘novice’’ (fewer than 10 chest tubes placed) or ‘‘expert’’ (10 or more placed), were assigned to either the video or control group. A trained clinician used the checklist to rate participants while they inserted a chest tube on a TraumaMan simulator.
p o 0.001) and clamp the distal end of the chest tube (42%, p o 0.001). Of all the steps, experts least frequently completed full finger sweeps (70%) and avoided the neurovascular bundle (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p ¼ not significant). CONCLUSIONS: Avoiding the neurovascular bundle,
controlled pleural entry, and finger sweeps are most often performed incorrectly among novices. This information can help instructors to emphasize key didactic steps, possibly C 2013 easing trainees’ learning curve. ( J Surg 70:334-339. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
SETTING: University of Miami, Miller School of Medi-
KEY WORDS: chest tube, thoracostomies, surgical educa-
cine, a tertiary care academic institution.
tion, simulation, instruction, procedure
PARTICIPANTS: Current medical students, residents, and
COMPETENCIES: Patient Care, Medical Knowledge,
the United States Army Forward Surgical Team members rotating through the institution. One hundred twenty-eight subjects entered and finished the study.
Practice-Based Learning and Improvement
RESULTS: One hundred twenty-eight subjects enrolled in the study; 86 (67%) were residents or US Army Forward Surgical Team members, 66 (77%) were novices, and 20 (23%) were experts. Novices most frequently connected the tube to suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). They least frequently completed full finger sweeps (33%), avoided the neurovascular bundle (35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to correctly perform a finger sweep (42%,
INTRODUCTION
Correspondence: Inquiries to Carl I. Schulman MD, PhD, MSPH, FACS, University of Miami—Miller School of Medicine, DeWitt Daughtry Family Department of Surgery, P.O. Box 016960 (D-40) Miami, FL 33101; fax: 305-326-7065; e-mail: [email protected] Sources of Support: DoD Grant W81XWH-10-2-0109. This manuscript was presented at the Annual Meeting of the American College of Surgeons, Chicago, Illinois, October 3, 2012.
334
The turn of the 20th century has borne witness to a fundamental paradigm shift in medical education. Resident work-hour restrictions,1,2 increasingly stringent rules regarding attending supervision,3-5 and exponential growth of medical technology have conspired to end the era of ‘see one, do one, teach one’. Today, Halstedian didactic paradigms have been replaced by more data-driven aspects of medical education.6 In many ways, the golden age of medical simulation has arrived.7 Simulation is particularly applicable to the hands-on aspects of medicine. Endoscopic and thoracoscopic surgeries, along with minor procedures like central lines, have all been taught and reinforced through simulation.8-10 Medical education through simulation frequently follows a general pattern: subjects who receive simulation training are subsequently evaluated based on a standardized checklist. Subject performance is compared either through
Journal of Surgical Education & 2013 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2012.12.005
pretest and posttests, or vis-a-vis a control group. In either case, outcomes are based solely on total-aggregate checklist score or specific outcome-related benchmarks. To date, no simulation study has focused on the individual, discrete procedural steps to improve future instruction. It would be beneficial to know, for example, that most residents learn the subclavian landmarks relatively easily, but struggle when actually cannulating the vein. Such information might affect how procedures are taught and reinforced. This descriptive study examines the manner in which novices and experts perform the steps of chest tube placement. Specifically, we evaluate their ability to correctly execute each step of chest tube placement. This information is potentially useful for subsequent teaching and testing of different learner groups. Our findings are then discussed in the context of learning theory, suggesting new avenues of inquiry and application in surgical education.
METHODS This study was conducted as part of a larger undertaking regarding the University of Miami Miller School of Medicine’s Trauma and Critical Care Mobile-Learning Curriculum, part of which has been evaluated and presented elsewhere.11,12 A 14-item skills checklist, modeled after key steps in chest tube insertion highlighted in the video, was developed by the Director of Clinical Education and pilot tested with PGY4 surgical residents who had inserted over 20 chest tubes previously (Appendix 1). The skills checklist went through several iterations before the final version was completed. Figure 1 is a screenshot from the chest tube module. Participants for this study were medical students, residents, and the United States Army Forward Surgical Team (FST) members rotating through the Army Trauma Training Center . FSTs consist of discrete 10-20 person
units, who train at the Army Trauma Training Center prior to their deployment.13 At minimum, FSTs consist of a general surgeon, nurses, and paramedics, all of whom are considered capable of placing a chest tube in the field. Recruitment took place from July to December, 2011. All participants filled out a standardized questionnaire regarding prior experience in placing and learning about chest tubes. Consenting participants were assigned to either the intervention group, which viewed the mobile-learning module on an Apple iPod Touch (Cupertino, CA), or the control group, which did not view the mobile-learning module or receive any other instruction. Those in the intervention group were monitored to ascertain that they watched the module and did not share it with controls or other bystanders. All subjects received explicit instruction not to share information regarding the chest tube procedure or study with their peers. Participants were presented with a standardized patient scenario and asked to place a chest tube on the TraumaMan task simulator (SIMULAB Corporation, Seattle, WA). Two surgical residents with training in the correct placement of chest tubes observed the participants insert a chest tube using the skills checklist to assess performance. The evaluators used the content of the modules to determine what constituted accepted thresholds for adequate technique. For the purpose of analysis, participants were defined as ‘‘novice’’ (fewer than 10 chest tubes placed) or ‘‘expert’’ (10 or more chest tubes placed) based on the participants’ questionnaire responses. This threshold was selected because the American College of Chest Physicians practice guidelines state that medical professionals must perform a minimum of 10 tube thoracostomies to achieve competence.14 Medical students were considered as a discrete group because of their complete lack of skill and experience in placing chest tubes. Descriptive statistics were calculated for each step using SPSS 19.0 (Chicago, IL), and each group was analyzed using a student t-test with significance level set at p r 0.05. The research was approved by the Institutional Review Boards at both the University and the United States Department of Defense.
