teaching procedural skills - university of colorado · pdf file ·...

Teaching Procedural Skills: an overview of the literature

Matt Rustici M.D. Instructor of Pediatrics Denver Health, Children’s Hospital Colorado Katie Rustici M.D. PGY4, OBGYN CU Denver, Anschutz Campus

How did we get here?

CU Residents Academy of Medical Educators Literature review Workgroup formed to create new model to teach procedures

Schedule 3 levels of learners ◦ Beginner Skill automation

*** Small group activity ◦ Intermediate Cue recognition ◦ Advanced Hypothetical situations

Practice teaching procedural skills in small groups ◦ Master Deliberate practice

*** Group Competition

3 STAGE LEARNING OF PROCEDURAL SKILLS

Teaching is procedural skills is hard

Watch the video

Evaluate what is done well or …

not so well

Teaching is procedural skills is hard

Feedback?

Categorization of Learners

Beginner Learners ◦Steps

Intermediate Learners ◦Cues

Advanced Learners ◦Troubleshooting

Categorization of Learners

Teaching in a systematic way can improve learning

Assessing and categorizing a learner allows for directed teaching

Focus on ALL three levels

Grantcharov, Teaching procedural skills. BMJ, 2008. Aggarwal, Framework for systematic training and assessment of technical skills. J Am Coll Surg, 2007

Kruglikova, The impact of constructive feedback on training in GI endoscopy using high fidelity virtual reality simulation Gut, 2009.

BEGINNER LEARNERS

Beginners Learners

HOW DO I DO IT? ◦ Entry level learners for a specific procedural skill ◦Have little past experience with procedure ◦Often are still trying to figure out how the procedure should progress

Dance, Dance, Revolution: motor skills in the “real world”

http://en.wikipedia.org/wiki/File:Dance_Dance_Revolution_North_American_arcade_machine_3.jpg

http://en.wikipedia.org/wiki/File:Stemania4_Alpha4.png

SKILL AUTOMATION

How the brain learns skills

Initially multiple brain areas activated

Becomes streamlined Require repetition Learning curves are

different but everyone can become competent with practice

Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Barsuk, J.H., et al., Crit Care Med, 2009

Automated Knowledge “Second nature” Un-accessible to the teacher Multi-faceted ◦Motor ◦Assessment ◦Cognitive

Brain changes with practice

Increased practice => reduction in un-necessary brain activation

Ericsson K. The Cambridge Handbook of Expertise and Expert Performance. 2006

Motor skill acquisition

• 37 Surgical residents • 12 tasks that required mastery to move forward

Implementation, Construct Validity, and Benefit of a Proficiency-Based Knot-Tying and Suturing Curriculum, Goova, et al. J Surg Educ, 2008

Motor skill acquisition TABLE 1. Task Descriptions and Expert Proficiency Levels Task Cutoff Time (seconds) Proficiency Score* 1. Palm needle driver (7 seconds, no errors) 2. 2-Handed knot tying without tension (10 seconds, no errors) 3. 1-Handed knot tying without tension (10 seconds, no errors) 4. 2-Handed knot tying with tension, surgeon’s knot (13 seconds, no errors) 5. 2-Handed knot tying with tension, slip knot (15 seconds, no errors) 6. 1-Handed knot tying with tension, slip knot (15 seconds, no errors) 7. Simple interrupted suturing (18 seconds, no errors) 8. Interrupted horizontal mattress suturing (31 seconds, no errors) 9. Interrupted vertical mattress suturing (31 seconds, no errors) 10. Simple running suturing (165 seconds, no errors) 11. Subcuticular running suturing (204 seconds, no errors) 12. Subcuticular interrupted suturing (33 seconds, no errors) *Score = cutoff time - completion time - 10 x sum of errors.


Motor skill acquisition


Beginner Learners

Teaching Tips ◦ Describe movements with simple terms

and from the perspective of the learner ◦ Demonstrate with movements ◦ Be patient

*** Remember the steps are often highly automated

Tips from the Literature

Interference leads to less learning

◦ Limit distractions during learning

◦ Minimize talking the first time someone

sees a procedure

Build motor skills in non-clinical settings

Elliott, D. et al. Action representations in perception, motor control and learning: implications for medical education. Medical Education, 2011

Reznick, R.K. and H. MacRae, Teaching surgical skills--changes in the wind. N Engl J Med

Schedule 3 levels of learners ◦ Beginner Automation

*** Small group activity ◦ Intermediate Cue recognition

◦ Advanced Hypothetical situations

◦ Master Deliberate practice

*** Group Practice

Practice teaching procedural skills in small groups

Automation of Knowledge In small groups:

1. Designate a teacher 2. Pick up the banana and suture kit 3. Without talking, teach the group

how to close a laceration 4. Group members should try to

document each step in the procedure (physical and mental)

5. Compare procedural steps when finished

Automation: Discussion

Was suturing easy to teach without talking?

