Haptics in medicine and clinical skill acquisition

THE clinical skills of medical professionals rely strongly on the sense of touch, combined with anatomical and diagnostic knowledge. Haptic exploratory procedures allow the expert to detect anomalies via gross and fine palpation, squeezing, and contour following. Haptic feedback is also key to medical interventions, for example when an anaesthetist inserts an epidural needle, a surgeon makes an incision, a dental surgeon drills into a carious lesion, or a veterinarian sutures a wound. Yet, current trends in medical technology and training methods involve less haptic feedback to clinicians and trainees. For example, minimally invasive surgery removes the direct contact between the patient and clinician that gives rise to natural haptic feedback, and furthermore introduces scaling and rotational transforms that confuse the relationship between movements of the hand and the surgical site. Similarly, it is thought that computer-based medical simulation and training systems require high-resolution and realistic haptic feedback to the trainee for significant training transfer to occur. The science and technology of haptics thus has great potential to affect the performance of medical procedures and learning of clinical skills. This special section is about understanding

Therapist characteristics and their effect on training outcomes: what counts?

Background: Evidence exists for a relationship between individual characteristics and both job and training performance; however relationships may not be generalizable. Little is known about the impact of therapist characteristics on performance in postgraduate therapist training programmes. Aims: The aim of this study was to investigate associations between the grades of trainee Low-Intensity and High-Intensity cognitive behavioural therapists and individual characteristics. Method: Trainee Low-Intensity (n=81) and High-Intensity (n=59) therapists completed measures of personality and cognitive ability; demographic and course grade data for participants were collected. Results: Degree classification emerged as the only variable to be significantly associated with performance across assessments and courses. Higher undergraduate degree classifications were associated with superior academic and clinical performance. Agreeableness was the only dimension of personality to be associated (positively) with clinical skill. Age was weakly and negatively associated with performance. Conclusions: Relationships between individual characteristics and training outcomes are complex and may be context specific. These results could have important implications for the selection and development of therapists for Low or High-Intensity cognitive behavioural therapy (CBT) training.

How initial vocational education and training (IVET) teachers in Sweden perceive their prospects of being able to prepare upper secondary school pupils for a future occupation

Vocational teachers in Swedish upper secondary schools are a heterogeneous category of teachers, connected to different types of trade. These teachers represent a broad set of trade skills varying in content and character. In their teacher role, they continue to wear the clothes, speak the language, share the culture and remain mentally in their former professions. Still, it is central that they keep up this contact to be able to school the pupils into the environment of the trade in question, but also to help them to understand what skills a profession demands. However, the individual teacher also has to distance himself from the negative elements in the culture of the profession: patterns and habits that, for various reasons, have to be broken or changed. This paper draws attention to the ways in which a group of vocational teachers, who were participants in a project that aimed to train unauthorized vocational teachers, expressed their ambitions to prepare the pupils for a future professional career. When collecting information, we used the degree dissertations they produced and discussed in seminars, and informal dialogues. The result shows that it is important that the instruction location resembles a real working site as far as possible. These places are more or less realistic copies of a garage, a restaurant kitchen, a hairdressing salon, and so on, in order to give the pupils a realistic setting for instruction. However, the fact that these simulated workplaces lack the necessary support functions that exist in a company creates problems, problems which make a lot of extra work for the teachers. Vocational teachers also have to instruct the pupil in the experienced practitioner’s professional skills and working situation, but the pupil herself/himself must learn the job by doing it in practice. Some vocational upper secondary programs lack relevant course literature and the businesses give little support. This also makes extra work for the teachers. Moreover, the distance between the vocational programs and the trainee jobs was experienced as being difficult to overcome. One reason seems to be differences between businesses and differing preconditions between small and big companies’ abilities to take care of these pupils. The upper secondary school vocational programs also play a role in cementing existing gender roles, as well as perpetuating class-related patterns on the labour market.

How initial vocational education and training (IVET) teachers in Sweden perceive their prospects of being able to prepare upper secondary school pupils for a future occupation

