Module 3: Teaching Physical Exams and Procedural Skills

Module 3: Teaching Physical Exams and Procedural Skills
Residents as Teachers & Leaders Module Created by: Nadia J. Ismail, M.D., MPH Assistant Professor of Medicine & Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medicine Web Page and Module Formatting by: Maria Victoria Tejada-Simon, Ph.D. Assistant Professor of Molecular Physiology and Biophysics

Click here if you completed the pre-test.
Welcome Welcome to Module 3: Teaching Physical Exams and Procedural Skills. You should have completed a pre-test for this module. Did you complete the “honesty pledge” question? In that pledge you agreed to take the pre-test first, then read the module and then take the post-test after reading the module. If you did not complete the pre-test, please exit the module now and complete it; then return to the module. Your honesty is appreciated. Click here if you completed the pre-test.

Welcome Module 3 will take approximately minutes to complete. If you do the practice exercises included in the module it will take you longer, closer to 60 minutes. There is no time limit to complete the module. Resources to Module 3 can be found on the main RATL web page.

Welcome Psychomotor skills is a term used to describe any procedure or physical exam skill. Being able to teach a psychomotor skill is an important concept in advancing medical students and peer’s performance.

Welcome As an intern, you will need to learn many skills before teaching one. Most interns focus their teaching of psychomotor skills on physical exam skills such as heart, lung, abdominal, and musculoskeletal exams. However, evidence supports that students also need teaching on other basic skills such as taking blood pressures, eye exams and GU exams.

Welcome As a resident, you will be the key individual teaching student procedural skills. They will learn important points such as indications, contraindication and the steps involved with a skill from you. So once again, your role as the teacher of a psychomotor skill is very important because students get to observe an expert, gain experience under your watchful eye and build confidence in their abilities to perform such skills based on your feedback and instruction.

Welcome As you progress in your training and your own proficiency improves, especially for the surgical and procedure-oriented specialties, you will become a master-teacher of psychomotor skills. You will become so competent in certain skills it may be hard to recall how to break it down. This is when you are an expert and are unconsciously competent in your skill.

Welcome In this module we will focus on teaching medical students and colleagues basic physical exam and procedural skills. Evidence exists that residents can improve their confidence and teaching abilities as well as their own physical exam and procedure skills by being able to teach them.

Welcome You should have completed your pre-test for Module 3. If you have not, please exit now, take the test and return to the module. You will complete a post-modules test after you finish reading Module 3. Thank you again for your honesty and effort!

Goals The goals of Module 3 are to reinforce organized teaching using Irby’s three phases while emphasizing teaching psychomotor skills to learners and peers using a 5-step model and a modification of the 5-step model. We’ve also planned reflection and practice opportunities in this module. A 2-hour workshop is also available for more practice opportunities for teaching psychomotor skills.

Objectives Upon completion, you should be able to:
List the three components of organized clinical teaching. (Irby’s model) State in order, the 5-steps involved in teaching psychomotor skills. Discuss the components and importance of effective communication during teaching a procedure.

Agenda In this module, we will cover the following:
Organizing teaching sessions Steps for teaching psychomotor skills Communication & feedback while teaching psychomotor skills Summary

Introduction “Anybody who believes that all you have to do to be a good teacher is to love to teach, also has to believe that all you have to do to become a good surgeon is to love to cut.” L. Mansnersus. The New York Times. November 7, 1993: Section 4A

Introduction This quote emphasizes the important point that the desire to learn a skill does not equate to proficiency in performing a skill. Mastering skills includes performing the task flawlessly under normal conditions and also being able to respond appropriately in the event of complications or equipment failure.

Introduction Mastering a skill may take many attempts of performing it both correctly and incorrectly. Evidence suggests that perfecting even basic skills may take at least 24 or more performances to master the skill.

Introduction Reflect when you first learned a particular physical exam or procedural skill from a resident, attending or other teacher.

Introduction What on this list did the “teacher” do well in order to help you learn that skill? Demonstrated enthusiasm Was supportive Was organized Assessed my comfort Demonstrated the skill Guided my performance Communicated clearly Broke down the skill into easy to follow steps Provided feedback Allowed for my reflection Was professional Demonstrated patience Assured patient safety

Introduction In your reflection, your teacher probably demonstrated some and hopefully most of the characteristics of a good teacher listed in the previous table. Each of these characteristics is essential to teaching psychomotor skills. Organizing your teaching Effective communication throughout Assessing the learner’s skill level Demonstrating and providing guidance Allowing for reflection and providing immediate feedback Assuring patient safety Teaching in a professional manner

Introduction Many times you are asked to teach a skill that you may not have mastered yourself. The old “see one, do one, teach one” is a myth. It is an unrealistic expectation to believe that you can master or correctly teach a skill after performing it only once. But the model of watching an expert, attempting under their guidance and practicing is a much better model to use for your teaching and learning.

