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Anesthesiology became the first Chilean medical specialty certification board to incorporate an objective structured clinical examination (OSCE) into its certification system. The main reason for the introduction of an OSCE is to include an evaluation that allow candidates to demonstrate what they really "do" in clinical practice domains. Inherent in this justification is that the OSCE detects competences that are not well evaluated in current written and oral exams. This article describes the process of implementing an OSCE in Anesthesiology certification and a description of its application after one year of operation.

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Anesthesiology became the first Chilean medical specialty certification board to incorporate an objective structured clinical examination (OSCE) into its certification system. The main reason for the introduction of an OSCE is to include an evaluation that allow candidates to demonstrate what they really "do" in clinical practice domains. Inherent in this justification is that the OSCE detects competences that are not well evaluated in current written and oral exams. This article describes the process of implementing an OSCE in Anesthesiology certification and a description of its application after one year of operation.

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Developing high levels of competence in the execution of surgical procedures through training is a key factor for obtaining good clinical results in healthcare. To improve the effectiveness of the training, it is advisable to provide feedback to each student tailored to how the student has performed the procedure on each occasion. Current state-of-the-art feedback is based on Checklists and Global Rating Scales, which indicate whether all process steps have been carried out and the quality of each execution step. However, there is a process perspective that is not captured successfully by these instruments, e.g., steps performed, but in an undesired order, group of activities that are repeated an unnecessary number of times, or an excessive transition time between two consecutive steps. In this research, we propose a novel use of process mining techniques to effectively identify desired and undesired process patterns regarding rework, the order in which activities are performed, and time performance, in order to complement the tailored feedback for surgical procedures using a process perspective. The proposed approach was applied to analyze a real case of ultrasound-guided Central Venous Catheter placement training. It was quantitatively and qualitatively validated that the students who participated in the training program perceived the process-oriented feedback they received as favorable for their learning.

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PURPOSE: Safe perioperative care remains a large public healthcare problem in low- and middle-income countries. Anesthesia care provided by trained professionals is one of the essential determinants to address this situation. This article reports the design and implementation of a focused anesthesia educational program for nurses in Chad. METHOD: This program consisted of four full-time courses of one month each, taught in a local hospital. The program included supervised practice in the operating room and post-anesthesia recovery room, skills lab simulation training, high fidelity crisis simulation, theoretical classes, integration sessions, evaluations, and structured feedback sessions. RESULTS: Seven male nurses, aged 28-40 yr, were accepted and successfully completed the program. The median [interquartile range] students' global satisfaction with the program was high (86 [85-93]%). Cognitive and skills assessment improved significantly after the program. Students subsequently worked in city and district hospitals performing essential and emergency surgical interventions. CONCLUSIONS: This is a novel south-south academic cooperation program for nurses in Chad. The program evaluation indicated a high level of satisfaction, effective cognitive and skills learning, and changes in clinical behaviour. Addressing the lack of adequate provision of anesthesia care is a task still to be faced, and this program depicts a bridge alternative until formal educational programs are implemented in the country.

RéSUMé: OBJECTIF: Des soins périopératoires sécuritaires demeurent un important problème de santé publique dans les pays à faible et à moyen revenu. Les soins anesthésiques offerts par des professionnels formés constituent l'un des éléments déterminants essentiels pour régler le problème. Cet article rapporte la conception et la mise en œuvre d'un programme spécialisé de formation en anesthésie s'adressant au personnel infirmier au Tchad. MéTHODE: Ce programme était composé de quatre cours intensifs d'une durée d'un mois chacun, donnés dans un hôpital local. Le programme comportait une pratique supervisée en salle d'opération et en salle de réveil, des séances pratiques en laboratoire de simulation, une simulation de crise haute fidélité, des classes théoriques, des séances d'intégration, des évaluations et des séances de rétroaction structurées. RéSULTATS: Sept infirmiers âgés de 28 à 40 ans ont été acceptés dans le programme et l'ont terminé avec succès. La satisfaction globale moyenne [écart interquartile] des étudiants était élevée (86 [85­93] %). L'évaluation cognitive et des connaissances s'est considérablement améliorée après avoir suivi le programme. Les étudiants ont par la suite travaillé dans des hôpitaux de ville et de district réalisant des interventions chirurgicales essentielles et urgentes. CONCLUSION: Il s'agit d'un programme de coopération universitaire sud-sud innovant au Tchad. L'évaluation du programme a indiqué un niveau élevé de satisfaction, un apprentissage efficace au niveau cognitif et des compétences, ainsi que des changements au niveau du comportement clinique. Il reste encore beaucoup de travail pour régler le problème suscité par l'absence d'une offre adéquate de soins anesthésiques, et ce programme décrit une alternative temporaire intéressante jusqu'à ce que des programmes de formation formels soient mis en œuvre dans ce pays.