How many steps did your group identify? Were there steps that were noticed by

the group but not the teacher? As a learner, was it helpful or difficult to

watch a procedure without narration?

INTERMEDIATE LEARNERS

What is a Cue?

Sounds, sights, smells, auras, gut feelings that let you know things are RIGHT or WRONG

Barely noticeable to advanced learners, not known by beginners

Examples of Missed Cues

Why didn’t you stop? You could see the area was bleeding.

Why did you keep cutting? You could obviously see you were in the wrong tissue plane.

Why did you tie that knot? You were clearly in the wrong spot.

Intermediate Learners HOW DO I KNOW I’M DOING IT

RIGHT? ◦Well acquainted with how procedure

should progress ◦ Capable of performing procedure with

close supervision ◦Often are competent in a normal

uncomplicated procedure but may not be confident that their assessment and decisions are correct

Teaching procedural skills is hard

Feedback?

Intermediate Learners

Teaching Tips ◦ Identification of landmarks How do you know its not an artery How do you know you are pulling on a

structure too hard How do you know the bleeding is

really stopped

From Minnesota Surgical Error Attorneys Website Surgical Suture Errors Use of the wrong suture. Some materials are not

recommended for patients with anemia, malnutrition, or other conditions. A surgeon who overlooks these health warnings can injure their patient.

Poor stitching technique. A suture that is not inserted correctly may allow the wound to remain partially open. This makes it very difficult for the wound to heal, while also allowing bacteria to get inside the patient’s body.

http://www.tsrinjurylaw.com/minnesota-surgical-error-attorneys

From Minnesota Surgical Error Attorneys Website Surgical Suture Errors Incorrect removal. If a medical worker removes a

suture prematurely or incorrectly, the wound’s healing process will be interrupted.

Health Consequences to Suture Errors: Victims of improper suturing may suffer from serious medical complications, including infection and excessive blood loss. These complications can be very expensive to treat, as well as painful and potentially traumatic for the patient. Fortunately, there are legal options for anyone who has been injured by surgical suturing errors.

http://www.tsrinjurylaw.com/minnesota-surgical-error-attorneys


Teaching Tips ◦ Teach checkpoints to ensure things are going correctly Ex: Stopping to make sure the patient

is correctly positioned at certain points

◦ Think of transitions between steps and how you know the last step is complete and correct


Teaching Tips ◦ Teach cues for when things are going wrong How do you know the patient is becoming

unstable How do you know when something “just

doesn’t look right” How do you know when you cut/punctured

something wrong


Observation is a good surrogate for

experience and picking up on cues

◦ Much better outcomes with feedback

◦ Learners should observe from behind the

person doing procedure


Grantcharov, T.P. and R.K. Reznick, Teaching procedural skills. BMJ, 2008.

Why is teaching intermediate learners so difficult?

Knowledge is half-automated

Learner already can do steps

Learners often don’t show

knowledge gaps until a

complication occurs

ADVANCED LEARNERS

Dance, Dance, Revolution: Advanced

What makes this child advanced?

Do you think he memorized it?

How good would he be at a

different version of DDR?

Where is he now?

Advanced Learners HOW DO I TROUBLESHOOT IT? ◦ Confident in their ability to perform

procedures in a correct and efficient manner ◦ Can identify abnormalities or

complications within a procedure ◦Often have seen only a few

complications or rare abnormalities within a procedure and are not comfortable managing all situations

Advanced Learners

“How do you troubleshoot it?” Teaching Tips: ◦ Common pitfalls ◦ Uncommon complications ◦Management of unusual circumstances

*** Minimally automated, use hypothetical situations


Realistic situations are best for

advanced skills

Learning without feedback is poor

Not all learners of the same year are of

the same level


Kruglikova, I., et al., The impact of constructive feedback on training in gastrointestinal endoscopy using high fidelity virtual reality simulation. A randomized controlled trial. Gut, 2009.

Review of Learner Categories

Beginner Learners ◦What do I do?

Intermediate Learners ◦How do I know its correct?

Advanced Learners ◦How do I get myself out of trouble?

Schedule 3 levels of learners ◦ Beginner Skill Automation


Practice teaching procedural skills in small groups ◦ Mastery Deliberate practice


Small Group Practice

Role Play Directions 1. Return to small groups 2. Give case scenario to one group member

* This person should read the case to themselves, they will be the learner

3. Chose another group member to be the teacher

4. Role play the scenario 1. Determine level of learner 2. Structure teaching to the appropriate level 3. Give Feedback

5. Discuss as a group

Specific Teaching Tips

Beginner

Intermediate

Advanced


*** Small group activity ◦ Intermediate Cue recognition

◦ Advanced Hypothetical situations

Practice teaching procedural skills in small groups ◦ Mastery Deliberate practice


Defining an Master/Expert Pick the MASTER NFL quarterback?