Introduction If you take this model and put it to use, you are more likely to become an expert and you will be better suited for teaching the same skill to learners. Some procedures are fairly easy and with low risk to patients. A fundoscopic exam and blood pressure are examples. These can certainly be attempted by an inexperienced learner with little harm to a patient.

Introduction For more challenging or risky procedures, it is extremely important for you to reflect on how comfortable you are with that procedure so that you know when you should ask for help. The more experience you have, the more comfortable you will feel. Recall, it may require more than twenty times of performing a skill before you are comfortable. So allow yourself to feel comfortable before you teach complex skills.

Introduction That’s why Reznick et al. in his 2006 NEJM article states that: “Sheer volume of exposure… is the current hallmark in surgical training.” ~Reznick et al. NEJM 2006 Thus repetition and practice are key to performing and teaching psychomotor skills.

Definition What is a psychomotor skill?
Psychomotor skills are skills that require a physical or muscular movement in an appropriate series of steps to complete the task accurately. Psychomotor skills can be lumped into physical exams (PE) or procedure skills (p-skills).

Definition Examples of psychomotor skills include:
Doing a physical exam of any body part: Fundoscopic exam of the eye Auscultation the heart or lungs Range of motion for a joint Palpation of the liver and spleen Doing any procedure from gram staining sputum to performing a heart transplant.

Review – Irby’s Model There are several elements that are necessary to achieve a positive and effective teaching experience. Recall Module 2 -Teaching 101, what are some ways to create a safe learning environment?

Review – Irby’s Model You can create a safe learning environment by setting ground rules, communicating effectively, and organizing your teaching. Organizing your teaching into three stages helps you teach efficiently and effectively. What are the three phases of organized teaching?

Review – Irby’s Model The three phases of organized teaching are: preparation, teaching and reflection. We will use Irby’s model of clinical teaching to demonstrate how to organize teaching encounters for physical exams and procedures. Using this model will help you be a more effective and efficient teacher.

Review Three Stages of Clinical Teaching by Irby:
Preparation Teaching Reflection Before During After Adapted from: David Irby, How attending physicians make instructional decisions when conducting teaching rounds. Acad. Med., 1992; 67(10):

Click here for the answer
Teaching PE & P-Skills The first thing to do before embarking on a teaching session is to prepare. Can you recall the 4 key components of the preparation phase? Preparation Reflection Teaching Before During After Click here for the answer

Preparation 4 Key Components: Teacher (self) Learner Patient Context

Preparation-Teacher Preparation In preparation, you prepare yourself as the teacher first, then prepare the learner, the patient and the teaching context (or environment). As the teacher, you should feel prepared to teach the skill by enhancing your knowledge of the steps involved in the skill, its indications & contraindications, risks & benefits, materials & equipment, potential complications, and cost/system issues.

Preparation-Teacher Preparation This means you may have to read more, talk with consultants, and practice before performing the skill on a patient. If you do not feel comfortable with the knowledge or the steps to perform for a particular skill, you can and should seek the assistance of someone who is “expert” – e.g.: chief residents, fellows, attending physicians, nurses, etc.

Preparation-Teacher Preparation Make sure you feel confident in your knowledge and skill level before attempting any invasive procedures that may be harmful to the patient. This critical step helps to prevent harming our patients. Today we have simulations, videos, plastic modules, web modules, etc. to help enhance skills.

Preparation-Teacher Preparation Such tools are helpful for preparing both teacher and learner for both basic and more difficult procedures. Simulation helps to reduce the risk to patients and allows the learner to practice and gain proficiency. Here is a list of other teaching tools that can be used to prepare both teacher and learner.

Toolbox of Teaching Techniques
Preparation-Teacher Preparation Toolbox of Teaching Techniques Mini-didactics Readings Role plays Draw diagrams Practice sessions/simulations Web/computer sources Delegation of teaching Checklists Round Robin Questions Brainstorming Site visits Handouts Demonstrations Games AV/TV/Audio/Video-tapes

Preparation-Teacher Preparation Those items listed on the left hand side are very useful for preparing to teach PE skills & procedures. Which of these have you used and which will you plan to add to your teaching activities? Try role plays, drawings, checklists, and observations. These can be fun and improve learning. We’ve provided and example of a check list later in this module.

Preparation-Learner Preparation Another very important element of the preparation phase is assessing & preparing the learner. You want to know how competent they are or are not in the skills they are trying to perform. You want to make sure the learner is ready to perform a skill or procedure on a patient. Thus, as the teacher, you must assess the learner’s stage of competency.

