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.
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
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”
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.
Implementation, Construct Validity, and Benefit of a Proficiency-Based Knot-Tying and Suturing Curriculum, Goova, et al. J Surg Educ, 2008
Motor skill acquisition
Implementation, Construct Validity, and Benefit of a Proficiency-Based Knot-Tying and Suturing Curriculum, Goova, et al. J Surg Educ, 2008
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?
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
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
Intermediate Learners
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
Intermediate Learners
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
Tips from the Literature
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
Elliott, D. et al. Action representations in perception, motor control and learning: implications for medical education. Medical Education, 2011
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
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
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
Tips from the Literature
Realistic situations are best for
advanced skills
Learning without feedback is poor
Not all learners of the same year are of
the same level
Elliott, D. et al. Action representations in perception, motor control and learning: implications for medical education. Medical Education, 2011
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
*** Small group activity ◦ Intermediate Cue recognition ◦ Advanced Hypothetical situations
Practice teaching procedural skills in small groups ◦ Mastery Deliberate practice
*** Group Competition
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
Schedule 3 levels of learners ◦ Beginner Skill automation
*** Small group activity ◦ Intermediate Cue recognition
◦ Advanced Hypothetical situations
Practice teaching procedural skills in small groups ◦ Mastery Deliberate practice
*** Group Competition
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
Ericsson K. The Cambridge Handbook of Expertise and Expert Performance. 2006
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
Ericsson K. The Cambridge Handbook of Expertise and Expert Performance. 2006
Medical Expertise
Ericsson. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004
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
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
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