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One study, examining death notification skills of trainees, used ED volunteers who are specifically involved in the care of bereaved families. Three of the five studies reported the use of (and provided examples of) checklists, which were filled in by the observer during the clinical encounter. One example of such a checklist can be found in Shayne et al.23 Although some learners were initially apprehensive, all studies that measured learner reaction report an enthusiastic response to direct observation. A single paper was identified examining the effect of the presence of a consultant anesthesiologist CEP-40783 on patient outcomes in the setting of emergency intubation.24 This was a prospective cohort study examining 322 consecutive patients who required emergency tracheal intubation by anesthesia trainees. Instances where a consultant anesthetist was present were compared to instances where there was no direct senior supervision. Respiratory therapists who were assisting with the intubation recorded data on patient demographics, clinical management, and immediate complications. Additional data on patient outcomes were extracted from the patient��s medical records. There were no differences between the groups at baseline. Supervision of anesthesia trainees by a consultant anesthetist was associated with a significant decrease in the rate of immediate complications (6.1% vs. 21.7%, p?<?0.0001), particularly aspiration (0.9% vs. 5.8%, p?=?0.037). There were no differences in patient outcomes at 28?days. The paper does not report any information on learning experiences, changes in trainee behavior, or changes in organizational practice. When compared to interns and residents, attending EPs are more efficient at patient care,11 and their presence has been associated with improved patient outcomes.10 A similar association of senior staff presence with improved patient outcomes has been noted for emergency airway management by anesthesia trainees.24 Direct supervision of residents has high face validity��they are observed performing tasks in a clinical environment. This review has identified a small number of studies that describe the effects of this direct observation educational intervention in the ED. The papers in this review comprise descriptive and observational studies, qualitative studies, one survey, and two cohort studies. No study fulfilled all the criteria in the relevant checklist for methodologic rigor. All reported learning outcomes are ��positive,�� based on the self-report of participants. It is a weakness of the current literature in this area that more definite information on the effects of learning through direct observation of clinical practice is lacking. None of the studies were able to demonstrate a sustained change in behavior. This may be due to the difficulty in attributing behavior change to a single educational intervention.</div>
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