1. Teaching a skill V. Ashoorion MD., Msc Medical Education Research Center

2. 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

3. 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

4. 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

5. Skills training must be –systematic –carefully planned –fully evaluated

6. 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

7. teaching procedural skills methods Teaching methods can be divided to two categories: –Traditional giving lecture see one, do one, teach one –Non-traditional

8. "see one, do one, teach one" the most common method of teaching procedural skills in medical school and residency settings

9. 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

10. 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).

11. 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

12. Review performance objective 1-Plan ahead Assess 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 practice Encourage self – assessment and reflection Be specific and descriptive4-Provide feedback Ensure feedback is non-judgemental and performance -based Perceived level of skills 5-Encourage learners' self assessment of Perceived areas requiring improvement Ensure varying degree of complexity6-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

13. 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.

14. 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?

15. 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).

16. Closure. –Can they do it? –Do you need to explain how the procedure may differ under different circumstances?

17. 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.

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

19. 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.

21. 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

22. 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).

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

24. 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.

25. Animals/ cadavers Medical students ٭٭ Manikin with role playing actor Real patient Manikin  Low High LowRealism (fidelity) Low High LowVerbal interaction Anatomy different Noninvasive only HighLowHigh Perform procedure High (aLow (d)High (a, c)Low (b)High (a)Safety Very high (e)HighLow HighEthical concerns HighLowHighLowHighCosts Methods of teaching procedural skills – attributes

26. Thank you Any Question?