Teaching Procedural Skills

Teaching Procedural Skills

Amy S. Oxentenko, MD, FACP, FACG, AGAFMayo Clinic, Rochester

No Disclosures

Objectives

• Create an educational contract with a trainee before an endoscopy session.

• State the basic features of creating the appropriate learning environment.

• Describe the stages of conscious competence.• Reiterate the 4-step approach to teaching

psychomotor skills.• List factors for when to take over the scope.• Give feedback applying Pendleton’s Rules.

Outline of Talk

• Set-Dialogue-Closure Model• Peyton’s Learning Cycle of Competency• 4-Step Process of Teaching a Psychomotor Skill• Instruction and Communication• Performance-Enhancing Feedback• Pendleton's Rules• Simulator Training

If a Colleague was Sick and Coverage Was Needed, Would You Rather…

A. Supervise in the fellow continuity clinic?

B. Give your canned talk to the med students?

C. Perform a few hospital consults?

D. Supervise a fellow doing colonoscopy? During their first week EVER of scoping

Why is teaching endoscopy so challenging???

Teaching a Procedural Skill: Why Does it Feel so Tough?

• Many have not had instruction in teaching a procedural skill

• Many were taught varying ways to do the same thing as trainees, so it is not always clear what is the “best” way

• It requires a balance of patience, diligence, and removing ourselves from the “expert” stage of competence in order to teach

Let’s See How Well We Are Doing?

• How many of you currently set an agenda with every trainee before an endoscopy shift?

• How many of you give specific feedback after a procedure shift?

• How many of you create a learning plan for a trainee for their next procedure shift?

Set-Dialogue-Closure Model

Set-Dialogue-Closure Model

• Set– Period before training begins– Verbal: Assessment of skills, agenda setting, develop an

educational contract– Physical: equipment, ergonomics, room set-up, position

• Dialogue– Delivery of actual training (4-step process)

• Closure– Summarize and reflect– Performance-enhancing feedback– Define learning objectives for the next session

Framework for Endoscopy Training

• Preparation• Assessment• Align agendas, set objectives/ground rules

Set

• Clear, consistent, concise, common• Performance –enhancing instruction• Dual task interference/cognitive overload

Dialogue

• Summary• Performance-enhancing feedback• Take-home message

Closure

Educational contract

The Set

Framework of the Agenda

Knowledge

Skills

Attitudes

• Pre/post/intraoperatively• Awareness of pt needs

• Endoscopic technique• Prioritization• Time management

• Motivation• Relationship with team• Relationship with pt

Setting Learning Objectives:“SMARTER”

• S Specific• M Measurable• A Achievable• R Relevant• T Timely• E Economical• R Reviewed (modified prn)

The Dialogue

Psychomotor (Bloom’s) Taxonomy for Hierarchy of Skills

MasteryDoes

Shows howKnows howKnows whatAwareness

Peyton’s Learning Cycle of Competency

Unconscious Competence

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

Competency Learning Model

• Aware that you lack a skill.

• Working on a skill; requires thought.

• Not aware that you lack a skill.

• So skilled you don’t have to think about it.

Unconscious Competence

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

Competency Learning Model

• Uh-oh. There’s something I don’t know.

• I can do this when I am deliberate about it.

• I don’t know what I don’t know.

• I can do this without even thinking.

Unconscious Competence

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

Competency Learning Model

• Trainee• Teacher

• Early trainee

• Expert

Unconscious Competence

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

Competency Learning Model

• Early trainee

Unconscious Competence

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

Competency Learning Model

• Trainee

• Early trainee

Unconscious Competence

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

Competency Learning Model

• Expert

Unconscious Competence

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

Competency Learning Model

• Teacher

• Expert

Unconscious Competence

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

How to Instruct When Teaching a Psychomotor Skill

1. Trainer perform, trainee observes, with no verbal explanation.

2. Trainer performs, trainee observes, with the trainer explaining the procedure in detail, breaking it down into steps.

3. Trainer performs, and the trainee explains the procedure in detail, breaking it down into steps.

4. The trainee performs the procedure, and verbalizes what they plan to do before they do it.

Demonstration of Teaching a Skill

Review of Teaching a Psychomotor Skill

• Explain the 4-step process before beginning• Follow the 4-step process • Pick a standard case to demonstrate• Do not do deliberate errors to prove a point• Do not go into lengthy discussions• Avoid shortcuts

Once In the Endoscopy Suite

• Where are you standing?– Can you see trainee’s hands and scope?– Can you see monitor?

