evidence based approach to teaching obstetric anesthesia
TRANSCRIPT
R O B E R T G A I S E R , M . D . , M . S . E D .P R O F E S S O R O F A N E S T H E S I O L O G Y A N D
C R I T I C A L C A R EH O S P I T A L O F T H E U N I V E R S I T Y O F
P E N N S Y L V A N I A
Evidence Based Approach to Teaching Obstetric Anaesthesia
No financial disclosureNo off-label use
Goals
Develop a framework for the teaching of obstetric anaesthesia
Understand the evidence behind teaching procedures
Incorporate assessment into measurement of knowledge
Appreciate and incorporate the psychology of education
Penguins
King Macaroni
Adelie Rockhopper
What type of penguin?
Three Main Learning Theories
Behaviorist Learning has only taken place if a change in behavior is
observed Not concerned with internal processes, rather external
exhibitions
Cognitivist A semi-permanent change in mental processes or associations No outward exhibition but rather internal processes
Constructivist People create their own meaning through experience Students discover the main ideas and then derive the details
Basic Principles of Learning
Student’s prior knowledge may help or hinder learning
How students organize knowledge influences how they learn and apply what they know
Students’ motivation determines, directs, and sustains what they do learn
Ultimate Goal of Teaching
To become self-directed learners, students must learn to monitor and adjust their approaches to learning
What is Obstetric Anaesthesia?
Knowledge and Procedures Applied to the Parturient that demonstrates: Judgment Adaptability Communication Professionalism Practice-based learning Systems-based practice
Domain of Knowledge for Obstetric Anesthesia
A. Maternal Physiology B. Maternal-Fetal
Considerations C. Pathophysiology of
Complicated Pregnancy Problems During Pregnancy
and Delivery Problems of Pregnancy and
Delivery Resuscitation of Newborn
A multigravid woman is receiving oxytocin by infusion for augmentation of labor. Fetal heart rate is 190 bpm with beat-to-beat variability of 6 to 8 bpm. What is the MOST appropriate immediate action? A. Continue observation B. Sample fetal scalp blood C. Discontinue oxytocin D. Deliver the fetus
Content Outline: II.D.3.b.3
What is Best Means for Teaching
One hour lecture every three days (3, 6, and 9)
One hour lecture on day 1, 3, and 9
Test administered on day 9 and on day 10
Who performed better on day 9 and day 10?
Which method of learning was preferred?
Learners prefer a set schedule but learn better with an expanding schedule
Knowledge is best retained when presented in expanding schedule
Vlach HA. J Exp Child Psychol 2014;123:129-37
Errors Enhance Learning
Children learning a foreign language Failed test with immediate
feedback Failed test with delayed
feedback Presentation only
Failed test activates the semantic network enhancing mapping to the correct response with immediate feedback
Hays MJ. J Exp Psychol: Learning, Memory & Cognitition 2013;39:290-6
Spacing Improves Learning
Four hours of studying at one time versus four one-hour periods over four days
Immediate testing –cramming worked
Testing in one week –spacing worked
Learners preferred cramming
Kornell N. Psychology & Aging 2010;25:498-503
What type of penguin?
How is Knowledge Conveyed?
Lectures Textbooks Web-Based Flipped Classroom
Web-Based Learning
Universal acceptance Ease in updating content Hyperlink allows ease in
cross-referencing
Systematic Analysis 20 studies identified Web-based programs
were not better than traditional educational methods
Chumley-Jones HS. Academ Med 2002;77:S86
Web-Based Learning
1990-2008 Identified 20 studies No difference in time
between internet and traditional methods
Knowledge based upon scores correlated with amount of time spent on topic
Correlated time with performance on the ITE
Correlation coefficient 0.64
Minimal amount of time to pass exam 10.5 hours
Cook DA. Adv in Health Sci Educ 2010;15:755 Phillip J. J Clin Anesth 2006;18:471
When is Web-Based Learning Important
372 providers 231 traditional teaching 141 web-based learning
Asked to estimate blood loss Accuracy pre-learning -
4% Accuracy post-learning -
34% No difference between
web-based and traditional learning
Global implications
Toledo P. Am J Obstet Gynecol 2010;202:400
Technique: Epidural
11 CA-I residents Success defined as no
assistance from faculty member
Epidural Most difficult task 80% success rate after 90
attempts 60% success rate after 20
attempts
Konrad C. Anesth Analg 1998;86:635
Technique: Spinal
22 CA-I residents Success defined as no
assistance from faculty Spinal To reach a success rate of
90%, 71 attempts were required
Konrad C. Anesth Analg 1998;86:635
Technique: Obstetric Analgesia
Competence – ability of individual to a job properly
Success: quality of analgesia throughout labor was good
81 trainees studied: Mean success rate for
trainees: 76.8% Required 46 attempts to
achieve success RRC minimal - 40
Mean success rate for first 100 obstetric epidurals
Drake EJ. BJA 2015;1-7
Technique: More than Finding Space
35 videos of residents performing epidural analgesia for labor
Good inter-rater reliability
Technical skills improved over time (r=0.7)
Aseptic technique did not change with time despite teaching (no formal training) (r=0.23)
Friedman Z. Anesthesiology 2008;108:914.