Preparation-Learner Preparation When first learning procedures, we all start at the unconsciously incompetent stage and move to the unconsciously competent stage. Thus we move from novice to expert. The diagram on the next slide shows the stages of competency starting at novice at the bottom (unconsciously incompetent) to expert at the top (unconsciously competent).

Stages of Competence Unconsciously incompetent Consciously incompetent
Preparation Un- consciously competent Expert Consciously competent Consciously incompetent Unconsciously incompetent Novice

Preparation-Learner Preparation It may take years to get to the top of the pyramid or to the unconsciously competent stage, but continued practice is the key to getting there. Stage 1 – unconsciously incompetent can be defined as those early learners who are unaware of what they should know. Stage 2 – consciously incompetent are those who have the knowledge or cognition to know what they are doing but lack the skill.

Preparation-Learner Preparation Stage 3 – the consciously competent are those who have knowledge and are able to perform the skill in usual situations. Their skills are fixed. Stage 4 – those who are unconsciously competent – they perform procures almost automatically without thinking about the knowledge or steps and can generally adjust to unusual situations or complications.

Preparation-Learner Preparation For beginners, you first try to move them from the level of being unaware to the level where they have knowledge. Ask them to read up on the procedure or watch videos and experts. This provided the knowledge they need. Then you try to move them from knowledge to being able to perform the skill. This is where allowing them to watch you and then try it under your watchful eye is key.

Preparation-Learner Preparation Lastly, allow them opportunity to practice. They now have knowledge and skill at this level but need continued practice to improve and perfect their skills. With more practice, experience, time and guidance, they become more competent and move to an automatic performance level. This can be demonstrated with another diagram. Here an expert is at autonomous performance – basically “auto pilot.”

Stages of Competence Unaware Cognition Expert Fixation Novice
Preparation Autonomous Performance Expert Fixation Cognition Unaware Novice

Preparation-Learner Preparation Learners need to know the basics about the procedure as well as the steps to the procedure. Allow your learners to learn on their own. Think outside the box to find ways to help learners gain knowledge by self learning. Suggest different formats of gaining basic knowledge of procedures using the tool box for teaching.

Preparation-Learner Preparation This helps them be more prepared while you can focus on other tasks. Remember we want to be efficient in our teaching but we also want to keep the learner involved. Think back to your toolbox and select a way for students to learn on their own. You can click below to review the tool box or skip tool box. Review Tool Box Skip Tool Box

Toolbox of Teaching Techniques
Preparation-Teacher Preparation Toolbox of Teaching Techniques Mini-didactics Readings Role plays Draw diagrams Practice sessions/simulations Web/computer sources Delegation of teaching Checklists Round Robin Questions Brainstorming Site visits Handouts Demonstrations Games AV/TV/Audio/Video-tapes

Examples of Some Tools Delegate teaching – the more someone teaches something the better they learn it. Round robin questions – a method to elicit everyone’s responses in order to make everyone feel part of the group and to avoid embarrassing one learner – e.g.: ask everyone in the group to give their best guest at what is going on or to state their thoughts about something. Site visits – take them to the cath lab, pharmacy or radiology to learn about what goes on there. Games – create games – they are fun and learners like doing them – e.g.: scavenger hunts for learners using up-to-date pages *remember to keep it focused on the patient case

Preparation ~Confucius 450 BC

Preparation-Learner Preparation Confucius understood that adult learners need to be involved in order to retain more information. So involve learners and help them understand the following for each procedure: Why learn the procedure? What tools are involved? What are the indications? Contraindications? What are the risks? Benefits? What are the potential complications? Are there alternatives?

Preparation-Learner Preparation As the teacher, you can use questions to help identify what level the learner is currently at. This allows you to “diagnose the learner.” Examples: Have you ever done this procedure before? Describe the steps of the procedure. Compare and contrast the risks and benefits of the procedure? Discuss common complications and what to do in the event of a complication.

Preparation-Learner Preparation These questions highlight a balance of higher order questions discussed in Module 1. Based on the student’s answer to your questions, you should answer any incorrect knowledge, reinforce correct answers and direct the learner to self-teaching activities to fill in their “gaps in knowledge.” However, you don’t want to ask the student to tell you everything they know – this is not efficient.

Preparation-Learner Preparation Let’s use performing a blood pressure procedure on a patient as an example. You should first ask if they know what a blood pressure is and describe the technique, the purpose and reasons for doing blood pressures. Then ask about their experience with doing blood pressures and ask them to list the steps involved in measuring blood pressure.

