A Patient Needs To Learn To Use A Walker. Which Domain Is Required For Learning This Skill?

• Journal Listing
• BMJ
• v.336(7653); 2008 May 17
• PMC2386620

BMJ. 2008 May 17; 336(7653): 1129–1131.

Teaching Rounds

Didactics procedural skills

Teodor P Grantcharov

¹University of Toronto

²Partition of Full general Surgery, St Michael's Hospital, Toronto, ON M5B 1W8, Canada

Richard K Reznick

^aneAcademy of Toronto

"See one, do one" is non the best way to teach the circuitous technical procedures needed in many hospital based specialties

For many patients, a successful clinical consequence depends on having a well performed technical procedure. Crucial for surgeons, technical competence is condign an of import element of training for many infirmary based specialists: interventional radiologists, cardiologists, gastroenterologists, endovascular therapists, and others. "See one, practise one" is no longer appropriate for educating health professionals to perform complex procedures. Graduated independence, the hallmark of the approach to didactics procedural skills, is being challenged by concerns for patients' safety, the skyrocketing complexity of procedures, and a diminishing work week for trainees. Finding the balance betwixt patients' prophylactic and doctors' training will crave a more structured approach to our skills curriculum, including continuous assessment of skills, constructive feedback, and provision of opportunities for deliberate do in the education environment.

This paper aims to provide an show based algorithm for procedural skills training. It focuses on educational activity technical skills, which are just i component of a successful procedure—others are clinical judgment, communication, and squad piece of work.

What practice we know well-nigh electric current pedagogy of procedural skills?

Currently, training in technical procedures is often unsystematic and unstructured. Educational tools that have been validated are often underutilised,¹ and evidence is growing that adjunctive methods for procedural didactics, such equally the use of virtual reality, take not been translated into clinical practice. Teaching communities worldwide would do good from standardised validated curriculums that utilise proved technology for didactics technical competence finer, minimise wasted time, and focus on the breadth of skills needed for a specific do.

Pre-patient preparation

Pretraining for technical skills should involve three major components, which should exist done outside the clinical setting:

• The cerebral knowledge surrounding the specific medical conditions, the steps of a procedure, and the part and performance of equipment;

• Instruction in basic, generic enabling skills that will prepare students by giving them the fundamental elements needed to perform specific procedures; and

• An opportunity to perform a procedure in a diversity of different platforms, such as virtual reality training, demote model simulations, and cadaver and live animal model surgery.

The educational experience of these imitation models tin be enhanced by designing patient focused, realistic scenarios involving false patients and team members.² During all of these three elements learners must have access to patient, expert teachers who provide ongoing summative and formative evaluation.

This approach would bring to our operating theatres the strategies that accept in the literature on learning motor skills, proved efficacious. Instead of learning how to do a cholecystectomy in the operating theatre, trainees would become comfortable with basic laparoscopic psychomotor skills before performing their first alive laparoscopic procedure.³ This tin exist effective: in a randomised controlled trial of 16 surgical trainees, those who had received virtual reality simulation grooming for a laparoscopic procedure were faster, made fewer errors, and showed greater economic system of motility than those who had non received such grooming.⁴ To this cease, we have designed and are currently validating standardised comprehensive "pre-patient" curriculum (fig i)​ .

Fig 1 Pre-patient training programme

Grooming in a clinical situation

At the completion of a period of "pre-training," learners should be exposed to technical procedures in clinical situations, following validated models for didactics psychomotor skills, such equally those of George and Doto and of Walker and Peyton.^{v 6} A systematic clinical exposure can be achieved through the steps shown in effigy two​ .

Fig 2 Training in a clinical situation: curriculum in basic laparoscopy (laparoscopic cholecystectomy)

Practise bones psychomotor skills until proficiency criteria are achieved

Basic skills should generally be practised in the simulation lab. The traditional arroyo has been based on time spent, but as students learn at unlike rates we should use a proficiency based system that allows advocacy once competence in subordinate skills has been shown.⁷

Acquire knowledge that is specific to the procedure

Knowledge specific to the procedure should include knowledge of the instrumentation, beefcake, indications, and possible complications associated with the procedure, preoperative work-upwardly, and postoperative management, every bit well equally successful completion of an cess procedure. In one case criteria take been met successfully, the learner should be considered competent to start on basic skills procedures.

