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Female physicians often report lower self-confidence in their procedural and clinical competency compared to male physicians. There is limited data regarding self-reported confidence of female versus male trainees and any relation to objective competency in central venous catheter insertion. To analyze differences between male and female trainees in self-confidence and skill-based outcomes in placing central venous catheters. Using data from a central venous catheter simulation training program at a large tertiary medical center, we performed linear regressions to analyze confidence difference pre- and post-training, number of restarts, and number of cannulation attempts while controlling for baseline demographic characteristics of the sample. PGY-1 physician residents in all residency specialties who insert central venous catheters in the clinical setting at a tertiary academic center with a sample size of 281 residents. Confidence difference pre- and post-training measured on a Likert scale 1-5, number of restarts (novel global assessment variable), and number of cannulation attempts during the competency evaluation. Female trainees had both lower pre-program confidence (1.35 versus 1.74 out of 5, p < 0.001) and lower post-program confidence (3.77 versus 4.12 out of 5, p = 0.0021) as compared to male trainees. There was no statistically significant difference in number of restarts (95% CI - 0.073 to 0.368, p = 0.185) or cannulation attempts (95% CI - 0.039 to 0.342, p = 0.117) between sexes in linear regressions controlled for age, specialty designation, prior central venous catheter training, prior ultrasound guided vessel cannulation training, and pre-training confidence level. Female trainees rated their confidence significantly lower than their male counterparts both before and after the training program, despite no significant difference in skill-based outcomes. We discuss potential implications for trainees acquiring procedural skills during residency and for physician educators as they design training programs and delegate procedural opportunities.

The benefits of fetoscopic laser photocoagulation (FLP) for treatment of twin-to-twin transfusion syndrome (TTTS) have been recognized for over a decade, yet access to FLP remains limited in many settings. This means at a population level, the potential benefits of FLP for TTTS are far from being fully realized. In part, this is because there are many centers where the case volume is relatively low. This creates an inevitable tension; on one hand, wanting FLP to be readily accessible to all women who may need it, yet on the other, needing to ensure that a high degree of procedural competence is maintained. Some of the solutions to these apparently competing priorities may be found in novel training solutions to achieve, and maintain, procedural proficiency, and with the increased utilization of ‘competence based’ assessment and credentialing frameworks. We suggest an under-utilized approach is the development of collaborative surgical services, where pooling of personnel and resources can improve timely access to surgery, improve standardized assessment and management of TTTS, minimize the impact of the surgical learning curve, and facilitate audit, education, and research. When deciding which centers should offer laser for TTTS and how we decide, we propose some solutions from a collaborative model.

Objectives: Pediatric emergency medicine (PEM) physicians receive little opportunity to practice and perform chest tube insertion. We sought to develop and validate a scoring tool to assess chest tube insertion competency and identify areas where training is required for PEM physicians. Methods: We developed a 40-point, 20-item (scored 0, 1, or 2) assessment tool entitled the Tool for Assessing Chest Tube Insertion Competency (TACTIC) and studied how PEM physicians and fellows scored when inserting a chest tube into a pork rib model. Participants were scored at baseline and compared to themselves after receiving targeted training using Web-based animations and presentations followed by expert instruction and practice on chest tube insertion task trainers. All insertions were video recorded and reviewed by two blinded reviewers. Eight common videos were reviewed to assess interrater reliability. Results: The TACTIC demonstrated good interrater reliability with an r 2 =0.86. Our cohort demonstrated a significant improvement in TACTIC scores by taking part in targeted training (precourse TACTIC=65%, 95% CI 54–76 v. postcourse TACTIC=84%, 95% CI 80–88), highlighting the construct validity of the TACTIC. Individual participants increased their TACTIC scores by an average of 17%. Conclusions: The TACTIC demonstrates good interrater reliability, content validity, and construct validity in assessing a PEM practitioner’s skill inserting chest tubes in a simulated setting. Objectifs: Les médecins en médecine d’urgence pédiatrique (MUP) ne procèdent pas souvent à la pose de drains thoraciques. Aussi avons-nous cherché à élaborer et à valider un instrument de notation visant à évaluer la compétence relative à la pose de drains thoraciques, et à cerner les points faibles qui nécessiteraient une formation chez les médecins en MUP. Méthode: Nous avons élaboré un instrument d’évaluation portant sur 20 tâches et noté sur 40 points (0, 1, 2), appelé Tool for Assessing Chest Drain Insertion Competency (TACTIC), et avons étudié les résultats de médecins et de stagiaires en MUP relativement à la pose de drains thoraciques dans un modèle porcin de gril thoracique. Les participants ont été évalués au départ, puis comparés à euxmêmes après une formation ciblée, comportant des animations et des pré sentations sur le Web, un enseignement thé orique donné par des spé cialistes et la pratique de la pose de drains thoraciques sur des simulateurs passifs («task trainers»). Toutes les poses de drain ont été enregistrées sur vidéo, puis examinées par deux examinateurs tenus dans l’ignorance des faits. Huit vidéos courantes ont été revues aux fins d’évaluation de la fiabilité interévaluateurs. Résultats: L’instrument TACTIC a obtenu de bons résultats au regard de la fiabilité interé valuateurs: ρ 2=0.86. De son côté , la cohorte a connu une amélioration sensible des résultats, selon la grille TACTIC (avant le cours: 65%; IC à 95%: 54–76; après le cours: 84%, IC à 95%: 80–88), après avoir suivi une formation ciblée, ce qui confirme la validité de construction de l’instrument TACTIC. La note de chacun des participants, selon la grille TACTIC, a augmenté en moyenne de 17%. Conclusions: Les résultats de l’étude ont démontré que l’instrument TACTIC possé dait une bonne fiabilité interévaluateurs, une validité de contenu et une validité de construction, dans l’évaluation de la compétence de praticiens en MUP, relative à la pose de drains thoraciques, en simulation.