Preparation-Learner Preparation Answer questions appropriately and direct learners to self-learn. They can learn on their own until you feel they are ready to try taking a blood pressure. That’s when you move to the phase 2 - teaching. But first, let’s finish preparing by addressing how to prepare your patient and the teaching context.

Preparation-Patient Preparation In all cases, except emergent life threatening situations, talk to the patient ahead of time about any procedures to be performed. This allows for a more controlled and relaxed discussion. Provide informed consent and inform the patient when and where the procedure is to be done. Timing is everything! Don’t schedule to teach a procedure during the patient’s meal times or other scheduled procedures such as x-rays or blood draw times.

Preparation-Patient Preparation Have your student witness your discussion with the patient. This demonstrates to the patient that the student is part of the team. During this discussion, you can also get the patient’s consent for the student’s role during the procedure.

Preparation-Patient Preparation Inform the patient that “student Blank will assist me and perform parts or all of the procedure.” Ask the patient if they agree with the student’s role and illicit any comments, concerns and questions about the procedure. This keeps the patient in the decision-making process and demonstrates effective patient-centered communication for the student.

Preparation-Context Preparation The final step in preparation is preparation of the teaching context or environment. When possible, make sure to set up in advance. Keep these few things in mind: A private or enclosed location Room/space is comfortable for all-including room temperature Gather all supplies (with a few extras just in case) Make sure the patient & learner are available Inform nurses-they can make sure to arrange nursing duties around the procedure

Preparation Preparation In summary, preparation gets everyone on board and can bring learners up to speed. In the example of teaching how to take a blood pressure, if well prepared – you, the teacher, would have reviewed the steps involved and be prepared for teaching the skill. You would make sure the learner is aware of the importance and steps, perhaps they have watched a few examples and you have assessed their competence level. Your patient would be available and ready; the BP cuff and equipment would be at the bedside and you would expect few, if any, interruptions.

Teaching PE & P-Skills Now that you, your learner, your patient and the teaching context are prepared, you are ready for your teaching encounter. Teaching a skill uses similar teaching principles discussed in Module 1 – setting a learning environment, questioning and assessing learners, using effective communication, providing immediate feedback and including the patient. Now we will focus on the specific skills needed for teaching PE & P-Skills.

Teaching Teaching: Setting a safe learning environment - the tone
Preparation Reflection Before During After Teaching: Setting a safe learning environment - the tone Teaching a PE and P-Skill Providing continuous feedback during the teaching

Teaching Teaching Again, we emphasize setting the tone - provide an overview for the learner and patient, describe what is to be done, inform the learner what to focus on and that all questions are appropriate. A nice option is to give learners the option to take a time out – meaning if the student feels uncomfortable at some point during the teaching session or gets nauseous or is unsure of the next step – it is ok to ask for a time out. You can then step in and complete the procedure or get them ready to proceed.

Teaching Teaching In teaching PE & P-Skills, recall there are some that are low risk and conducive to allowing learners to try with minimal skills – BP measures, fundoscopic exams and perhaps drawing blood. (We will come back to less invasive procedure in the end of this section.) But for more complicated procedures or procedures/PE with higher risk to the patient – pelvic exams, a-lines, lumbar punctures or surgical procedures, we recommend trying the 5-step method.

Teaching 5-Step Teaching Model: Preceptor gives overview
Preceptor demonstrates without commentary Preceptor demonstrates with commentary Learner talks through skill with teacher Learner performs skill under watchful eye of the teacher

Teaching 5-Step Teaching Model:
Step 1 -Preceptor gives overview (can be done in preparation phase and immediately repeated before procedure). Step 2 -Preceptor demonstrates without commentary. The teacher does the complete blood pressure measurement without speaking. This allows the student to gain a mental “big picture” at least once. From: George, JH, and Doto, FX; For the Office-based Teacher of Family Medicine; Family Medicine (2001) Vol 33, No. 8, p. 577.

Step 3 -Preceptor demonstrates with commentary. The teacher repeats the blood pressure measurement but this time talks through each step. This allows the learner to gain a verbal and repeated visual picture. Step 4 - Learner talks through skill. This allows the teacher to assess how well the learner has the steps committed to memory.

Step 5 – Learner performs skill under watchful eye of the teacher. This allows learners to practice with direct supervision to prevent complications and reinforce correct behaviors.

Teaching Teaching The five step model is an excellent model to follow when you have multiple opportunities to practice the same procedure – i.e.: IVs, ABGs, blood draws, gram stains, lung exam, blood pressures, etc. However, if you want to teach a skill that occurs rarely during a rotation (for example a pericardiocentesis or lumbar puncture), you may have to adjust your model.

Teaching Teaching Steps 1-3 can be accomplished in simulation labs or with videos. But steps 4-5 should always be done under your tutelage and watchful eye.