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Abstract Introduction: The primary purpose of this study was to compare the effect of high fidelity simulation versus a computer-based case solving self-study, in skills acquisition about malignant hyperthermia on first year anesthesiology residents. Methods: After institutional ethical committee approval, 31 first year anesthesiology residents were enrolled in this prospective randomized single-blinded study. Participants were randomized to either a High Fidelity Simulation Scenario or a computer-based Case Study about malignant hyperthermia. After the intervention, all subjects' performance in was assessed through a high fidelity simulation scenario using a previously validated assessment rubric. Additionally, knowledge tests and a satisfaction survey were applied. Finally, a semi-structured interview was done to assess self-perception of reasoning process and decision-making. Results: 28 first year residents finished successfully the study. Resident's management skill scores were globally higher in High Fidelity Simulation versus Case Study, however they were significant in 4 of the 8 performance rubric elements: recognize signs and symptoms (p = 0.025), prioritization of initial actions of management (p = 0.003), recognize complications (p = 0.025) and communication (p = 0.025). Average scores from pre- and post-test knowledge questionnaires improved from 74% to 85% in the High Fidelity Simulation group, and decreased from 78% to 75% in the Case Study group (p = 0.032). Regarding the qualitative analysis, there was no difference in factors influencing the student's process of reasoning and decision-making with both teaching strategies. Conclusion: Simulation-based training with a malignant hyperthermia high-fidelity scenario was superior to computer-based case study, improving knowledge and skills in malignant hyperthermia crisis management, with a very good satisfaction level in anesthesia residents.

Resumo Introdução: O objetivo primário deste estudo foi comparar o efeito da simulação de alta-fidelidade versus autoestudo baseado em resolução de casos no computador, a aquisição de habilidades sobre hipertermia maligna em residentes de anestesiologia do primeiro ano. Métodos: Após a aprovação do Comitê de Ética institucional, 31 residentes de anestesiologia do primeiro ano foram inscritos neste estudo prospectivo, randômico e encoberto. Os participantes foram randomizados para um ambiente de simulação de alta-fidelidade (SAF) ou um estudo de caso (EC) em computador sobre hipertermia maligna. Após a intervenção, o desempenho de todos os indivíduos foi avaliado através de um ambiente de simulação de alta-fidelidade utilizando uma rubrica de avaliação previamente validada. Além disso, uma pesquisa de satisfação e testes de conhecimento foram aplicados. Por fim, uma entrevista semiestruturada foi realizada para avaliar a autopercepção do processo de raciocínio e da tomada de decisão. Resultados: Vinte e oito residentes do primeiro ano concluíram o estudo com sucesso. Os escores dos residentes na aquisição de habilidades no manejo da hipertermia maligna foram globalmente maiores no Grupo SAF que no Grupo EC, mas a significância foi em quatro dos oito elementos da rubrica de desempenho: reconhecer os sinais e sintomas (p = 0,025), priorizaras ações iniciais do manejo (p = 0,003), reconhecer complicações (p = 0,025) e comunicação (p = 0,025). As médias dos escores nos questionários de conhecimento pré- e pós-teste melhoraram de 74% para 85% no Grupo SAF e diminuíram de 78% para 75% no Grupo EC (p = 0,032). Em relação à análise qualitativa, não houve diferença nos fatores que influenciaram o processo de raciocínio e de tomada de decisão dos alunos com ambas as estratégias de ensino. Conclusão: O treinamento baseado em simulação com um ambiente de alta-fidelidade de hipertermia maligna foi superior ao estudo de caso em computador, melhorou o conhecimento e as habilidades no manejo de crises de hipertermia maligna, com um nível de satisfação muito bom entre os residentes de anestesia.

