How not to do things

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  • How not to do thingsElapulli Prakash, Division of Basic Medical Sciences, Mercer University School of Medicine,Georgia, USA

    In regard to demonstratingprocedural skills to medicalstudents either in the human

    physiology lab or the clinicalskills centre, Ive observed teach-ers typically focus on instructinghow a procedure should be done,so that a valid and reliable resultcan be obtained, but in practicewe also express concern with thelimited engagement some stu-dents show in learning proceduralskills. Although we allude to andexplain why some precautionsshould be undertaken in perform-ing a procedure, the experience Iwish to share here is the potentialvalue of deliberate demonstra-tion, when appropriate, of hownot to do certain things, in addi-tion to showing how to do thingsright, and using this as a meansto promoting learners activeengagement with the technicalconcepts underlying the proce-dure.

    Take blood pressure measure-ment by sphygmomanometry, forexample. The basic steps are wellconveyed in this demonstration,1

    and some precautions needed are

    verbalised. Ill give two examplesof extensions to this demonstra-tion that I use when I teachstudents this skill for the firsttime. The question as to why thearm is normally held at the levelof the heart will arise, and anexplanation can be offered forthis, but I also have students takea reading with the arm kept at thelevel of the head in a subject whois standing, and let them see thedifference. Regarding using anappropriately sized cuff, I havethem try a measurement with acuff that is smaller than it shouldbe, and then with an appropri-ately sized cuff and let themexplain their observations interms of what they already know.

    As another example, whendemonstrating the clinicalexamination of extraocular mus-cles, I volunteer as the subjectand move my head in the direc-tion of the examining studentsmoving finger. Usually a studentin the group is quick to ask menot to move my head. When Iask why, one of them willrespond that it is because we

    intend to test the action ofextraocular muscles and not themuscles of the head.

    From speaking with my stu-dents, I know that they appreci-ate the learning opportunitiesthat this strategy of showinghow not to do things creates,and scholarly literature supportsthis concept.2 Grounding learn-ing in concrete experiences andusing them to facilitate reflec-tion, abstract conceptualisationand active experimentation,called experiential learning, isconsistent with a constructivistnotion of adult learning,3 andthis approximates scientificinquiry.4

    The specific use of a how notto do strategy is not new, but as amedical educator I tend to bedisappointed with it not beingeffectively used in the domain ofskills teaching with understand-ing and cooperative healthy vol-unteers, typically the studentsthemselves. To what extent weuse this depends, of course, onlearners prior knowledge, what

    I know thatstudentsappreciate thelearningopportunitiesthat thisstrategy ofshowing hownot to do thingscreates

    The viewfrom here

    2013 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2013; 10: 333334 333

  • we want them to learn and thelearning context. In clinical skillsteaching performed with patients,however, it is not appropriate toshow how not to do certain things(such as how not to do a lumbarpuncture), and the effort in suchinstances should by necessity beinvested in facilitating suitableabstract experiences or saferand ethical simulations of thatexperience.


    1. Williams JS, Brown SM, Conlin PR.

    Videos in clinical medicine. Blood-

    pressure measurement. N Engl J Med

    2009;360:e6. Available at http: doi full 10.1056 NEJMvcm0800157. Accessed on 1

    November 2012.

    2. Gosen J, Washbush J. A review of

    scholarship on assessing experien-

    tial learning effectiveness.

    Simulation and Gaming


    3. Sutherland P. Experiential learning

    and constructivism: potential for a

    mutually beneficial synthesis. in:

    Adult Learning: A Reader. Sutherland

    P ed., pp. 8092. London: Kogan

    Page Ltd; 2003.

    4. Kolb DA, Boyatzis RE, Mainemelis C.

    Experiential learning: previous re-

    search and new directions. in: Per-

    spectives on cognitive, learning, and

    thinking styles. Sternberg RJ, Zhang

    L, eds, pp. 193210. NJ: Lawrence

    Erlbaum; 2000.

    Corresponding authors contact details: Elapulli S. Prakash, MBBS, MD, Associate Professor of Physiology, Division of Basic Medical Sciences,Mercer University School of Medicine, 1550 College St, Macon, GA, 31207, USA. E-mail:

    Funding: None

    Conflict of interest: None

    Ethical approval: Not applicable

    doi: 10.1111/tct.12003

    It is notappropriate to

    show how not todo certain


    334 2013 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2013; 10: 333334