Teaching Teaching All procedures or exam skills can and should be broken down into large steps for the learner to remember. For example, a cardiac exam can be broken down into the following broad steps: Positioning the patient Inspection Palpation Auscultation

Teaching Teaching Each step may have one or more sub-steps. Learners can probably remember three to four basic steps. More than that and you may find using a mnemonic or checklist helpful. It’s no secret that mnemonics help improve recall – so use them; make some up if you have too! E.G.: PIPA Positioning the patient Inspection Palpation Auscultation

Teaching Teaching Check lists are also a good way to review important details or steps that you must teach. They also serve as a learning tool & reference for the learner. Click here to see example of a check list Click here to skip example of a check list

Checklist: BP Teaching Step 5: Remove cuff Step 1: Position patient
Patient seated, feet flat on the floor, are at heart level. Ask patient to remain silent. Step 2: Apply cuff Roll up or remove sleeve. Locate artery marking on cuff. Palpate brachial artery Line up cuff marking and artery Wrap cuff snuggly around arm and Velcro into place Step 3: Check for obliteration point Close insufflation bulb valve. Palpate radial artery Inflate cuff until the radial pulse is obliterated. Note number on sphygmomanometer and deflate cuff by releasing the insufflation valve. Document the pulse obliteration point. Step 4: Measure blood pressure Place stethoscope in ears and diaphragm on brachial artery. Close valve and insufflate the cuff. Insufflate the cuff to 20 mmHg above the pulse obliteration point. Slowly release the pressure on the insufflation valve by no more than 2 mmHg per second. Note the point on the meter in which you hear the first Korrotkoff noise. Continue deflating the pressure. Note the point in which the transition to the last Korotkoff noise is made. Release the pressure by opening the insufflation valve. Remove stethoscope. Step 5: Remove cuff Remover BP cuff. Assist patient in covering arm. Step 6: Document & provide patient measure Document the BP in systolic and diastolic numbers as mmHg. Discuss results with patient

Teaching Teaching Demonstrating a PE or P-Skill is important and a powerful learning tool. Utilize this often – especially when time is of the essence. The 5-step model allows you to demonstrate a skill at least two times for the learner to benefit from. But if running late and you need to draw blood quickly – have the learner watch as you talk through the steps or have them talk through the steps with your feedback. Remember, the learner cannot read your mind – think out loud!

Teaching Teaching Two key concepts in teaching PE & P-Skills is to make sure you directly observe the learner performing each step - be prepared to step in for possible complications and provide continuous feedback and commentary. Continuous feedback and commentary keeps your learn on the path to success. If you are teaching a procedure and not constantly talking – you are not maximizing their learning, your ability to teach or your time.

Teaching E.G.: Blood draw with commentary
“That’s the appropriate placement of the tourniquet…[pause & observe] ..that may be a little too tight, notice their fingers are becoming cyanotic – let’s loosen it up… [pause & observe] …excellent your vein is visible and their fingers aren’t blue…proceed…. [observing] .. That’s a good angle – remember – barrel up…[observing] – good now insert your needle…”

Teaching on the Go! Teaching Be efficient – you can give an overview, assess student knowledge and have students recite procedural steps anytime during the work day. E.g.: walks between patient rooms; down to radiology; or on the way to conference.

Teaching Teaching If you want to allow the learner some role in performing a procedure but perhaps not all of the procedure (steps 4 or 5), we strongly suggest a “hands over hand” method – the teacher has their hands on top of the students hands for an important action – then the teacher completes the procedure. Lend a helping hand!

Teaching Teaching e.g.: Pericardiocentesis - In this situation the teacher uses their hands over the students hands so that both are palpating the subxyphoid notch. It is your hands over theirs doing the insertion of the needle. It is your hands over theirs that feels for the beat of the myocardium against the needle. They experience the procedure through your hands guiding their hands. Again we will emphasize – the safety of the patient comes first.

Teaching Teaching It is important to observe closely and to be prepared to step in as needed. If while performing a thoracentesis, you notice the student percussing at T-8 instead of T-10, you can simply place your hands on their hands, move their hands into the correct position T-10, and then let them proceed. Try to avoid yelling or making sudden moves/comments – this can scare the learner and the patient.

Listen to demonstration
Teaching Teaching Remaining silent and moving their hands into the correct position is a nice way of intervening without the patient becoming concerned about their safety and well-being and the student doesn’t feel embarrassed. Click here to hear an example of how to provide immediate feedback at a potentially critical point during a procedure. Listen to demonstration Skip demonstration

Teaching Teaching The advantage of using the 5-step model is that it gives the learner four exposures before performing the task. This is especially useful for first time procedures. Remember, repetition is key to mastering a skill! Provide opportunities to practice. If you remember these 5-steps and commit them to memory, you will be better prepared and more organized for your teaching session.

