Faculty Bibliography

BACKGROUND/UNASSIGNED:Although technology is rapidly advancing in immersive virtual reality (VR) simulation, there is a paucity of literature to guide its implementation into health professions education, and there are no described best practices for the development of this evolving technology. OBJECTIVE/UNASSIGNED:We conducted a qualitative study using semistructured interviews with early adopters of immersive VR simulation technology to investigate use and motivations behind using this technology in educational practice, and to identify the educational needs that this technology can address. METHODS/UNASSIGNED:We conducted 16 interviews with VR early adopters. Data were analyzed via directed content analysis through the lens of the Unified Theory of Acceptance and Use of Technology. RESULTS/UNASSIGNED:The main themes that emerged included focus on cognitive skills, access to education, resource investment, and balancing immersion. These findings help to clarify the intended role of VR simulation in health professions education. Based on our data, we synthesized a set of research questions that may help define best practices for future VR development and implementation. CONCLUSIONS/UNASSIGNED:Immersive VR simulation technology primarily serves to teach cognitive skills, expand access to educational experiences, act as a collaborative repository of widely relevant and diverse simulation scenarios, and foster learning through deep immersion. By applying the Unified Theory of Acceptance and Use of Technology theoretical framework to the context of VR simulation, we not only collected validation evidence for this established theory, but also proposed several modifications to better explain use behavior in this specific setting.

BACKGROUND:Although technology is rapidly advancing in immersive virtual reality (VR) simulation, there is a paucity of literature to guide its implementation into health professions education, and there are no described best practices for the development of this evolving technology. OBJECTIVE:We conducted a qualitative study using semi-structured interviews with early adopters of immersive VR simulation technology to investigate utilization and motivations behind employing this technology in educational practice, and to identify the educational needs that this technology can address. METHODS:We conducted 16 interviews with VR early adopters. Data were analyzed via Directed Content Analysis through the lens of the Unified Theory of Acceptance and Use of Technology (UTAUT). RESULTS:The main themes that emerged included Focus on Cognitive Skills, Access to Education, Resource Investment, and Balancing Immersion. These findings help to clarify the intended role of VR simulation in health professions education. Based on our data, we synthesize a set of research questions that may help define best practices for future VR development and implementation. CONCLUSIONS:Immersive VR simulation technology primarily serves to teach cognitive skills, to expand access to educational experiences, to act as a collaborative repository of widely relevant and diverse simulation scenarios, and to foster learning through deep immersion. By applying the UTAUT theoretical framework to the context of VR simulation, we not only collected validation evidence for this established theory, but also proposed several modifications to better explain use behavior in this specific setting.

Despite a rapidly evolving role for advanced therapeutic interventions, the majority of patients with high-risk pulmonary embolism (PE) are still undertreated. Due to complex diagnosis and management, along with a high associated mortality rate, high-risk PE offers an excellent opportunity for simulation training. We present a simulated case of high-risk PE in a post-operative patient that is designed to teach key principles of diagnosis and management. The script is widely adaptable to many institutions and customisable to diverse learner populations.

BACKGROUND/UNASSIGNED:Advanced critical care echocardiography comprises a specific set of qualitative and quantitative point-of-care echocardiography skills, including a reliable, noninvasive method to measure cardiac output. This technique requires echocardiographic measurement of left ventricular outflow tract (LVOT) diameter and LVOT velocity time integral (VTI). Although there is a demand among critical care fellows to learn these advanced techniques, there are no data describing the acquisition of mastery in these skills. OBJECTIVE/UNASSIGNED:This pilot study aims to describe the accuracy of echocardiographic measurement of LVOT diameter and LVOT VTI obtained by critical care fellows after an educational intervention, as well as to enhance validation evidence for an image scoring assessment that is applicable to these measurements. METHODS/UNASSIGNED:We implemented a brief mastery learning intervention to teach the measurement of LVOT diameter and VTI. Fellow measurements of these parameters, along with the corresponding echocardiographic images, were compared with a gold standard of measurements obtained by professional echocardiography technicians and interpreted by cardiologists. RESULTS/UNASSIGNED: = 0.004), with a mean percent difference of 8.05 ± 7.0%. The sensitivity for fellows to detect an abnormal LVOT VTI was 91%, with a specificity of 43%. CONCLUSION/UNASSIGNED:Critical care fellow measurement of LVOT VTI and LVOT diameter demonstrated strong and moderate positive correlations with cardiologist-reported values, respectively, with acceptable clinical agreement. However, interrater reliability and percent differences showed room for improvement. Education in these advanced skills is resource intensive, and additional research is needed to determine the most effective approach to training fellows.

Traditionally measured with invasive methods or specialized equipment, stroke volume and cardiac output can be determined reliably with transthoracic echocardiography. This video guides the viewer in a step-by-step fashion through the technical aspects of Doppler echocardiographic assessment of cardiac output.