The overall prevalence of chronic kidney disease in the general population is ∼14% with more than 661,000 Americans having a kidney failure. Ultrasound (US)-guided renal biopsy is a critically important tool in the evaluation and management of renal pathologies. This Letter presents KBVTrainer, a virtual simulator that the authors developed to train clinicians to improve procedural skill competence in US-guided renal biopsy. The simulator was built using low-cost hardware components and open source software libraries. They conducted a face validation study with five experts who were either adult/pediatric nephrologists or interventional/diagnostic radiologists. The trainer was rated very highly (>4.4) for the usefulness of the real US images (highest at 4.8), potential usefulness of the trainer in training for needle visualization, tracking, steadiness and hand-eye coordination, and overall promise of the trainer to be useful for training US-guided needle biopsies. The lowest score of 2.4 was received for the look and feel of the US probe and needle compared to clinical practice. The force feedback received a moderate score of 3.0. The clinical experts provided abundant verbal and written subjective feedback and were highly enthusiastic about using the trainer as a valuable tool for future trainees.

Innovation is now a feature of daily life. In a rapidly changing market environment and amid fierce competition, organizations pursue survival and growth through innovation, and the key driver of innovation is the creativity of employees. Because the value of creativity has been emphasized, many organizations are looking for effective ways to encourage employees to be creative at work. From a resource perspective, creativity at work can be viewed as a high-intensity job demand, and organizations should encourage it by providing and managing employee resources. This study is an attempt to empirically investigate how competence and abusive supervision affect the relationship between procedural justice and creativity from the conservation of resources perspective. Findings from two-wave time-lagged survey data from 377 South Korean employees indicate that procedural justice increases creativity through the mediation of competence. Furthermore, abusive supervision has a negative moderating effect on the relationship between procedural justice and competence. The findings show that competence moderates the relationship between procedural justice and creativity and that the lower the level of abusive supervision, the greater the effect of procedural justice on competence and creativity.

BackgroundEmergency medicine (EM) training programmes are being conducted around the world but no study has assessed the procedural competence of developing nations' EM trainees.ObjectivesTo quantify the number of core procedures and resuscitations performed and describe the perceived procedural competency of graduates of Africa's first EM registrarship at the University of Cape Town/Stellenbosch University (UCT/SUN) in Cape Town, South Africa.MethodsAll 30 graduates from the first four classes in the UCT/SUN EM programme (2007–10) were asked to complete a written, self-administered survey on the number of procedures needed for competency, the number of procedures performed during registrarship and the perceived competence in each procedure ranked on a five-point Likert scale. The procedures selected were the 10 core procedures and four types of resuscitations as defined by the US-based Residency Review Committee. Results were compiled and analysed using descriptive statistics.ResultsTwenty-seven (90%) completed surveys. For most core procedures and all resuscitations, the number of procedures reported by respondents far exceeded the Residency Review Committee minimum. The three procedures not meeting the minimum were internal cardiac pacing, cricothyrotomy and periocardiocentesis. Respondents reported perceived competence in most procedures and all resuscitations.ConclusionsEM trainees in a South Africa registrarship report a high number of procedures performed for most procedures and all resuscitations. As medical education moves to the era of direct observation and other methods of assessment, more studies are needed to define and ensure procedural competence in trainees of nascent EM programmes.