A) Peyton Manning

B) Kyle Orton

C) Tim Tebow

Defining Expertise

•Experience ≠ Expertise

•Expertise is validated via expert performance

(measurable accomplishments)

•What do we measure in medicine?

The Path to Expertise


Deliberate Practice Focusing on improving small

aspects of a procedure/task Training drills With more experience

errors decrease, smoother, less concentration needed (automated)

10,000 hours


Medical Expertise

Ericsson. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004

Group Practice

Suture Competition Goal: Fastest “correct” simple interrupted

suture Rules: ◦ All materials start on table separated ◦ Participants start and stop their own timer ◦ Must drive needle, puncture banana, tie 4 ties and

cut string ◦ Cannot use fingers ◦ Any suture technique is permitted (instrument,

single handed, double handed) ◦ Maximum 3 attempts ◦ “Correctness” determined by judges (tight knot,

square knot, orientation) Prize: fastest suturer gets Starbucks card

Suture Competition

Would this be an effective training technique?

Was it fun? Do you need a prize?

Summary 3 levels of learners ◦ Beginner Automation hard to teach

◦ Intermediate Cue recognition often forgotten

◦ Advanced Hypothetical situations are fun

◦ Master Deliberate practice is paramount

Thank You Questions/Discussion?

An expert is one who knows more and more about less and less. Nicholas M. Butler An expert is somebody who is more than 50 miles from home, has no responsibility for implementing the advice he gives, and shows slides. Edwin Meese

References: 1. Reznick, R.K. and H. MacRae, Teaching surgical skills--changes in the wind. N Engl J Med,

2006. 355(25): p. 2664-9. 2. Mason, W.T. and P.W. Strike, See one, do one, teach one--is this still how it works? A

comparison of the medical and nursing professions in the teaching of practical procedures. Med Teach, 2003. 25(6): p. 664-6.

3. Ericsson, K.A., Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med, 2004. 79(10 Suppl): p. S70-81.

4. Wanzel, K.R., et al., Teaching technical skills: training on a simple, inexpensive, and portable model. Plast Reconstr Surg, 2002. 109(1): p. 258-63.

5. Song, S., Consciousness and the consolidation of motor learning. Behav Brain Res, 2009. 196(2): p. 180-6.

6. Schaafstal, A., J.M. Schraagen, and M. van Berlo, Cognitive task analysis and innovation of training: the case of structured troubleshooting. Hum Factors, 2000. 42(1): p. 75-86.

7. Velmahos, G.C., et al., Cognitive task analysis for teaching technical skills in an inanimate surgical skills laboratory. Am J Surg, 2004. 187(1): p. 114-9.

8. Sullivan, M.E., et al., The use of cognitive task analysis to improve the learning of percutaneous tracheostomy placement. Am J Surg, 2007. 193(1): p. 96-9.

9. Aggarwal, R., T.P. Grantcharov, and A. Darzi, Framework for systematic training and assessment of technical skills. J Am Coll Surg, 2007. 204(4): p. 697-705.

10. Kruglikova, I., et al., The impact of constructive feedback on training in gastrointestinal endoscopy using high fidelity virtual reality simulation. A randomized controlled trial. Gut, 2009.

References: 11. Ericsson, K.A., K. Nandagopal, and R.W. Roring, Toward a science of exceptional

achievement: attaining superior performance through deliberate practice. Ann N Y Acad Sci, 2009. 1172: p. 199-217.

12. Barsuk, J.H., et al., Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med, 2009. 37(10): p. 2697-701.

13. Gaies, M.G., et al., Reforming procedural skills training for pediatric residents: a randomized, interventional trial. Pediatrics, 2009. 124(2): p. 610-9.

14. Boehler, M.L., et al., A theory-based curriculum for enhancing surgical skillfulness. J Am Coll Surg, 2007. 205(3): p. 492-7.

15. Dinsmore, R.C. and J.H. North, Basic skin flaps for the general surgeon: a teaching method. South Med J, 2000. 93(8): p. 783-6.

16. Halm, E.A., C. Lee, and M.R. Chassin, Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med, 2002. 137(6): p. 511-20.

17. Barrett, M.J., et al., Mastering cardiac murmurs: the power of repetition. Chest, 2004. 126(2): p. 470-5.

18. Goova, M.T., et al., Implementation, construct validity, and benefit of a proficiency-based knot-tying and suturing curriculum. J Surg Educ, 2008. 65(4): p. 309-15.

19. Elliott, D. et al. Action representations in perception, motor control and learning: implications for medical education. Medical Education, 2011: 45: 119-131

teaching procedural skills - university of colorado · pdf file ·...

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