• Have you considered the ergonomics?– Wrists, shoulders, back– Table height, scope weight, scope handling, shoes

• Are you being consistent in your practice?– How to hold and position the scope– How to insert the scope

Instruction and Communication During a Procedure

• Timing of instruction

• Type of instruction

• Specific language

• Teaching vignettes

Timing of Instruction• Avoid dual-task interference (cognitive overload)– Cannot listen and perform at same time• Example: Balance checkbook while someone asks questions

– Don’t ask them to provide ongoing commentary• Silence is OKAY!!!• Occasional words of praise• If instruction needed:– Pause and instruct– Ask intermittent questions

Types of Instruction

–Directive • Use more for the inexperienced or when struggling• “Deflect the tip up.”

–Didactic• Use before starting a specific task (polypectomy)

–Questioning• Use more for the experienced• “What do you think is the problem?”• “What are your options for this polyp?”

Specific Language(12 Terms to Use)

1. Stop2. Slow down3. Pull back4. Advance5. Blow6. Suck

7. Tip up8. Tip down9. Tip right10.Tip left11.Clockwise torque12.Counter-clockwise torque

Using specific terms will avoid more vague or differing ways to describe the same task

Teaching Vignettes

• Can do these before or after the case:• Before:– “This patient has diarrhea. Describe what you will be looking

for? What do you plan to do if the mucosa looks normal versus abnormal?”

• After:– “So you removed a small pedunculated polyp with a cold

snare. Tell me how you would have remove a polyp if 0.5 cm vs 1 cm vs 2 cm? What if sessile vs pedunculated. Snare or forceps? Hot or cold? Settings?”

Before Taking the Scope Away

• Do you know what the problem is?• Are your instructions correct?• Are your instructions clear?• Are your instructions understood?• Were your instructions carried out?• Is the technical challenge above skill level?

• If “yes” for 1-6, then consider taking scope

Patient Factors Affecting When to Take the Scope Away

• Previous experience• Team concerns• Pain• Complications• Indications for the case

• Withdrawal of consent• Change in clinical

parameters• Age• Time• Pathology found

The Closure

Feedback During Endoscopy

• Better defined as:– “Performance-enhancing training”

• Includes:–Performance-enhancing instruction–Performance-enhancing feedback• Follows the rules of giving feedback in general

–Decision training–Checking for understanding

Example During Colonoscopy

• “You did that wrong. Next time, turn the dial up and torque to the right.”

• VERSUS

• “Let’s talk about what you think happened and what you need to do next time to avoid that same problem.”

Pendleton’s Rules

1. Trainer asks trainee what went well2. Trainer says what he/she thought went well3. Trainer asks trainee what might be done

differently next time4. Trainer says what he/she thinks should be

done differently next time5. Trainer then does a summary statement for

the learner to have a learning plan

Simulation Training

• “Something that is made to look, feel, or behave like something else especially so that it can be studied or used to train people”

• Merriam Webster Dictionary

• May allow more rapid progress of skills in the endoscopy suite

• Can range from videos to patient simulation to animal models to box simulators to advanced simulators

Simulation Training

• Don’t expect to send a trainee alone to practice on a simulator for the 1st time– Learn incorrect technique– No feedback provided

• Use simulator to practice a technique once known

• Simulators should be used at each level of training

Questions?

Summary

• Use the Set-Dialogue-Closure Model to format your teaching sessions in endoscopy; never forget to set the agenda!

• Appreciate that as an expert, you need to transition yourself to the phase of “conscious competence” in order to effectively teach a procedural skill.

• Use the 4-Step Process of Teaching a Psychomotor Skill when teaching a trainee a new technique.

• Utilize Pendleton's Rules to give performance-enhancing feedback after a teaching session, and set objectives for the trainee’s next session as well.

Thank you!

Oxentenko.amy@mayo.edu