Procedural skills have historically been taught at the bedside. In this study, we aimed to increase resident knowledge of uncommon emergency medical procedures to increase residents' procedural skills in common and uncommon emergency medical procedures and to integrate cognitive training with hands-on procedural instruction using high- and low-fidelity simulation. We developed 13 anatomically/physiologically-based procedure modules focusing on uncommon clinical procedures and/or those requiring higher levels of technical skills. A departmental expert directed each session with collaboration from colleagues in related subspecialties. Sessions were developed based on Manthey and Fitch's stages of procedural competency including 1) knowledge acquisition, 2) experience/technical skill development, and 3) competency evaluation. We then distributed a brief, 10-question, online survey to our residents in order to solicit feedback regarding their perceptions of increased knowledge and ability in uncommon and common emergency medical procedures, and their perception of the effectiveness of integrated cognitive training with hands-on instruction through high- and low-fidelity simulation. Fifty percent of our residents (11/22) responded to our survey. Responses indicated the procedure series helped with understanding of both uncommon (65% strongly agreed [SA], 35% agreed [A]) and common (55% SA, 45% A) emergency medicine procedures and increased residents' ability to perform uncommon (55% SA, 45% A) and common (45% SA, 55% A) emergency medical procedures. In addition, survey results indicated that the residents were able to reach their goal numbers. Based on survey results, the procedure series improved our residents' perceived understanding of and perceived ability to perform uncommon and more technically challenging procedures. Further, results suggest that the use of a cognitive curriculum model as developed by Manthey and Fitch is adaptable and could be modified to fit the needs of other medical specialties.

A review of the research literature reveals that there is no generally agreed upon definition of treatment failure. Historically, many of the types of problems and difficulties that have been associated with treatment failure or drop out have been understood with reference to the concept of “resistance”. A contemporary Cognitive Behavioural Therapy (CBT) view on the nature of therapeutic resistance strongly support a view of these phenomena as “understandable”, “adaptive” and as “making sense” from the perspective of the client at some level. The procedural competence of being able to employ CBT theory to devise tentative hypotheses or formulations of what might be maintaining the resistance is an important aspect of developing appropriate flexibility and artistry as a CBT therapist. Difficulties with resistance and therapy interfering behaviours often escalate to the point that a rupture in the working alliance occurs.

Rendaku is a well-documented phenomenon in Japanese phonology in which a word-initial voiceless obstruent becomes voiced when it is the second member of a compound (e.g., ori + kami → origami ‘paper folding’). It was hypothesized that Japanese specifically language-impaired (SLI) children who appear to rely on explicit declarative memory as opposed to implicit procedural memory to learn language would have difficulty forming such compounds: word-initial voiceless obstruents would remain unvoiced in the second members of non-frequent and novel compounds. Six Japanese SLI children, ranging in age from 8;9 to 12;1, 6 age-matched non-SLI children and 4 younger non-SLI children were given a word formation task involving three different categories of compounds. A significant difference in performance between the groups was found. The data indicate that the SLI children did not in fact voice most of the initial obstruents of the second member in non-frequent and novel compounds, whereas the age-matched non-SLI children did voice the appropriate obstruents of all the compounds and the younger non-SLI children voiced some initial obstruents of all the compounds. Qualitative differences in the responses provide evidence that the SLI children did not have or were unable to construct a productive procedural rule of voicing.

In the advent of concerns for patient safety, simulation training is emerging as a method to train healthcare providers to perform invasive procedures such as central venous catheter (CVC) insertion while minimising harmful complications to the patient. New technologies in medical simulation have begun to shift research attention to the performance component of clinical competency. Accurate assessment of healthcare provider competence is a major priority in medical education necessitating the development of valid and reliable assessment tools. In the past year alone, nine evaluative tools, both global rating scales and procedural checklists, have been published in the research literature to evaluate the insertion of CVCs. A review of the advantages of published evaluation tools helps inform users with regard to the critical components necessary for a checklist. Ease of use, ability to be completed by a non-expert, categorical breakdown of critical actions involved in CVC insertion and the need for a comprehensive stepwise procedural checklist are discussed. The development of an ideal checklist may improve future competency-based training and performance evaluation in the clinical setting. A more thorough understanding of the status of checklists as evaluation tools in assessing performance of invasive procedures will lead to better training protocols and ultimately to improved patient safety.