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INTRODUCTION: The primary purpose of this study was to compare the effect of high fidelity simulation versus a computer-based case solving self-study, in skills acquisition about malignant hyperthermia on first year anesthesiology residents. METHODS: After institutional ethical committee approval, 31 first year anesthesiology residents were enrolled in this prospective randomized single-blinded study. Participants were randomized to either a High Fidelity Simulation Scenario or a computer-based Case Study about malignant hyperthermia. After the intervention, all subjects' performance in was assessed through a high fidelity simulation scenario using a previously validated assessment rubric. Additionally, knowledge tests and a satisfaction survey were applied. Finally, a semi-structured interview was done to assess self-perception of reasoning process and decision-making. RESULTS: 28 first year residents finished successfully the study. Resident's management skill scores were globally higher in High Fidelity Simulation versus Case Study, however they were significant in 4 of the 8 performance rubric elements: recognize signs and symptoms (p = 0.025), prioritization of initial actions of management (p = 0.003), recognize complications (p = 0.025) and communication (p = 0.025). Average scores from pre- and post-test knowledge questionnaires improved from 74% to 85% in the High Fidelity Simulation group, and decreased from 78% to 75% in the Case Study group (p = 0.032). Regarding the qualitative analysis, there was no difference in factors influencing the student's process of reasoning and decision-making with both teaching strategies. CONCLUSION: Simulation-based training with a malignant hyperthermia high-fidelity scenario was superior to computer-based case study, improving knowledge and skills in malignant hyperthermia crisis management, with a very good satisfaction level in anesthesia residents.

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background: Appropriate sedation is crucial for a successful gastrointestinal endoscopy procedure (GEP); however, this is associated with adverse events, therefore adequate capacitation in this subject is mandatory. Simulation is an excellent teaching tool but its use in the setting of sedation teaching for GEP has not bee explored. The aim of this study was to assess the impact of a simulation course on sedation for GEP procedures done by endoscopist. Methods: A checklist to assess the endoscopists’ sedation performance for GEP was developed. This checklist was used to assess the sedations’ quality before and after a high fidelity sedation simulation course for GEP. Differences before/after the intervention was calculated using the McNemar’s test. A p ≤ 0,05 was considered significant. Results: All participants were assessed 15 times pre and post intervention. After the simulation, there was a significant improvement in patients’ airway assessment, in the level of awareness about patients’ condition during the procedure and in the monitoring after the procedure. All participants considered simulation should be compulsory before obtaining a license to sedate patients. Conclusions: The implementation of a sedation course based on simulation cases directed to endoscopists improved patient safety and sedations’ quality during the procedure. Simulation should be considered as a valid teaching tool, which is an enormous challenge to the anaesthesiologists.

Introducción: Una adecuada sedación contribuye al éxito de un procedimiento endoscópico gastrointestinal (PEG); sin embargo, esto puede estar asociado a eventos adversos, siendo importante la capacitación al respecto. La simulación es una excelente herramienta docente, pero su uso en la enseñanza de sedación para PEG no ha sido explorada. El objetivo de este estudio fue evaluar el impacto de un curso de sedación para PEG dirigido a endoscopistas basado en simulación. Materiales y Métodos: Se diseño una lista de cotejo para evaluar la calidad de la sedación impartida por endoscopistas durante PEG. Con dicho instrumento se determinó la calidad de la sedación antes y después de un curso de simulación de alta fidelidad sobre sedación para PEG. La magnitud de las diferencias secundario a la intervención se calcularon utilizando el test de McNemar. Una p ≤ 0,05 se consideró significativa. Resultados: Todos los participantes fueron evaluados 15 veces antes y después de la intervención. Después de la intervención, mejoró significativamente la evaluación de vía aérea, el nivel de alerta por las condiciones del paciente durante el procedimiento y el seguimiento posterior. Todos los participantes consideraron que la simulación debería ser obligatoria antes de obtener privilegios clínicos. Conclusiones: La implementación de un curso de sedación basados en simulación dirigidos a endoscopistas mejora la calidad de esta y la seguridad del paciente durante el procedimiento. La simulación debe ser considerada como una estrategia de enseñanza válida en este contexto lo que plantea un gran desafío a todos los anestesiólogos.

