commentaries 17 Alonso A, Rutan JS. Shame and guilt in supervision. Psychotherapy 1988;25 (4):576–81. 18 Mazor KM, Fischer MA, Haley H-L, Hatem D, Quirk ME. Teaching and medical errors: primary care preceptors’ views. Med Educ 2005;39:982–90.

19 Brown B. Daring Greatly: How the Courage to be Vulnerable Transforms the Way We Live, Love, Parent, and Lead, 1st edn. New York: Penguin Group 2012. 20 Fried JM, Vermillion M, Parker NH, Uijtdehaage S. Eradicating medical student mistreatment: a longitudinal study of one

institution’s efforts. Acad Med 2012;87 (9):1191–8. 21 Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman-Levitan S, Meyer GS, Healy GB. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med 2012;87 (7):853–8.

Improving patient outcomes through supervision and simulation Dayna A Burrell & Jessica L Bienstock Health professional education programmes are under constant pressure to train caregivers in fundamental skills even as the opportunities to practise those skills change dynamically. Consider, for example, the rate of operative deliveries in the USA. Caesarean deliveries increased from 22.7% of all deliveries in 1990 to 32.8% in 2011.1 In view of the associated risk for maternal morbidity, the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine have strongly recommended operative vaginal delivery (e.g. forceps- and vacuum-assisted) as an intervention to reduce primary caesarean delivery. Unfortunately, operative vaginal delivery rates have declined as caesarean delivery rates have increased,2 yielding a

Baltimore, Maryland, USA

Correspondence: Jessica L Bienstock, Department of Gynaecology and Obstetrics, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 280, Baltimore, Maryland 21287, USA. Tel: 00 1 410 955 8487; E-mail: [email protected] doi: 10.1111/medu.12762

situation in which many graduates do not feel competent to perform a forceps-assisted vaginal delivery.3 As operative deliveries comprise nearly half of births, and in recognition of the need to decrease caesarean delivery rates, expertise and training in vacuum-and forceps-assisted vaginal delivery need to be at the forefront of our resident education programmes even as these practices have become less common. Operative vaginal delivery rates have declined as caesarean rates have increased and many graduates do not feel competent in forceps-assisted vaginal delivery

In their paper, published in this issue, Aiken et al.4 recognise the need for physician learners to build a solid foundation of supervised experience prior to performing operative deliveries independently. An increase in operative deliveries performed under direct supervision prior to operating without direct supervision was shown to decrease the occurrence of procedure-related

complications and adverse events.4 Increasing the number of procedures performed under direct supervision is arguably a standard towards which all residency training programmes should strive, but achieving that standard is not without its challenges. In addition to the decline in opportunities to be involved in certain procedures, the more general restriction on resident work hours and associated limitations in hands-on training contribute further to the issue.5,6 How can these challenges of time, exposure and experience be overcome? The answer, as proposed by Aiken et al.4 and others, may lie in simulation. Increasing the number of procedures performed under direct supervision is arguably a standard towards which all residency training programmes should strive

Although simulation may seem to be a relatively new phenomenon, especially given its growing prominence across medical disciplines, the history of simulation in obstetrics dates back to the childbirth

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commentaries simulators developed in the 1600s.7 Since then, an infant-sized doll and replicated maternal pelvis have served as the mainstays of simulation of simple and complex obstetric procedures. Simulators have developed into low- and highfidelity models which differ in cost, complexity and the degree to which they provide realistic sensory cues and situational feedback.8 As a considerable amount of research has now been conducted, it is clear that simulation-based training can improve competency and confidence,9 can yield better communication among team members10 and can, thereby, improve patient safety.11–13 As a result, simulation as a training modality has become broadly endorsed as a means to improve the quality of patient care in labour and delivery.14 We still, however, have much to learn about the optimal way to implement simulationbased training, including about whether or not it can be made sufficient to offset the lack of experience and direct workplacebased supervision that Aiken et al.4 demonstrate to be detrimental to safe and effective practice. Further, to what extent is direct supervision in the simulated environment itself necessary for optimal performance gains to be achieved? Such questions are informed by the literature examining the capacity of learners to self-regulate,15 but rarely have such studies examined the complex real-world skills required of trainees as they become progressively more independent. An equally pressing concern refers to the fact that we do not yet have adequate models of the costs and benefits of different training modalities. Such models are difficult to create, but focusing on constrained domains like operative delivery, with its clear and precise patient outcomes, may enable the generation of useful

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insights through systematic, crosscultural and longitudinal study. We still have much to learn about the optimal way to implement simulationbased training

Obstetrics and gynaecology specialist training programmes in the USA require a total of 4 years of direct supervision, whereas programmes in the UK system require 2 years of practice under direct supervision plus 5 years under indirect supervision. It is worth questioning, given the results reported by Aiken et al.,4 whether rates of operative delivery complications differ between US and UK trainee groups as a result of differences in the periods of direct supervision or of any supervision. Of course, many things differ between these health and training systems and hence it is difficult to pin down specific causal factors. There are previously published precedents, however, that demonstrate that tracking large-scale interventions over time can yield valuable information about patient outcomes. Combining such longitudinal studies with cross-cultural comparisons may enable inference by triangulation. For example, Crofts et al.12 compared neonatal outcomes for births complicated by shoulder dystocia 4 years prior to the implementation of a simulation training programme relative to those occurring during the 1– 4 years (early training) and 8– 12 years (late training) following its institution. They reported a notable reduction in brachial plexus injury at birth across the study groups from a high of 7.4% pre-training to a low of 1.3% in the late training group.12 Notably, over 85% of the staff participating in this study received annual training, which speaks of the importance of widespread use of

simulation and repetition of training.12 What more could be learned if such long-term comparisons were made between institutions and between countries with careful tracking of the supervision and simulation strategies used? It is worth questioning whether rates of complications differ between trainee groups as a result of differences in the periods of direct supervision or of any supervision