RESULTS
FIGURE 1. Screen shot from one mobile learning module. The figure depicts a heavy curved forceps entering the pleural cavity above the rib during a chest tube placement procedure.
A total of 128 subjects were enrolled in the study, of whom, 44 (34%) were residents, 42 (33%) participants were members of the FST, and 42 (33%) were medical students. Among residents and FSTs, 66 (77%) were novices and 20 (23%) were experts. The results of the novice group are recorded in Table 1. In general, they most frequently connected the tube to wall suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). However, novices least frequently completed intrapleural finger sweeps for adhesions (33%), avoided the neurovascular bundle
Journal of Surgical Education Volume 70/Number 3 May/June 2013
335
TABLE 1. Novice Performance on Discrete Steps of Chest Tube Insertion (n ¼ 66) Steps Most Frequently Performed 2. Sterile preparation 3. Anesthetize area 5. Blunt dissection 14. Connect chest tube to wall suction
Percentage 80 80 82 91
Steps Least Frequently Performed 8. Avoid neurovascular bundle 9. Enter pleura in a controlled fashion 12. Place finger inside pleura to check for adhesions
35 39 33
Largest Percent Differences (Video vs No Video) 1. Identify insertion site 4. Transverse incision 12. Place finger inside pleura to check for adhesions 13. Clamp the distal end
27 27 42 42
*p o 0.05.
(35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to perform an intrapleural finger sweep (42%, p o 0.001) and clamp the distal end of the chest tube prior to insertion (42%, p o 0.001). The results of the expert group are recorded in Table 2. Overall, experts least frequently performed finger sweeps (70%), avoided the neurovascular bundle (75%), and opened the hemostat widely to expand the pleural puncture (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p ¼ not significant). Medical students (Table 3) performed the most poorly overall; they least frequently used the hemostat to puncture the pleura (26%), entered the pleura in a controlled fashion (17%), and spread the hemostat widely (26%). In evaluating the medical student video group with the control group, the video group was significantly more likely to identify the insertion site (48%; p o 0.05), dissect over the rib (48%; p o 0.05), and clamp the distal end of the chest tube prior to insertion (52%; p o 0.05).
DISCUSSION Over the past decade, many technology-based surgical education tools have been created and tested. These tools foster both trainee knowledge and technical skill. In most cases, the evaluation process includes a standardized checklist of steps necessary for completing the procedure with all items weighted equally, producing an aggregate score.15,16 Some checklists involve a more complex scoring system that may require fulfillment of major and minor criteria.17 Also, completing a specific ‘critical step’ may be prerequisite to achieving competency. Checklists and stepwise learning of procedural tasks are directly rooted in learning theory. Learning theory asserts that humans learn procedures better when broken up into individual steps.18 Mayer’s cognitive theory of adaptive learning extended the concept to multimedia formats, which should also proceed in a segmented fashion.19 In the age of medical simulation and testing, learned procedural skills are tested in a stepwise format, as well.20 Nevertheless, it is incongruous to employ a stepwise checklist, as procedure-based studies often do, while
TABLE 2. Expert Performance on Discrete Steps of Chest Tube Insertion (n ¼ 20) Steps Most Frequently Performed 2. Sterile preparation 14. Connect chest tube to wall suction
336
Percentage 100 100
Steps Least Frequently Performed 8. Avoid the neurovascular bundle 10. Spread hemostat widely 12. Place finger inside pleura to check for adhesions
75 75 70
Largest Percent Differences (Video vs No Video) 4. Transverse incision 12. Place finger inside pleura to check for adhesions 13. Clamp the distal end
20 20 20
Journal of Surgical Education Volume 70/Number 3 May/June 2013
TABLE 3. Medical Student Performance on Discrete Steps of Chest Tube Insertion (n ¼ 42) Steps Most Frequently Performed 2. 3. 4. 5.