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RATIONALE AND OBJECTIVES: Radiology teachers are well trained in their specialty; however, when working in academic institutions, faculty development and promotion through the education pathway tends to be based on their teaching knowledge and skills. The aim of this study is to assess psychometric properties of the Medicina Universidad Católica-Radiology 32 items (MEDUC-RX32), an instrument designed to evaluate the performance of postgraduate radiology teachers and to identify the best teachers. MATERIALS AND METHODS: Mixed methodology was used, including qualitative and quantitative phases. The psychometric properties of the MEDUC-RX32 survey were performed by factor analysis (validity), Cronbach alpha coefficient, and G coefficient (reliability). The residents assessed their teachers and simultaneously voted for the "best teacher," which was used as a gold standard for the receiver operating characteristic curves construction comparing their votes with the global score. RESULTS: A total of 28 residents answered 164 surveys. The global score was 6.23 ± 0.8 (scale from 1 to 7). The factor analysis showed six domains of the resident's perception: (1) tutorial teaching, feedback, and independent learning; (2) communication and teamwork; (3) learning objectives; (4) respectful behavior; (5) radiological report; and (6) teaching and care support. The tutor's strengths were related with respectful behavior and teamwork. The instrument is highly reliable with a Cronbach alpha of 0.937 and a G coefficient of 0.831 (with a minimum of 8 residents). The MEDUC-RX32 instrument has a sensitivity of 91.7% and specificity of 83.3% to identify tutors as best teachers with at least one vote with an area under the receiver operating characteristic curve of 0.931 with a cutoff of 5.94. CONCLUSIONS: The MEDC-RX32 instrument is a multidimensional, valid, and highly reliable method to evaluate radiology teachers, identifying teachers with excellence in tutorial teaching in a postgraduate radiology program.

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BACKGROUND: Feedback is one of the most important tools to improve teaching in medical education. AIM: To develop an instrument to assess the performance of clinical postgraduate teachers in medical specialties. MATERIAL AND METHODS: A qualitative methodology consisting in interviews and focus-groups followed by a quantitative methodology to generate consensus, was employed. After generating the instrument, psychometric tests were performed to assess the construct validity (factor analysis) and reliability (Cronbach’s alpha). RESULTS: Experts in medical education, teachers and residents of a medical school participated in interviews and focus groups. With this information, 26 categories (79 items) were proposed and reduced to 14 items (Likert scale 1-5) by an expert’s Delphi panel, generating the MEDUC-PG14 survey, which was answered by 123 residents from different programs of medical specialties. Construct validity was carried out. Factor analysis showed three domains: Teaching and evaluation, respectful behavior towards patients and health care team, and providing feedback. The global score was 4.46 ± 0.94 (89% of the maximum). One teachers’ strength, as evaluated by their residents was “respectful behavior” with 4.85 ± 0.42 (97% of the maximum). “Providing feedback” obtained 4.09 ± 1.0 points (81.8% of the maximum). MEDUC-PG14 survey had a Cronbach’s alpha coefficient of 0.947. CONCLUSIONS: MEDUC-PG14 survey is a useful and reliable guide for teacher evaluation in medical specialty programs. Also provides feedback to improve educational skills of postgraduate clinical teachers.

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Background: Feedback is one of the most important tools to improve teaching in medical education. Aim: To develop an instrument to assess the performance of clinical postgraduate teachers in medical specialties. Material and Methods: A qualitative methodology consisting in interviews and focus-groups followed by a quantitative methodology to generate consensus, was employed. After generating the instrument, psychometric tests were performed to assess the construct validity (factor analysis) and reliability (Cronbach’s alpha). Results: Experts in medical education, teachers and residents of a medical school participated in interviews and focus groups. With this information, 26 categories (79 items) were proposed and reduced to 14 items (Likert scale 1-5) by an expert’s Delphi panel, generating the MEDUC-PG14 survey, which was answered by 123 residents from different programs of medical specialties. Construct validity was carried out. Factor analysis showed three domains: Teaching and evaluation, respectful behavior towards patients and health care team, and providing feedback. The global score was 4.46 ± 0.94 (89% of the maximum). One teachers’ strength, as evaluated by their residents was “respectful behavior” with 4.85 ± 0.42 (97% of the maximum). “Providing feedback” obtained 4.09 ± 1.0 points (81.8% of the maximum). MEDUC-PG14 survey had a Cronbach’s alpha coefficient of 0.947. Conclusions: MEDUC-PG14 survey is a useful and reliable guide for teacher evaluation in medical specialty programs. Also provides feedback to improve educational skills of postgraduate clinical teachers.

