Teaching a skillV. Ashoorion MD., Msc

Medical Education Research Center

Lesson Plan

• After this session you should :– Define Clinical Skills and Clinical Procedures– Nominate Four goal of any skill training

exercise– Rethink about the way acquiring a procedural

skill– Describe different teaching methods for

procedural skills– Discuss pros and cons of different teaching

methods

Clinical Skills

• clinical procedures • collaboration/ communication with

professionals• communication with patients and/or families• health promotion and risk assessment• legal, ethical, and value concerns• maintaining currency within the discipline• management and diagnosis• management of specific conditions• organ systems examinations

• A procedure is defined as a skill that involved physical interaction with patients that was either invasive or required the use of tools or equipment.

• Example– suturing – spinal tap – circumcision

• Skills training must be – systematic – carefully planned – fully evaluated

Four goal of any skill training exercise

• Acquisition: effective performance in appropriate circumstances.

• Competency: the skilled behavior will be performed to a predetermined level

• Retention: the skilled activity will be retained over time.

• Transfer: the training time directed to one skill will enhance the future the acquisition or application of new skills

teaching procedural skills methods

• Teaching methods can be divided to two categories: – Traditional

• giving lecture • see one, do one, teach one

– Non-traditional

" see one, do one, teach one "

• the most common method of teaching procedural skills in medical school and residency settings

Some critiques about the strategy

• This method may threaten patient safety • Some articles has suggested some modifications

– "read about one, go to a course on one, do fifteen simulated ones, be evaluated about one, have some clinical experience about one, then teach one and expect ongoing evaluation"

– “see one, do one, teach one, have one"• Shortage of enough opportunity for students to do

procedures• Physicians are often unwilling to provide training • Some procedures are so rare in clinical practice for

trainees to "see one, do one" let alone teach.• Training based on a systematic methodology is

preferred to the traditional "see one, do one, teach one" approach

• Skills require more than performing tasks. • They include:

– Knowledge (indications, contraindications, complications and their prevention)

– Skill (preparation, technique, dexterity)– Communication (consent, comfort and dignity

of patients; realising when to get help).

Five step to design

• This model, which is applicable to any procedural skill to be acquired in a medical context, can be summarized as having five steps:

• 1. Establishing the need• 2. Task analysis• 3. Developing objectives• 4. Instructional design and implementation of

skill training• 5. Program evaluation

Review performance objective

1-Plan aheadAssess learners need

Assure that the learner has prepared (e.g.; through lecture, discussion, visualization, CDs, books

Make explicit commentary during the demonstration 2- Demonstrate the procedure

Allow for questions or interruptions

Ask the learner to verbalize what s/he is doing 3-observe the learner in action and allow for practiceEncourage self –assessment and reflection

Be specific and descriptive 4-Provide feedback

Ensure feedback is non-judgemental and performance -based

Perceived level of skills5-Encourage learners' self assessment of

Perceived areas requiring improvement

Ensure varying degree of complexity 6-Allow for practice under less than ideal conditions

The unprepared learner

7- Prepare to modify approach for Different learning sites

"opportunistic" learning and teaching

Seven principle for Teaching Procedural and Technical Skills

A four-step approach to teaching skills

• Demonstration. Trainer demonstrates at normal speed, without commentary.

• Deconstruction. Trainer demonstrates while describing steps.

• Comprehension. Trainer demonstrates while learner describes steps.

• Performance. Learner demonstrates while learner describes steps.

Session structure

• Setting– Have you made assumptions about the

learners’ basic knowledge • (“You know that, don’t you?”).

– Consider their orientation: • are they sitting beside you or opposite (mirror

image)? • Are they left- or right-handed? can they see?

• Dialogue.– Have you broken the procedure into clear steps?– Is the task too large to learn at one sitting? – Are you giving positive feedback (what they did well,

what they could improve)? – Have you corrected mistakes? Avoid talking too much

— either giving too much detail (trying to cover too much in one sitting) or chatting about something else (worried they are bored).

• Closure. – Can they do it? – Do you need to explain how the procedure

may differ under different circumstances?

Application in practice

• Step 1 should be demonstrated with a real patient. It is important to allow the learner to identify with a competent performance.

• Steps 2 and 3 can be done theoretically or with the equipment, away from the patient.

• Steps 1 and 2 can be repeated in a larger group (eg, with a video), then steps 3 and 4 can be done in small groups.

• Steps should be done in more than one sitting.

Consider the way you currently teach a skill and think about what the four-step approach

may add

• The trainee has shifted from being “consciously incompetent” to being “consciously competent”

• Only with repeated practice will he or she be able to perform satisfactorily in a variety of situations.

Take-home message

• Teaching a skill involves knowledge – Indications– Contraindications– complications and prevention) – skill (dexterity, performance) – communication (consent, dignity, realizing when to get

help)– interpret the results of diagnostic procedures

• When teaching a skill, consider using or adapting a four-step approach.

• Consider the structure of your teaching session:– set (prior learning, orientation) – dialogue (manageable steps) – Closure (application to other settings).

• Facilities for teaching clinical Skills– Simulated patients– Videos– Manikins– Computers– virtual reality – lectures – slides– demonstrations– supervised hands‑on – practice on manikins – classmate volunteers

Benefit of Teaching with facilities

• Learning skills occurs– in a safe environment– receive feedback– reach a certain level of competence

• before they use the skills on patients.

Animals/ cadavers

Medical students٭

٭

Manikin with role playing actor

Real patient Manikin

Low Low High High Low Realism (fidelity)

Low Low High High Low Verbal interaction

Anatomy different

Noninvasive only

High Low High Perform procedure

High (a Low (d) High (a, c) Low (b) High (a) Safety

Very high (e) High Low Low High Ethical concerns

High Low High Low High Costs

Methods of teaching procedural skills – attributes

Thank you

Any Question?