A prospective, longitudinal, observational study of PGY1 residents during EM rotations conducted from April 1, 2019 to March 31, 2020 (2019–2020 fiscal year) was performed. Each rotation lasted for 2 months. The first hands-on FAST examination was implemented without lectures, so that PGY1 residents would perform the FAST using the skill and knowledge that they had learned in medical school. All participating PGY1 residents took a standardized list of key assessment points that was provided verbally and were instructed interactively after the first test to ensure consistency in the teaching points in the first week of the rotation. Although simulation-based training showed better performance than normal training without simulation-based training in diagnostic ultrasound scanning on real patients,8 PGY1 residents used the ultrasound machine for real patients only.
The ultrasound machine used in the emergency room was a GE LOGIQ E9 XDclear 2.0 ultrasound machine (GE Healthcare, Wauwatosa, WI, USA), and the PGY1 residents could use the machine for real patients under the supervision of attending EM physicians or for other PGY1 residents freely without supervision. The instructor did all scoring in real time. This study was conducted at an academic university hospital and was approved by the Institutional Review Board (2767), with the written, informed consent of all participants.
Participants
The participants were first-year rotating residents (PGY1) (n = 34) in the EM rotation at an academic university hospital during the 2019–2020 fiscal year. Table 1 shows information regarding the identified specialty of interest at the time of the rotation of the PGY1 residents. They were divided three categories, internal medicine group, surgery group, and others group. The internal medicine group included cardiology, gastroenterology, respiratory medicine, nephrology, neurology, hematology, and rheumatology. The surgery group included cardiovascular surgery, thoracic surgery, gastroenterological surgery, breast and endocrine surgery, orthopedic surgery, neurosurgery, obstetrics and gynecology, and emergency medicine. The others group included pediatrics, anesthesiology, ophthalmology, otorhinolaryngology, dermatology, plastic surgery, radiology, and psychiatry.
Table 1
Demographic and characteristics of the postgraduate year 1 residents.
|
Resident’s identified specialty of interest at the time of rotation
|
|
|
Internal medicine
|
Surgery
|
Others
|
Fisher exact test
|
Sex
|
|
|
|
0.395
|
female
|
1
|
0
|
4
|
|
male
|
7
|
9
|
13
|
|
Group
|
|
|
|
0.169
|
April-May
|
0
|
3
|
4
|
|
June-July
|
1
|
1
|
4
|
|
August-September
|
1
|
3
|
1
|
|
October-November
|
1
|
1
|
3
|
|
December-January
|
1
|
0
|
4
|
|
February-March
|
4
|
1
|
1
|
|
Evaluation
|
|
|
|
0.799
|
1
|
0
|
0
|
1
|
|
2
|
0
|
1
|
1
|
|
3
|
3
|
4
|
9
|
|
4
|
4
|
3
|
6
|
|
5
|
1
|
1
|
0
|
|
*Internal medicine includes cardiology, gastroenterology, respiratory medicine, nephrology, neurology, hematology and rheumatology. |
** Surgery includes cardiovascular surgery, thoracic surgery, gastroenterological surgery, breast and endocrine surgery, orthopedic surgery, neurosurgery, obstetrics and gynecology, and emergency medicine. |
*** Others include pediatrics, anesthesiology, ophthalmology, otorhinolaryngology, dermatology, plastic surgery, radiology and psychiatry. |
† Evaluation category means the average score by three third year EM residents for three-item survey regarding their clinical attitude, knowledge and skill for EM, and positive participation to EM practice on a scale of one to five with 5 being best. 1 means average score was greater than or equal to 1 and less than 2. 2 means average score was greater than or equal to 2 and less than 3. 3 means average score was greater than or equal to 3 and less than 5. 4 means average score was greater than or equal to 4 and less than 5. 5 means average score was 5. |
The simulated patient was the same in both the first and last weeks of the rotation, which thus reduced as much as possible the bias due to individual anatomical differences. A normal human model can provide good interpretation for normal anatomical landmarks, but this model does not have abnormal findings.9
A letter of information was provided to PGY1 residents, which included the elements of informed consent.
Assessment
An 18-item, hands-on performance test (total score 21) was developed to test medical students’ skills on the FAST exam (Fig. 1).10 The items and content on the test had been used previously.10 The test was administered to PGY1 residents individually in the first and last weeks of the EM rotation under the supervision of the principal investigator. Participation by PGY1 residents was voluntary and did not impact their status within the program. After finishing two months of the rotation, each PGY1 resident was assessed by three third-year EM residents (PGY3) using a three-item survey regarding their clinical attitude, knowledge and skills for EM, and positive participation in EM practice on a scale of one to five, with 5 being the best.11,12 The survey results are presented in Tables 1 and 2.
Table 2
Test results and evaluation of the postgraduate year 1 residents.
|
Resident’s identified specialty of interest at the time of rotation
|
|
Internal medicine
|
Surgery
|
Others
|
First week
|
|
|
|
Mean score (95%CI)
|
7.50 (5.18–9.82)
|
6.78 (5.85–7.70)
|
7.94 (6.83–9.05)
|
Last week
|
|
|
|
Mean (95%CI)
|
17.63 (16.54–18.71)
|
14.89 (12.57–17.21)
|
15.59 (14.44–16.74)
|
Difference
|
|
|
|
Mean (95%CI)
|
10.13 (7.74–12.51)
|
8.11 (5.61–10.62)
|
7.65 (6.41–8.88)
|
Evaluation*
|
|
|
|
Clinical attitude
|
|
|
|
Mean (95%CI)
|
4.29 (3.80–4.78)
|
4.12 (3.76–4.61)
|
3.75 (3.21–4.28)
|
Knowledge and skill
|
|
|
|
Mean (95%CI)
|
3.96 (3.42–4.49)
|
3.59 (3.09–4.10)
|
3.20 (2.81–3.58)
|
Positive participation
|
|
|
|
Mean (95%CI)
|
4.13 (3.60–4.65)
|
3.81 (3.11–4.52)
|
3.49 (3.00–3.98)
|
Total
|
|
|
|
Mean (95%CI)
|
4.13 (3.64–4.61)
|
3.86 (3.37–4.36)
|
3.48 (3.04–3.92)
|
*Evaluation means that each PGY1 was assessed by three third year EM residents (PGY3) for three-item survey regarding their clinical attitude, knowledge and skill for EM, and positive participation to EM practice on a scale of one to five with 5 being best. |
Statistical Analysis
The primary outcome was the mean difference between the hands-on FAST examination scores of the first week of the EM rotation and the same hands-on FAST examination scores of the last week of the EM rotation. The subgroup analysis included factors affecting the change in the score using simple and multiple linear regression analyses. The same instructor and simulated patient were used for both hands-on performance tests of the study.
Values are reported as means and standard deviation for continuous variables, and as frequencies with percentages for categorical variables. Fisher’s exact test was used for categorical variables. For the primary analysis, a paired t-test was used to examine differences in the hands-on FAST examination scores between the first week of the rotation and the last week of the rotation. A subgroup analysis according to the three categories of the identified specialty of interest at the time of the EM rotation of the PGY1 residents was performed, and the differences in the hands-on FAST examination scores were compared among the identified specialties of interest with multiplicity adjustment using Dunnett’s method. The relative effects of baseline characteristics (subphrenic space identified on the left side, correct probe orientation on the right side, and the identified specialty of interest) on differences in the hands-on FAST examination scores over the 2 months were examined using a simple and multiple linear regression models.
All tests were 2-tailed, with p < 0.05 considered significant. All analyses were performed with STATA (version 16.1; Stata Corp., College Station, TX, USA).