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BACKGROUND: In 2007, a Clinical-Case-Portfolio (CCP) was introduced as a new assessment instrument for fourth grade undergraduate medical students. Since then, several changes have been implemented such as reduction on the number of clinical cases, peer review and the introduction of virtual patient to the portfolio. AIM: To describe the virtual patient model incorporated to the CCP and assess the perception of this change and its effects on the performance of undergraduate students. MATERIAL AND METHODS: Virtual patients were implemented based on prototype clinical cases with specific syndromes. Students’ perceptions about CCP before and after the introduction of virtual patients were evaluated using a validated questionnaire that was answered voluntarily and anonymously. RESULTS: Overall perception of CCP significantly improved after the incorporation of virtual patients (97.1 ± 24.9 and 111.3 ± 25.7 points; 57.8 and 66.2% respectively). The same improvements were observed for the domains “Student Learning”, “Organization and Evaluation”, “Teaching Methodology” and “Integration”. In both years, students obtained high grades in CCP evaluations. However CCP grades were not significantly correlated with integrated final grades. CONCLUSIONS: The incorporation of virtual patients improved undergraduate students’ perception of CCP.

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Background: In 2007, a Clinical-Case-Portfolio (CCP) was introduced as a new assessment instrument for fourth grade undergraduate medical students. Since then, several changes have been implemented such as reduction on the number of clinical cases, peer review and the introduction of virtual patient to the portfolio. Aim: To describe the virtual patient model incorporated to the CCP and assess the perception of this change and its effects on the performance of undergraduate students. Material and Methods: Virtual patients were implemented based on prototype clinical cases with specific syndromes. Students’ perceptions about CCP before and after the introduction of virtual patients were evaluated using a validated questionnaire that was answered voluntarily and anonymously. Results: Overall perception of CCP significantly improved after the incorporation of virtual patients (97.1 ± 24.9 and 111.3 ± 25.7 points; 57.8 and 66.2% respectively). The same improvements were observed for the domains “Student Learning”, “Organization and Evaluation”, “Teaching Methodology” and “Integration”. In both years, students obtained high grades in CCP evaluations. However CCP grades were not significantly correlated with integrated final grades. Conclusions: The incorporation of virtual patients improved undergraduate students’ perception of CCP.

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BACKGROUND: The use of Workplace-Based Assessment (WBA) has increased in recent years. AIMS: To create a modified version of Direct Observation of Procedural Skills (DOPS) adapted to the Chilean context and establish its psychometric properties. METHODS: The content validity of DOPS was established through interviews and consensus survey. To be included in the new version, the respective domain should have been considered by over 80% of interviewers and it should have a Content Validity Index (CVI and kappa statistic over 0.78 and 0.6, respectively. For four months, the new DOPS was used to assess the intubation skills of the anesthesia trainees. Generalizability theory was used to establish reliability and internal consistency. RESULTS: The interview suggested a DOPS with twelve domains. All were included in the final version as the CVI and kappa values were above 0.9 and 0.8, respectively. 585 procedures were assessed. The G coefficient was 0.90. The intubation needs to be assessed with DOPS at least six times to obtain a G coefficient of 0.80. CONCLUSIONS: The modified DOPS was a valid, reliable and practical tool for assessing the intubation procedure. Effort needs to be made to improve the staff's feedback skills.

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Anesthesia awareness, or "unintended intra-operative awareness" occurs during general anesthesia, on the operating table, when a patient has not had enough general anesthetic or analgesic to prevent consciousness or waking up during surgery. According to international studies its global incidence ranges from 0.1 to 0.2%. Its impact on people can be as severe as other traumatic experiences such as natural disasters, violent fights or sexual abuse. The prevalence of symptoms compatible with post traumatic stress disorder can be as high as 50%, after experiencing the awareness phenomenon. This paper reviews the main issues of the awareness phenomenon.