Teaching Teaching Scenario: You are in the emergency room and it’s the last day of a prospective surgery student’s rotation. An MVA patient is brought in and needs a chest tube. The student has never done one but has seen one last week and is eager to learn. The patient is currently stable. How would you involved the student to get some “hands on experience” before ending the rotation?

Teaching Teaching First, while you are prepping the patient’s skin ask the student to recite the major steps for placing a chest tube. With your ears you are assessing that they know the steps in the procedure and with their eyes they are observing how to prep the patient in an semi-urgent setting. Then have them prep in sterile fashion and use their hands for land marks – so the student feels where the tub is to be placed in relation to normal land marks. Place their hand in the correct position if needed.

Teaching Teaching Then describe the steps you are performing to anesthetize the patient, cut through the skin and prepare to enter the pleural space. Once you are ready to insert the tub, allow the student to step in and use a “hand-over-hand” method. Then quickly place their finger in the incision to feel the pleura as you grab the tube and the forceps – clamp it and then put it in their hands. Then you hold their hands and push until it gets into place.

Teaching Teaching Allow the student to suture the tub in place at the procedure and move to the reflective stage. Again, the patient should be fairly stable so that any delay for teaching will not cause harm to the patient.

Teaching Teaching This is an example of modifying the 5-step model using step 3, 4 & 5 in combination with the hand over hands method. Recall the basic, low risk, non-invasive procedures we mentioned above? This is where you can modify the five steps into a shorter version in order to teach your learners. They can do steps 1- 4 on their own by watching a video & using props. Then you focus on teaching step 5 – they perform the BP measurement while you watch and provide continuous feedback and commentary.

Teaching Teaching Time to practice your own recall – try to list the five steps in the 5-step model. Click on the link below for the answer.

Teaching Answer: 5-Step Teaching Model:
Preceptor gives overview Preceptor demonstrates without commentary Preceptor demonstrates with commentary Learner talks through skill Learner performs skill under watchful eye of the teacher Don’t forget your continuous feedback and commentary!

Reflection You have just covered phases 1 (preparation) and 2 (teaching). Reflect on what you learned during the teaching phase. What is a key point you will take home with you? Let’s now focus our attention back to the Irby model. Can you describe important teaching concepts for phase 3 - reflection?

Reflection Reflection: Teacher and learner reflects on experience
Preparation Teaching Before During After Reflection: Teacher and learner reflects on experience Ask learner’s opinion Listen attentively & select teaching points Provide feedback Develop a plan for continued improvement

Reflection Reflection The last part of the Irby model is reflection. The overall purpose of this third phase is for both the teacher and the learner to have time to reflect on the teaching session and to develop a plan to continue learning and make improvements. As the teacher you should also be reflective – it will help you identify areas to improve your teaching. Ask yourself, “What did I do well and what could I have done better?” Decide what you will do differently the next time.

Reflection Some examples are below:
Then, ask the learner to discuss their experience. Here is a good place to use a balance of closed and open ended questions. Some examples are below: “So, how did things go for you?” “Let’s review what just happened. Describe your experience for me.” “Let’s reflect on this experience. What went well and what would you change the next time?” “Tell me how you did.”

Reflection Reflection Listen attentively and even jot down notes or key points if needed. While they talk, listen for teaching clues. Students may admit fear, uncertainty, concern about certain parts of the experience or be totally excited about being successful. As they talk they will probably give you a clue what they needed help with.

Reflection Reflection E.G.: “Well I thought everything went pretty well but I was concerned when the patient asked what I was doing. I got scared and didn’t know how to answer him.” They are practically begging for you to teach them how to communicate with the patient during the procedure. Take this opportunity and teach them.

Reflection Reflection In listening to their concerns or successes, select one or two points to help focus your teaching. Providing feedback on this point assures the learner that you listened to their comments and are willing to teach. Teaching points should come from both your direct observation of their skills and the learner’s reflection. Serious concerns should always be addressed immediately.

Reflection Reflection Scenario: The student is performing a breast exam – they unknowingly rest one hand on the patients breast while using the other hand to palpate for axillary nodes on the other side. Using your continuous feedback and commentary – you gently corrected the student during the procedure. During the reflection the student says the following:

Reflection Reflection “Overall I think things went well. I covered all the steps and I actually felt the breast mass. I would like to learn more about the different ways of examining the breasts.” The student is seeing their success and you can support that with positive feedback but they didn’t pick up on the importance of not resting their non-examining hand on the patient’s breast – maybe they did - but it’s still up to you to emphasize the teaching point.