Percentage
Sterile preparation Anesthetize area Transverse incision Blunt dissection
79 79 81 74
Skills Least Frequently Performed 7. Use hemostat to puncture pleura 9. Enter pleura in a controlled fashion 10. Spread hemostat widely
26 17 26
Largest Percent Differences (Video vs No Video) 1. Identify insertion site 6. Dissect over the rib 13. Clamp the distal end
48 48 52
*p o 0.05.
evaluating subjects solely based on their cumulative score. The specific stepwise responses possess inherent value in assessing individual and group performance. According to the principle of adaptive learning, a subject’s learning strengths and weaknesses may be used to direct future learning.21 Computerized adaptive testing applies the concept to testing: a subject’s answers to test questions are used to further refine the remainder of the examination.22,23 In either case, a feedback loop is established between the subject’s performance and future learning interactions. Our study on chest tube placement did not observe such a feedback loop to allow adaptive learning. Currently, the mobile-learning module does not contain that capability. However, as medical education embraces computerbased simulations, thoroughly researching and articulating
how computers can help trainees learn in simulated environments is imperative. Our results provide initial information that is prerequisite to applying adaptivelearning theory to mobile learning. In our study on chest tube placement, avoiding the neurovascular bundle, finger sweeps, and controlled pleural entry were most often performed incorrectly among novices. Interestingly, the first 2 actions also most often challenged experienced subjects as well. We attribute this to differences in significance and intuitiveness among the various procedural steps. Critical steps are steps without which successful execution of the procedure would be impossible. For example, a skin incision is necessary for placement of a chest tube. Other steps are intuitive to subjects with baseline medical knowledge as part of a standard medical approach. Prior to an invasive procedure, some form of anesthetic is frequently administered. These steps are more likely to be completed appropriately. In contrast, more advanced technical steps requiring detailed knowledge of anatomy and blind dissection are more challenging. Avoiding the neurovascular bundle and finger sweeps are steps that require more advanced knowledge of anatomic spatial relationships—it is these that novices and experts performed least well in our study. There are several limitations inherent to the nature of this study. As a pilot study, it is fundamentally limited by the small amount of data collected. However, the proliferation of medical simulation will only increase the volume of data available and allow for more accurate assessment and application of adaptive-learning principles. Secondly, data on subjects’ performance are somewhat dependent upon the educational tool being tested. A different educational intervention might lead to different postintervention results. As such, adaptive learning and testing technologies
TABLE A1. Checklist for Chest Tube Insertion
Critical Elements for Chest Tube Insertion
Criteria Met
Criteria Needs Review
1. Identify insertion site 5th intercostal anterior MAL on affected side or nipple line (not in females) 2. Sterile preparation of chest 3. Anesthetize skin and subcutaneous tissue and periostium of underlying rib and pleura just past the rib 4. 2-3 cm incision transverse incision parallel to the line of ribs at the predetermined site with a 11 scalpel 5. Bluntly dissect the subcutaneous tissue with a hemostat or scissors 6. Dissect over the top of the underlying rib to the next highest intercostal space 7. With the tip of the hemostat puncture the parietal pleura while pushing at the top border of the rib 8. Enter pleural space over the top of the rib to avoid damaging the neural vascular bundle 9. Enter in a control fashion to avoid laceration to the lung 10. Once inside the pleura spread the hemostat widely and withdraw while still open 11. Create a sufficient opening in the pleura for the chest tube 12. Place finger inside whole of pleura and move finger 360 degrees to confirm correct location and assure no impediment and adhesions 13. Clamp distal end of the chest tube (proximal optional) 14. Connect to an underwater seal collection chamber Journal of Surgical Education Volume 70/Number 3 May/June 2013
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may need to be specific to the intervention, rather than being specific to the procedure tested. Medical education should derive its techniques from an accepted, research-based theory of learning.19 Such derivations have been slow to arrive to medical simulation. This study is the first to evaluate the pretest knowledge and relative improvement on individual steps of chest tube insertion, both among novices and experts. This information provides the initial step towards applying adaptive learning to medical simulation technology. Further inquiries will be necessary to ascertain how adaptive learning can integrate into simulation, procedural instruction, and just-in-time learning.
8. Barsuk JH, McGaghie WC, Cohen ER, et al. Use of
simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4:397-403. 9. Solomon B, Bizekis C, Dellis SL, et al. Simulating
video-assisted thoracoscopic lobectomy: a virtual reality cognitive task simulation. J Thorac Cardiovasc Surg. 2011;141:249-255. 10. Walsh CM, Sherlock ME, Ling SC, Carnahan H.
Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy. Cochrane Database Syst Rev. 2012;6:CD008237. 11. Davis JS, Garcia GD, Wyckoff MM, et al. Use of
APPENDIX 1 CHECKLIST FOR CHEST TUBE INSERTION
mobile learning module improves skills in chest tube insertion. J Surg Res. 2012;177:21-26. 12. Schulman CI, Garcia GD, Wyckoff MM, et al.
TABLE A1.
Mobile learning module improves knowledge of medical shock for forward surgical team members. Mil Med. 2012;177(11):1316-1321.
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