Evidence Based Approach to Teaching Obstetric Anesthesia

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