Vocational teachers in Swedish upper secondary schools are a heterogeneous category of teachers, connected to different types of trade. These teachers represent a broad set of trade skills varying in content and character. In their teacher role, they continue to wear the clothes, speak the language, share the culture and remain mentally in their former professions. Still, it is central that they keep up this contact to be able to school the pupils into the environment of the trade in question, but also to help them to understand what skills a profession demands. However, the individual teacher also has to distance himself from the negative elements in the culture of the profession: patterns and habits that, for various reasons, have to be broken or changed. This paper draws attention to the ways in which a group of vocational teachers, who were participants in a project that aimed to train unauthorized vocational teachers, expressed their ambitions to prepare the pupils for a future professional career. When collecting information, we used the degree dissertations they produced and discussed in seminars, and informal dialogues. The result shows that it is important that the instruction location resembles a real working site as far as possible. These places are more or less realistic copies of a garage, a restaurant kitchen, a hairdressing salon, and so on, in order to give the pupils a realistic setting for instruction. However, the fact that these simulated workplaces lack the necessary support functions that exist in a company creates problems, problems which make a lot of extra work for the teachers. Vocational teachers also have to instruct the pupil in the experienced practitioner’s professional skills and working situation, but the pupil herself/himself must learn the job by doing it in practice. Some vocational upper secondary programs lack relevant course literature and the businesses give little support. This also makes extra work for the teachers. Moreover, the distance between the vocational programs and the trainee jobs was experienced as being difficult to overcome. One reason seems to be differences between businesses and differing preconditions between small and big companies’ abilities to take care of these pupils. The upper secondary school vocational programs also play a role in cementing existing gender roles, as well as perpetuating class-related patterns on the labour market.

Locating non-western enlightenment texts for a global curriculum

The context of this paper is a university-based teacher education course in Melbourne, Australia. The assumption underpinning the course is that it is crucial for trainee teachers to examine the lenses they typically use in terms of common-sense understandings of children and adolescents. We point to the 18th century Western enlightenment period as the source of this thinking. I argue that it is important to be aware of other enlightenments that have shaped the traditions of students in our multicultural mix. In this paper, I explore the writings of the Mahabharata and other early Indian texts to see how they have also influenced ways of thinking about childhood and adolescence. Data for this paper have been drawn from course materials, student responses, translations of early Indian texts and popular stories depicting childhood and adolescence.

On-screen supervision relationships versus face-to-face

Videoconferencing provides access to essential training for probationary psychologists in rural areas. However the unique aspects of videoconferenced communication (Jerome & Zaylor, 2000) challenge an assumed equivalency of face-to-face and videoconferenced interactions. This study investigated the relevance of power, involvement, and an established model of supervision (Bernard, 1979, 1997) to the working relationship in videoconferenced supervision. Semistructured interviews were conducted with four supervisors, eighteen trainees experienced in videoconferenced supervision and four trainees experienced in face-to-face supervision. Data were analysed by qualitative content analysis, coding pertinent theoretical constructs. Results confirmed that the roles defined by Bernard's supervision model (teacher, counsellor and consultant) were relevant to videoconferenced supervision. However a further role emerged as well. Power and involvement dimensions also had relevance for videoconferenced interactions with some suggestion that the power discrepancy between trainee and supervisor was increased. Complexities arising from videoconferencing included some trainees avoiding involvement by blaming technical malfunctions, some reporting curtailed emotional expression and others reporting freer emotional expression due to the distal nature of the medium. The findings affirm some unique features to videoconferenced supervision and validate a framework to further explore the impact of videoconferencing upon supervisory relationships.

The role of supervision in the training of a psychoanalyst

This paper discusses the role of clinical supervision in psychoanalytic training. It also discusses the impact of training modes on the psychoanalytic organisations that use these different models of training. The paper argues that psychoanalytic training consists of a unique combination of personal analysis, study of psychoanalytic theory and research and clinical supervision. Given the variation of these three components and their possible interactions, an overly prescriptive view of training can be detrimental and counterproductive. The effectiveness of psychoanalytic supervision is to a significant degree dependent upon a trainee being engaged in personal analysis. Clinical competency requires extensive clinical experience obtained in a variety of settings and with a broad exposure to patient groups. The detrimental implications of restrictive and reductive views on psychoanalytic training that seek to specify quantitative criteria rather than clearly articulate clinical competencies are discussed.

The performance of solarscan : an automated dermoscopy image analysis instrument for the diagnosis of primary melanoma

Objective To describe the diagnostic performance of SolarScan (Polartechnics Ltd, Sydney, Australia), an automated instrument for the diagnosis of primary melanoma.

Design Images from a data set of 2430 lesions (382 were melanomas; median Breslow thickness, 0.36 mm) were divided into a training set and an independent test set at a ratio of approximately 2:1. A diagnostic algorithm (absolute diagnosis of melanoma vs benign lesion and estimated probability of melanoma) was developed and its performance described on the test set. High-quality clinical and dermoscopy images with a detailed patient history for 78 lesions (13 of which were melanomas) from the test set were given to various clinicians to compare their diagnostic accuracy with that of SolarScan.

Setting Seven specialist referral centers and 2 general practice skin cancer clinics from 3 continents. Comparison between clinician diagnosis and SolarScan diagnosis was by 3 dermoscopy experts, 4 dermatologists, 3 trainee dermatologists, and 3 general practitioners.

Patients Images of the melanocytic lesions were obtained from patients who required either excision or digital monitoring to exclude malignancy.