Simulation and Technique
24 residents recruited Randomized to high
fidelity simulator and to low fidelity simulator
No difference noted between two groups
Both groups received similar didactics
No difference in global rating scale
Friedman Z. Reg Anesth Pain Med 2009;34:229
Methods to Improve Teaching Techniques
Use of epidural insertion simulator Manniken
Unable to adapt to changing patient
Haptic device with 3-D graphic model simulation Fixed needle insertion site
Vaughan N. Med Engineering and Physics 2013;35:1235.
Ultrasound Improves Learning Curve
Two groups of five residents randomized to epidural insertion traditional way or with ultrasound visualization first
Success defined as VAS < 1 Ultrasound Group 86% success after 10
attempts; 94% success by 60 attempts
Traditional Group 60% success after 10
attempts; 84% success by 60 attempts
Grau T. Can J Anesth 2003;50:1047
Judgment
Fundamental Attribution Error
Tendency to attribute the causes of other people’s behavior to their intrinsic nature
Tendency to over attribute one’s own behavior to external circumstances
Wason’s Confirmation Bias
Tendency to seek out evidence that supports our existing beliefs
We seek out and pay particular attention to information that supports our existing beliefs
Simulation: Teaching
10 teams participated in high-fidelity simulation
Simulation: epidural-induced hypotension and amniotic fluid embolism
Review of videotapes: Poor communication Not assuming a leadership
role Poor distribution of the
workload
Daniels K. Sim Healthcare 2008;3:154
Communication in OR
Obstetricians and Anesthesiologists in simulated high spinal, difficult airway, cardiopulmonary arrest
Obstetricians Advocated 73% of times Inquired 59% of times
Anesthesiologists Advocated 100% Inquired 11% of times
Minehart RD. Sim Healthcare 2012;7:166
Simulation
Development of simulation Labor intensive Expensive Requires organization of personnel
Pratt SD. Anesth Analg 2012;114:186
Negativity Bias
Negativity bias - humans are more attentive to and are more influenced by the negative aspects of their environment than by the positive
Anticipation of a negative interaction can change one’s behavior
Negative reinforcement, as opposed to comparable positive reinforcement, leads to faster learning that is more resistant to extinction
The culture of academic medicine has evolved to its current state because many aspects of the negativity bias enhance our culture
Haizlip J. Acad Med 2012;87:1205
The Hidden Curriculum
Informal, not taught, but present “Given the chance to observe and practice in situ the
behavior of members of a culture, people pick up relevant jargon, imitate behavior, and gradually start to act in accordance”
Jha V. Medical Education 2007;41:822.
Situational Learning
Learning is a function of the activity, culture, and context in which it occurs
Social interaction is critical Learners become involved in a community of
practice which embodies beliefs and behaviors to be acquired
Unintentional
Studies of Hidden Curriculum
128 hours of interaction in operating room observed Dominant themes: time, safety, sterility, resources,
and roles Generated tension Resident mimics tension generating response
Lingard L. Academ Med 2002;77:232
Assessment
Scoring system to evaluate resident performance during general anesthesia for cesarean delivery
8 CA-III and 8 CA-I residents
Good inter-rater reliability
CA-III – 150; CA-I - 128
Scavone BM. Anesthesiology 2006;105:260
Teaching Obstetric Anaesthesia:Backward by Design
Set your goals Decide upon your
assessment Design your curriculum
Summary
Knowledge – mainly depends upon time invested
Technical – may be taught on job or with simulator Requires a lot of encounters Research a means to reduce
this number
Judgment – depends upon experience and outcomes Impact of simulation on
judgment is unknown