Reflection So your reflection focus should be on 2 points:
Patient privacy and the potential problems associated with “violating boundaries” and what do you do with the non-examining hand? The three different methods for examining the breast, the differences in each technique and the sensitivity and specificity for each method.

Reflection Reflection Your active listening will make students feel like they are being attended to and heard. They will appreciate your interest in their learning. You can be supportive of their concerns by using agreement statements such as: “I remember when I did my first [blank] procedure. I was also very nervous about [blank].”

Reflection Reflection What a role model you will be to admit uncertainty and how you continued on to achieve mastery of the skill! Role models are not to be underestimated. Look at a few examples - Michael Jordan, Dr. Michael E. DeBakey, Sir William Osler, Florence Nightingale and others. Do you see yourself as a role model? You are!

Reflection Reflection “Perhaps most important of all, bedside teaching begins to foster another wonderful link with the past. The house staff [or student] watches you as carefully as does a child his parent, watch you attend to the patient, watch you observe, they catch your powers of diagnosis, the respect you hold for this other human being; they feel your attitude, your caring. The students witness your own dignity, and love you have for medicine, and for teaching. They link with you, and bond. And mentoring begins.” LaCombe, M.A., Ann Intern Med 1997

Reflection Reflection From direct observation you can isolate pinpoint skills to improve. If the student does every step well but fumbles the IV line during insertion – well there’s a reflection & teaching focus. Tell them exactly what they need to do to prevent fumbling the line in the future. This is focused and efficient teaching. It hones in on what they need to learn at this moment. It is also ‘effective feedback’.

Reflection Reflection Providing feedback is the 4th step in the reflection stage. Effective feedback can be defined as: A process by which a teacher provides a learner with the results of an evaluation with the purpose of improving the learner’s performance. Module 4 focuses on assessment, feedback and evaluation of learners. But for a brief introduction, you should provide feedback during the time you are teaching the physical exam or skill and during reflection.

Reflection Overall, feedback should be: Timely Specific
Based on objective observations Systematic Focused and limited Constructive and balanced Positive Regulated in quantity Nonjudgmental Expected Kronke, K. J Gen Int Med, 1992.

Reflection Reflection Let’s emphasize the importance of providing feedback based on a direct observation. Imagine judging a piano recital. How would you best assess the pianist’s ability to play the piano? You would watch them play of course. After, how would you tell them what was good or bad, or what to keep doing versus what needs improvement? Well, you would provide them with effective feedback.

Reflection Reflection So could you just ask them how they played? Sure you could but direct observation provides you with the information to provide meaningful feedback. You need to describe the characteristics of the performance that made it good (or bad) and you need to develop a plan to improve their playing.

Reflection Reflection Can you tell how well this student plays by the picture? Does this student play well? (Click on the icon to hear her play.) Think of an example you have had. Practice providing feedback to a student based on your observations. Make your feedback specific. Be sure to tell them what was “good” or the behaviors to continue doing. Then tell them what they need to do to improve. Altitude Piano

Reflection Reflection Module 4 will have more examples on providing effective feedback. Click here to hear a demonstration of a feedback statement after watching a student take a BP measurement. Skip Example Click for example

Reflection Reflection Feedback is most effective in changing behaviors when it is timely. When teaching physical exams and procedures, provide feedback immediately. Remember, adult learners want to be involved so include them in the process. Ask questions and allow time for reflection.

Reflection Reflection After providing feedback, help the student select a plan of action to improve their skills and prepare for the next procedure. Remember, immediate feedback and the opportunity to practice is important. Get them right in there to do the same procedure or physical exam skill as soon as possible. This is great reinforcement. You can send them off to learn, practice and then reattempt the skill.

Reflection Reflection Help your learners create a learning plan for success. If you identified learning deficits, help them identify how they will improve in that area. Deficient knowledge = read; skill = practice. You do not have to teach learners everything; self-learning is good. Ask them to read or watch videos in MDProcedures, up-to-date or other medical resources. Review topics with them and try to provide practice opportunities when possible.

Reflection Reflection The reflection phase is just as important in the three phases as preparation and teaching. Without reflection, the teaching encounter is incomplete. The reflection phase helps reinforce good behaviors, reduce future poor behaviors and continues learning. Reflection also provides opportunity for teachers to enhance their teaching skills.

Practice Question 1 What are the three phases of the Irby model of teaching? Click here for answer

Answer The three phases of Irby’s model are:
Preparation – before teaching Teaching - during Reflection – after teaching If you paid close attention you will see that you are really teaching and role modeling in every phase!! Thus a term coined at Baylor: “You cannot NOT teach!”