Main Outcome Measures Sensitivity, specificity, the area under the receiver operator characteristic curve, median probability for the diagnosis of melanoma, a direct comparison of SolarScan with diagnoses performed by humans, and interinstrument and intrainstrument reproducibility.

Results The melanocytic-only diagnostic model was highly reproducible in the test set and gave a sensitivity of 91% (95% confidence interval [CI], 86%-96%) and specificity of 68% (95% CI, 64%-72%) for melanoma. SolarScan had comparable or superior sensitivity and specificity (85% vs 65%) compared with those of experts (90% vs 59%), dermatologists (81% vs 60%), trainees (85% vs 36%; P =.06), and general practitioners (62% vs 63%). The intraclass correlation coefficient of intrainstrument repeatability was 0.86 (95% CI, 0.83-0.88), indicating an excellent repeatability. There was no significant interinstrument variation (P = .80).

Conclusions SolarScan is a robust diagnostic instrument for pigmented or partially pigmented melanocytic lesions of the skin. Preliminary data suggest that its performance is comparable or superior to that of a range of clinician groups. However, these findings should be confirmed in a formal clinical trial.

Diversity discourses / diversity experiences : teaching for and with cultural diversity

The contexts for 'cultural diversity education' usually reported in the research literature typically involve white middleclass people being prepared for teaching in ethnically diverse classrooms. The emphasis is thus on 'diversity' 'out there' in the classroom, with little acknowledgement of what such diversity education might mean for trainee teachers who themselves either identify as or are classified as culturally diverse. This study examines intercultural interactions reported by ethnically and culturally diverse teacher education students. Their difficulties with making sense of these interactions are described as 'intercultural disjunctions', often affecting personal or professional identity. I ide ntify three dominant discourses in the research literature that attempt to describe such disjunctions and analyse these in relation to the participants' stories. I conclude by outlining some implications for teacher education.

Investigative interviewers' perceptions of the value of different training Tasks on their adherence to open-ended questions with children

Prior research has highlighted the considerable difficulties investigative interviewers have in adhering to open-ended questions in child abuse interviews. Although improvements in interviewing can be achieved by providing training that incorporates multiple practice opportunities and feedback, currently little is known about the way in which these elements are best administered. The current study extends debate and research on this issue by examining the perceptions of 15 trainee interviewers (police as well as social workers) regarding the relative value of various practical training exercises experienced in a recent training program. The findings indicated that although practice in interviewing was deemed essential, not all tasks were perceived to be equally beneficial. The two most favoured exercises were (a) simulated interviews involving trained actors playing the role of the child, and (b) self-evaluation of a transcribed interview using an objective coding protocol. A summary of the participants' perceptions is provided along with a discussion of the implications for trainers and researchers.