PURPOSE:Evaluation of the medical profession at all levels has exposed episodes of gender-based role misidentification whereby women physicians are disproportionately misidentified as nonphysicians. The authors of this study investigate this phenomenon and its repercussions, quantifying the frequency with which resident physicians experience role misidentification and the effect this has on their experience and behavior. METHOD:In 2018, the authors conducted a cross-sectional survey study of internal medicine, surgical, and emergency medicine residents at a single, large, urban, tertiary academic medical center. The survey tool captured both the self-reported frequency and effect of professional misidentification. The authors used a t test and linear multivariate regression to analyze the results. RESULTS:Of the 260 residents who received the survey, 186 (72%) responded, and the authors analyzed the responses of 182. All 85 of the women respondents (100%) reported being misidentified as nonphysicians at least once in their professional experience by patients or staff members, compared with 49% of the 97 men respondents. Of those 182 residents, 35% of women were misidentified more than 8 times per month by patients compared with 1% of men. Of the 85 women physicians responding to the survey, 38% felt angry and 36% felt less satisfied with their jobs as a result of misidentification compared with, respectively, 7% and 9% of men. In response to role misidentification, 51% of women changed their manner of attire and 81% changed their manner of introduction, compared with, respectively, 7% and 37% of men. CONCLUSIONS:These survey results demonstrate that women physicians are more likely than men physicians to be misidentified as nonphysicians and that role misidentification provokes gender-polarized psychological and behavioral responses that have potentially important professional ramifications.

OBJECT/OBJECTIVE:Traumatic head injury (THI) is a highly prevalent condition in the United States, and concern regarding excess radiation-related cancer mortality has placed focus on limiting the use of CT in the evaluation of pediatric patients with THI. Given the success of rapid-acquisition MRI in the evaluation of ventriculoperitoneal shunt malfunction in pediatric patient populations, this study sought to evaluate the sensitivity of MRI in the setting of acute THI. METHODS:Medical records of 574 pediatric admissions for THI to a Level 1 trauma center over a 10-year period were retrospectively reviewed to identify patients who underwent both CT and MRI examinations of the head within a 5-day period. Thirty-five patients were found, and diagnostic images were available for 30 patients. De-identified images were reviewed by a neuroradiologist for presence of any injury, intracranial hemorrhage, diffuse axonal injury (DAI), and skull fracture. Radiology reports were used to calculate interrater reliability scores. Baseline demographics and concordance analysis was performed with Stata version 13. RESULTS:The mean age of the 30-patient cohort was 8.5 ± 6.7 years, and 63.3% were male. The mean Injury Severity Score was 13.7 ± 9.2, and the mean Glasgow Coma Scale score was 9 ± 5.7. Radiology reports noted 150 abnormal findings. CT scanning missed findings in 12 patients; the missed findings included DAI (n = 5), subarachnoid hemorrhage (n = 6), small subdural hematomas (n = 6), cerebral contusions (n = 3), and an encephalocele. The CT scan was negative in 3 patients whose subsequent MRI revealed findings. MRI missed findings in 13 patients; missed findings included skull fracture (n = 5), small subdural hematomas (n = 4), cerebral contusions (n = 3), subarachnoid hemorrhage (n = 3), and DAI (n = 1). MRI was negative in 1 patient whose preceding CT scan was read as positive for injury. Although MRI more frequently reported intracranial findings than CT scanning, there was no statistically significant difference between CT and MRI in the detection of any intracranial injury (p = 0.63), DAI (p = 0.22), or intracranial hemorrhage (p = 0.25). CT scanning tended to more frequently identify skull fractures than MRI (p = 0.06). CONCLUSIONS:MRI may be as sensitive as CT scanning in the detection of THI, DAI, and intracranial hemorrhage, but missed skull fractures in 5 of 13 patients. MRI may be a useful alternative to CT scanning in select stable patients with mild THI who warrant neuroimaging by clinical decision rules.

Vertebral artery (VA) occlusion is a serious and potentially life-threatening occurrence. Bow hunter's syndrome, a mechanical occlusion of the VA due to physiological head rotation, has been well described in the medical literature. However, mechanical VA compression due to routine flexion or extension of the neck has not been previously reported. The authors present the unique case of a woman without any history of trauma who had multiple posterior fossa strokes and was found to have dynamic occlusion of her right VA visualized via cerebral angiogram upon extension of her neck. This occlusion was attributed to instability at the occipitocervical junction in a patient with a previously unknown congenital fusion of both the occiput to C-1 and C-2 to C-3. An occiput to C-3 fusion was performed to stabilize her cervical spine and minimize the dynamic vascular compression. A postoperative angiogram showed no evidence of restricted flow with flexion or extension of the neck. This case emphasizes the importance of considering symptoms of vertebrobasilar insufficiency as a result of physiological head movement. The authors also review the literature on VA compression resulting from physiological head movement as well as strategies for clinical diagnosis and treatment.