Practice Question 2 Which of the following is an example of a psychomotor skill? Eliciting reflexes Appendectomy Lumbar Puncture Heart exam All of the above

Answer All of the above are examples of psychomotor skills because they require a physical or muscular movement in an appropriate series of steps to complete the task accurately. Psychomotor skills can be lumped into physical exams or procedures. Teaching psychomotor skills requires knowledge of general teaching concepts combined with close observation and continuous feedback and commentary.

Practice & Demonstrations
The next few slides provide opportunities for either practice or demonstration of teaching psychomotor skills. Click here to go through demonstrations. Click here to skip demonstrations. Practice & Demonstrations Skip Practice and Demonstrations

Step 2 – without commentary
Demonstrations Click here to see a video demonstration of step 2: Preceptor demonstrates without (Student gains a verbal picture). Step 2 – without commentary Click on video to start

Demonstrations Click here to hear how a teacher provides an overview, breaks down the steps, then talks through a procedure to complete step 3 of the 5-step model: Preceptor demonstrates with commentary (Student gains a verbal picture). Step 3 – with commentary

Practice Practice organizing your teaching session for the following examples. Heart exam Blood draws (venopunctures) BP measurement (click here to go through steps in a BP measurement.) Skip BP measurement example

Example: Steps in BP Break down steps of a procedure into large categories first, then individual steps. There are 6 major steps in taking a blood pressure. They are: Position patient comfortably Apply cuff to patients arm Check for obliteration point Measure blood pressure Remove BP cuff Document and provide patient with BP results

Example: Steps in BP Once the big steps are defined, provide the individual steps that make up each big step in the series. Recall that using a check list is an efficient way of providing the smaller, individual steps in a procedure. The next slide provides an example of all the individual/smaller steps in each of the big steps of measuring the BP. Did you know there was this many steps in taking a blood pressure?

Example: Steps in BP 1 4 2 Remove cuff 3 5 6 Position patient
Patient seated, feet flat on the floor, are at heart level. Ask patient to remain silent. Apply cuff Roll up or remove sleeve. Locate artery marking on cuff. Palpate brachial artery Line up cuff marking and artery Wrap cuff snuggly around arm and Velcro into place Check for obliteration point Close insufflation bulb valve. Palpate radial artery Inflate cuff until the radial pulse is obliterated. Note number on sphygmomanometer and deflate cuff by releasing the insufflation valve. Document the pulse obliteration point. Measure blood pressure Place stethoscope in ears and diaphragm on brachial artery. Close valve and insufflate the cuff. Insufflate the cuff to 20 mmHg above the pulse obliteration point. Slowly release the pressure on the insufflation valve by no more than 2 mmHg per second. Note the point on the meter in which you hear the first Korrotkoff noise. Continue deflating the pressure. Note the point in which the transition to the last Korotkoff noise is made. Release the pressure by opening the insufflation valve. Remove stethoscope. Remove cuff Remover BP cuff. Assist patient in covering arm. Document & provide patient measure Document the BP in systolic and diastolic numbers as mmHg. Discuss results with patient 1 4 2 3 5 6

Poor Teaching Poor teaching can have its consequences! Those affected may include: Patients Learners Teachers Health care system Poor teaching can inhibit a student’s learning, cause harm to patients, add cost to the system, contribute to the hidden curriculum and perpetuate ineffective teaching skills. Do your best to follow the 3 phases in clinical teaching and reduce the effects of poor teaching.

Summary In teaching psychomotor skills, always provide a safe learning environment for your learners and patients. Follow Irby’s model to keep you organized and make sure you and everyone else is well prepared for the teaching session. The three phases are preparation, teaching and reflection.

Summary Assess both learner & yourself on the competency pyramid and always put the patient’s safety first. Use the 5-step model for teaching PE (physical exams) and P-Skills (procedural skills). Modify it based on competency levels, knowledge, time and risk to the patient. Use effective communication throughout and always provide effective feedback during and after each teaching encounter.

Take Home Points Psychomotor skills are both PE and P-Skills.
Use Irby’s model to organize teaching. Continuous feedback and commentary are very important in teaching psychomotor skills. The 5-step model can be used for teaching both common non-invasive or invasive procedures. Know when to modify the 5-step model and when to use the hands over hands method.

Conclusions We hope this module introduced you to some approaches to teaching psychomotor skills in an organized and effective format and how communication and patient safety are extremely important in teaching psychomotor skills.

Closing Instructions You have now successfully completed Module 3: Teaching Physical Exams and Procedural Skills. Please take a few minutes to complete the post-test and the evaluation for this module. The evaluation form and other learning materials for module 3 can be found on the main RATL web page. Thank you for participating!!!

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Module 3: Teaching Physical Exams and Procedural Skills

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