Case study of electronic networking in an initial teacher education course

Electronic networking ('computer-mediated communication1), considered to be ‘unique domain for educational activity’ (Harasim, 1989:50) and ‘new educational paradigm’ (Mason & Kaye, 1989:23), has been widely used and researched in K-12 schooling, place-based undergraduate subjects and distance education courses. However, only a limited number of reports of usage with experienced teachers (professional development), beginning teachers (induction support) and trainee teachers (initial training) have been published. Hence, little is known about the ways in which this new medium might contribute to the acquisition and maintenance of professional knowledge in the field of teacher education. The purpose of this study was to document an application of electronic networking in an initial 'school-based1 teacher education course. Three factors which were considered to be important in the adoption of electronic networking were specifically addressed: (a) the potential of the medium to attract and maintain a representative and comprehensive audience', (b) the willingness of participants to use the medium for the notation of ideas about teaching; and, (c) the extent to which reflection on practice was evident in network messages. This study also identified and investigated other effects which emerged as participants attempted to negotiate personal relationships with new technology. A case study was selected to investigate audience, notation, reflection, and other effects, in a particular application. Data were collected using participant observation, software-generated statistics, printed documentation, university records, questionnaires, interviews and content analysis of messages. These data were used to describe and analyse network participation by trainee teachers, classroom teachers and university staff. The data revealed that an audience did exist on the electronic network but that this was not comprehensive. Teachers had difficulty accessing the network because of other school commitments, access to equipment and personal competence with microcomputers. These difficulties indicated that developing and maintaining the teacher audience may be a major problem with electronic networking in initial teacher education. This case study revealed that deeply held concerns about notation of ideas by trainee teachers and classroom teachers can be powerful reasons for limited network participation. For trainee teachers, recording ideas publicly presented special difficulties associated with written communication. They were concerned about writing for an audience; about what to write about and how to write it. The loss of visual and verbal cues which form part of face-to-face communication was also a problem leading to concerns about how messages would be received by others. However, the overwhelming concern of almost all trainee teachers about presenting their own ideas was Tear of criticism' from peers (in particular), and other participants on the network. Trainee teachers expressed concerns about the 'dangers' of putting their thoughts in writing, the scrutiny their messages might have received from others, and the public 'criticism' about what they wrote which might have appeared on the network. Knowing that messages were stored on the network, and could be retrieved at some later date, heightened anxiety about the vulnerability of written communication; what was written on one occasion may have to be defended at some later date when the views expressed initially were no longer held. Classroom teachers were also unsure about recording their own ideas in an electronic form. Like trainee teachers, they were concerned about the scrutiny their contributions might receive from other users, and the lack of visual and verbal cues which they had learnt to use in face-to-face communication. Notating ideas in text-based messages which were archived (by the software), and retrievable by others later, was also daunting to many teachers. Another major 'danger' for teachers was the possible repercussions of 'public comment' about curriculum policy and initiatives which they thought might get them into 'trouble' with their employer. Since very few messages were contributed to conferences, there was little evidence of reflection in network communication. In the main, the network was not used to share information and ideas about curriculum and teaching. Public examples of collaboration between participants were not evident, and the 'special knowledge' held by members in each distinct group of users was not elaborated and discussed. Messages were not used to request information or clarification about issues, to outline the processes by which decisions about teaching were reached, or to synthesis ideas from different sources. The potential of the medium to operationalise reflective practice was not realised. Among the effects observed, the use of an anonymous account to access the network, and the impact this had on participation (in one conference) was considered to be a particularly significant finding. While the opportunity to systematically investigate the effects of anonymity on network participation and message contributions was not realised (by the author) while the research was in progress, the effects observed and discussed are considered to be important and worthy of further investigation. In this case study, the anonymous account helped trainee teachers mask concerns about personal writing skills and fear of criticism from others, indicating that anonymity may alter communication patterns, particularly in the early stages of network use. Given the data collected in this case study, and the interpretations placed on it by the author, a pessimistic assessment of the place of electronic networking in initial teacher education courses was presented. For this situation to change - that is, for electronic discussions to become more fully integrated into course activities - four issues which need to be addressed were identified and discussed. These included clarification of the role of collaboration amongst participants in initial teacher education, the ways in which collaboration can be facilitated using electronic networking, the problems of notation - such as the difficulty of expressing ideas about teaching in written form, and the concerns about permanently archived messages - for teachers and trainee teachers, and the lack of skills which many trainee teachers bring to electronic discussions. In the context of initial teacher education, it was suggested that these four aspects require clarification and development before the potential advantages of electronic networking can be realised. Some specific suggestions about how these issues might be resolved were presented.

Haptically simulating soft tissue using spherical voxel and reactive agents

This thesis describes technology developed by the author enabling trainee surgeons to perform needle insertion procedures with force feedback (haptics) on a virtual patient. Addition of the sense of touch to medical simulation is arguably the most important step forward in the evolution of haptic technology to this day.

The psychological contract in apprenticeships and traineeships : differing perceptions

As with any contract of employment, the mutual expectations of the employer and the apprentice/trainee are very important. Apprenticeships and traineeships have greater expectations than other employment contracts of employment because of the training component of the contract. This paper reports on some of the findings of a major NCVER-funded national project examining mutual expectations in apprenticeships and traineeships through the concept of the psychological contract. The paper focuses on the differences between employers and apprentices/trainees, in the expectations each party has of the other and in the extent to which the expectations are perceived to have been met.

Enhancing narrative coherence in simulated interviews about child abuse

Purpose – Simulated child interviews, where adults play the role of a child witness for trainee investigative interviewers, are an essential tool used to train investigators to adhere to non-leading, open-ended questions. The aim of this study is to examine whether the use of a training procedure that guides persons playing the role of a child in simulated interviews results in interviewees producing more coherent narratives (measured by the number of story grammar details).

Design/methodology/approach – A total of 80 police officers individually engaged in ten-minute interviews, whereby an untrained (colleague), or trained respondent, played the role of the child interviewee. For each child respondent condition, the interviews varied according to child age (five or eight years).

Findings – As predicted, trained respondents reported a higher proportion of story grammar elements and a lower proportion of contextual information than the untrained respondents, as well as more story grammar elements in response to open-ended questions. However, there were limitations in how well both groups tailored their story grammar to the age of the child they were representing.

Originality/value – These findings demonstrate that our training procedure promotes a more coherent interviewee account, and facilitates a response style that is more reinforcing of open-ended questions.

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk : the COSMOS randomised controlled trial

Objective  To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care.

Design  Randomised controlled trial.

Setting  Tertiary-care women’s hospital in Melbourne, Australia.

Population  A total of 2314 low-risk pregnant women.

Methods  Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by ‘back-up’ midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care.

Main outcome measures  Primary outcome: caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight.

Results  In total 2314 women were randomised–1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67–0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06–1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79–0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67–0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44–0.90; P = 0.01). No infant outcomes favoured standard care.

Conclusion  In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births.