However, regardless of the amount of supervision or simulation provided, we must not lose sight of the fact that competence is an individual characteristic. In the USA, the Accreditation Council for Graduate Medical Education requires that each graduate perform a minimum number of supervised procedures during residency training in order for the programme to maintain its accreditation.16 There is no set number of repetitions, however, that guarantees competency in any procedure.16 This is the root of the competence-based education movement that has led many groups to develop milestones that can be assessed from the start of resident or fellow education through graduation to unsupervised practice.17 We wonder if this too is an area in which the concepts of supervision and simulation can be combined to provide better guidance to both trainees and medical educators. Readily available pelvic models in combination with a doll can be used to demonstrate the application of forceps or vacuum and can be stored on delivery units for easy access in a manner that would allow for pre-procedure performance review,18 perhaps as a means of determining how much supervision is required and when it should be pulled back to enable

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commentaries the learner to develop his or her skill more completely.19 This is an important factor in deciding how much supervision is enough because ultimately the goal of simulation training must be to improve confidence and competence if long-term patient outcomes are to improve. Regardless of the amount of supervision or simulation provided, we must not lose sight of the fact that competence is an individual characteristic

In summary, Aiken et al.4 raise valid points indicating that increased supervision of operative deliveries among physicians in training may be associated with a reduction in adverse patient outcomes. How much direct supervision is required, for how long, and at what point it starts to hamper the trainee’s capacity to achieve greater heights are all important issues that require further research. We agree with the authors4 that simulation offers a key opportunity to positively impact both maternal and neonatal outcomes and would encourage further consideration of how simulated activities might combine with supervisory practices in both the classroom and the workplace.

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obstetrical outcomes from 1992 to 2006. Med Care 2010;48 (5):487– 93. Powell J, Gilo N, Foote M, Gil K, Lavin JP. Vacuum and forceps training in residency: experience and self-reported competency. J Perinatol 2007;27 (6):343–6. Aiken CE, Aiken AR, Park H, Brockelsby JC, Prentice A. Factors associated with adverse clinical outcomes among obstetric trainees. Med Educ 2015;49:674–83. Blanchard MH, Amini SB, Frank TM. Impact of work hour restrictions on resident case experience in an obstetrics and gynaecology residency programme. Am J Obstet Gynecol 2004;191 (5):1746–51. Birsner ML, Satin AJ. Developing a programme, a curriculum, a scenario. Semin Perinatol 2013;37 (3):175–8. Buck GH. Development of simulators in medical education. Gesnerus 1991;48 (Pt 1):7–28. Ennen CS, Satin AJ. Training and assessment in obstetrics: the role of simulation. Best Pract Res Clin Obstet Gynaecol 2010;24 (6):747–58. Monod C, Voekt C, Gisin M, Gisin G, Hoesli IM. Optimisation of competency in obstetrical emergencies: a role for simulation training. Arch Gynecol Obstet 2014;289 (4):733–8. Goffman D, Heo H, Pardanani S, Merkatz IR, Bernstein PS. Improving shoulder dystocia management among resident and attending physicians using simulations. Am J Obstet Gynecol 2008;199 (3):294. Argani CH, Eichelberger M, Deering S, Satin AJ. The case for simulation as part of a comprehensive patient safety programme. Am J Obstet Gynecol 2012;206 (6):451–5. Crofts J, Lenguerrand E, Bentham G, Tawfik S, Claireaux H, Odd D, Fox R, Draycott T. Prevention of

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brachial plexus injury – 12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2015; doi: 10.1111/14710528.13302. [Epub ahead of print.] Siasskos D, Hasafa Z, Sibanda T, Fox R, Donald F, Winter C, Draycott T. Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG 2009;116 (8):1089–96. Lawrence HC III, Copel JA, O’Keefe DF et al. Quality patient care on labour and delivery: a call to action. Am J Obstet Gynecol 2012;207 (3):147–8. Brydges R, Butler D. A reflective analysis of medical education research in self-regulation in learning and practice. Med Educ 2012;46:71–9. Accreditation Council for Graduate Medical Education. Minimum thresholds for obstetrics and gynaecology procedures. 2012. http://www.acgme.org/ acgmeweb/Portals/0/PFAssets/ ProgramResources/220_Ob_Gyn Minimum_Numbers_Announc ment.pdf. [Accessed 2 March 2015.] Bienstock JL, Edgar L, McAlister R. Obstetrics and gynaecology milestones. J Grad Med Educ 2014;6 (Suppl 1):126–8. Dupuis O, Moreau R, Silveira R, Pham MT, Zentner A, Cucherat M, Rudigoz RC, Redarce T. A new obstetric forceps for the training of junior doctors: a comparison of the spatial dispersion of forceps blade trajectories between junior and senior obstetricians. Am J Obstet Gynecol 2006;194 (6):1524– 31. Kennedy TJ, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: a tradition worth defending? Acad Med 2005;80 (Suppl):106– 11.

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Improving patient outcomes through supervision and simulation.

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