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Anesthesia awareness, or "unintended intra-operative awareness" occurs during general anesthesia, on the operating table, when a patient has not had enough general anesthetic or analgesic to prevent consciousness or waking up during surgery. According to international studies its global incidence ranges from 0.1 to 0.2 percent. Its impact on people can be as severe as other traumatic experiences such as natural disasters, violent fights or sexual abuse. The prevalence of symptoms compatible with post traumatic stress disorder can be as high as 50 percent, after experiencing the awareness phenomenon. This paper reviews the main issues of the awareness phenomenon.

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BACKGROUND: To guide anesthetic administration with electroencephalogram monitors in children, an adequate characterization of the anesthetic effect measured by these monitors in this population is needed. We sought to quantify and compare the dynamic profile of sevoflurane's effect measured with the cerebral state index (CSI) and the bispectral index (BIS) in children. METHODS: Fifteen healthy children, aged 3-15 yr, scheduled to undergo minor surgery were prospectively studied. During the simultaneous recording of CSI and BIS, the sevoflurane vaporizer was set at 6 vol % for 5 min and then decreased. End-tidal concentrations (C(ET)) were measured. The C(ET)-sevoflurane effect-site concentration equilibration and pharmacodynamics were modeled. Goodness of fit between models was compared. Data are typical value (coefficient of variation). RESULTS: Within the anesthetic depth range studied, the rate of change of sevoflurane's effect expressed as the effect-site equilibration half-life (t(1/2) k(e0)) was slower with the CSI [2.0 (14) min] than with BIS [1.2 (53) min] (P < 0.05). The estimated baseline effect of BIS and CSI before sevoflurane administration (E(0)) was 84 (39) for CSI and 87 (7) for BIS (NS). The sensitivity to sevoflurane hypnotic effect expressed in the C(50) [steady-state C(ET) eliciting half of the maximum response (E(max))] was 2.1 (68) % with CSI and 2.1 (16)% with BIS (NS). The E(max) with CSI 45 (0) was higher than that with BIS 27 (39) (P < 0.05). The population prediction error was significantly better for BIS (-0.7 +/- 26.9) than for CSI (-3.0 +/- 178.6) (P < 0.05). CONCLUSIONS: In children, the t(1/2) k(e0) of sevoflurane and the pharmacodynamics of sevoflurane were quantified and the results were entirely dependent on the monitor used to measure its hypnotic effect. Within the anesthetic depth range studied, the rate of change of sevoflurane's effect was slower with the CSI. To adequately guide sevoflurane administration with these monitors in children, these differences should be considered.

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BACKGROUND: The cerebral state monitor is a new device to measure depth of anesthesia. In this study we compared the cerebral state monitor with the bispectral index (BIS) monitor during propofol anesthesia. METHODS: Fifteen healthy patients received a continuous infusion of propofol (300 mL/h). The cerebral state index (CSI) and the BIS values were recorded until burst suppression ratio > or =60%. Baseline variability, prediction probability, and agreement analysis between indices were evaluated. Clinical markers of loss of consciousness were also assessed. RESULTS: Mean awake BIS and CSI values were 95.6 and 91.6, respectively (P = 0.01). BIS and CSI prediction probability values (mean +/- sd) were estimated to be 0.87 +/- 0.08 and 0.86 +/- 0.08, respectively (NS). The CSI tended to stabilize at values of 60-40 when estimated propofol concentrations at the effect site increased from 5 to 8 mug/mL. The BIS stabilized at values of 40-20 when the propofol concentrations at the effect site increased from 7 to 10 mug/mL. The mean BIS-CSI difference was -7.4 with 95% limits of agreement of 22.2 and -36.9. The BIS and CSI correlation with the burst suppression ratio was -0.60 and -0.97, respectively (P < 0.01). Predicted BIS and CSI values for loss of eyelash reflex in 50% and 95% of the patients were different (P < 0.05). CONCLUSION: The overall performance of both monitors during propofol induction was similar. However, the different dynamic profiles of these monitors indicate that BIS may be a more useful index for evaluating intermediate anesthetic levels, whereas CSI may be better for evaluating deeper anesthetic levels.

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