Demonstration of the procedure

The learner should review a video or a demonstration by an proficient of a existent procedure on patients.^vi This will allow the student to observe and empathize the skills necessary to perform the procedure.

Intermission the process into central steps

The trainer describes the steps while performing the process. This will help the learner identify and follow the fundamental steps of the procedure in the correct mode and club. Such deconstruction has established the key procedural steps for common surgical procedures such equally laparoscopic cholecystectomy, hernia repair, and Nissen'due south fundoplication.^{8 9}

Comprehension

The trainer demonstrates the steps of the procedure while the learner describes the steps. This aims to ensure that the learner understands the steps clearly.

Perform single components of a procedure

Fourth dimension limitation is often an of import obstruction for inferior doctors wishing to perform procedures in the clinical surround. One selection is to split each technical procedure into ii or three major steps and to allow learners to do but ane step at a time until each has been mastered. This allows the learner initially to exercise manageable steps, without influencing the flow of patients in a decorated schedule. This approach besides has the advantage of "setting the educational stage" for the learner, who knows that he or she will be expected to exercise a specific element of the procedure. This removes the ofttimes observed adverse psychological fallout of "non being allowed" (ofttimes without explanation) to complete the process. For example, in lower gastrointestinal endoscopy, the learner may start with retracting the endoscope, which already has been inserted by the teacher. When this has been mastered the learner may introduce the scope through the descending and ascending colon, and finally may try to pass the instrument through more than challenging areas such as the sigmoid colon or the splenic and hepatic flexures.

Performing an entire procedure

Once students have mastered each component of the procedure, they should exist allowed to perform the whole procedure under supervision.

Assessment and feedback throughout the learning procedure

To reinforce learning, each operative procedure should be followed by a debriefing session. Video recording the learner's performance of the procedure, followed by a review of this recording by both trainer and learner, could provide structured cess and effective feedback. This has been shown to contribute to faster conquering of skills and reduce the learning curves in the operating theatre.^ix

What are the challenges?

Difficulties associated with the organization

Often, educational opportunities cannot exist utilised considering of the pressure for speed and maximum efficiency. This is exacerbated when faculty and staff have to deal with overcrowding and schedules that are running late. A stepwise arroyo volition allow learners to exist exposed gradually to tasks they experience comfortable and competent with, and will minimise any "wasted" clinical time.

Exposure to technical procedures is currently lengthened and uneven, based on bachelor opportunity rather than on structured educational objectives. This can pb to inefficient preparation and prolong the time before competency with each procedure is achieved. A modular curriculum will focus the exposure to procedures and speed up learning.

Many training programmes maintain a hierarchical approach: inferior trainees are not taught tasks considered to be in the domain of more senior trainees. This may lead to wasted clinical time early in the career for many competent learners. A structured preparation curriculum should allow junior doctors to learn procedures once they have shown they accept adequate skills and noesis.

Difficulties associated with the learner

Observational studies have shown that trainees acquire knowledge and skills at different rates, and some find specific types of procedures challenging.^ten A pre-patient training programme will let simply those who show sufficient technical proficiency and knowledge of procedures to continue their training on patients.

Difficulties associated with the trainer

Concerns among attending physicians about the safety of training junior doctors in advanced procedures has often been an obstruction. Observational studies take indicated that these concerns are unjustified and that with appropriate safeguards, early training does not compromise patient safety.^xi

What next?

If the model we have described is to succeed, trainees must exist assigned to consummate modular based learning objectives and must spend long enough in environments where these tin be achieved. Future work should aim at piloting this approach, investigating its bear on on acquiring skills, and meeting the demand for acceptable preparation in less time.

Key points

• Technical competence is a key element in many surgical and non-surgical specialties

• Bones skills training should take place in the skills lab until proficiency criteria have been met

• Tools for training have been designed and validated

• Putting comprehensive teaching curriculums into clinical practise is the next step

• The impact on quality and speed of skills acquisition remains to be evaluated

Notes

This series provides an update on practical teaching methods for decorated clinicians who teach. The series advisers are Peter Cantillon, senior lecturer in the department of full general practice at the National Academy of Republic of ireland, Galway, Ireland; and Yvonne Steinert, professor of family medicine, associate dean for faculty development, and director of the Eye for Medical Education at McGill University, Montreal, Canada

Notes

Contributors: Both authors contributed every bit and both authors are guarantors.

Competing interests: None declared.

Provenance and peer review: Deputed; externally peer reviewed.

References

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386620/

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