Module 3: Teaching Physical Exams and Procedural Skills

1. Module 3:Teaching Physical Exams and Procedural Skills Residents as Teachers & Leaders Module Created by: Nadia J. Ismail, M.D., MPH Assistant Professor of Medicine & Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medicine Web Page and Module Formatting by: Maria Victoria Tejada-Simon, Ph.D. Assistant Professor of Molecular Physiology and Biophysics

2. Welcome • Welcome to Module 3: Teaching Physical Exams and Procedural Skills. You should have completed a pretest for this module. Did you complete the “honesty pledge” question? • In that pledge you agreed to take the pretest first, then read the module and then take the post-test after reading the module. If you did not complete the pretest, please exit the module now and complete it; then return to the module. Your honesty is appreciated. Click here if you completed the pretest.

3. Welcome • Module 3 will take approximately 35-45 minutes to complete. If you do the practice exercises included in the module it will take you longer, closer to 60 minutes. There is no time limit to complete the module. Resources to module 3 can be found on the main RATL web page.

4. Welcome • Psychomotor skills is a term used to describe any procedure or physical exam skill. • Being able to teach a psychomotor skill is an important concept in advancing medical students and peer’s performance.

5. Welcome • As an intern, you will need to learn many skills before teaching one. • Most interns focus their teaching of psychomotor skills on physical exam skills such as heart, lung, abdominal, and musculoskeletal exams. • However, evidence supports that students also need teaching on other basic skills such as taking blood pressures, eye exams and GU exams.

6. Welcome • As a resident, you will be the key individual teaching student procedural skills. They will learn important points such as indications, contraindication and the steps involved with a skill from you. • So once again, your role as the teacher of a psychomotor skill is very important because students get to observe an expert, gain experience under your watchful eye and build confidence in their abilities to perform such skills based on your feedback and instruction.

7. Welcome • As you progress in your training and your own proficiency improves, especially for the surgical and procedure-oriented specialties, you will become a master-teacher of psychomotor skills. You will become so competent in certain skills it may be hard to recall how to break it down. This is when you are an expert and are unconsciously competent in your skill.

8. Welcome • In this module we will focus on teaching medical students and colleagues basic physical exam and procedural skills. • Evidence exists that residents can improve their confidence and teaching abilities as well as their own physical exam and procedure skills by being able to teach them.

9. Welcome • You should have completed your pretest for module 3. If you have not, please exit now, take the test and return to the module. • You will complete a post-modules test after you finish reading module 3. Thank you again for your honesty and effort!

10. Goals • The goals of module 3 are to reinforce organized teaching using Irby’s three phases while emphasizing teaching psychomotor skills to learners and peers using a 5-step model and a modification of the 5-step model. • We’ve also planed reflection and practice opportunities in this module. A 2-hour workshop is also available for more practice opportunities for teaching psychomotor skills.

11. Objectives • Upon completion, you should be able to: • List the three components of organized clinical teaching. (Irby’s model) • State in order, the 5-steps involved in teaching psychomotor skills. • Discuss the components and importance of effective communication during teaching a procedure.

12. Agenda • In this module, we will cover the following: • Organizing teaching sessions • Steps for teaching psychomotor skills • Communication & feedback while teaching psychomotor skills • Summary

13. Introduction • “Anybody who believes that all you have to do to be a good teacher is to love to teach, also has to believe that all you have to do to become a good surgeon is to love to cut.” L. Mansnersus. The New York Times. November 7, 1993: Section 4A

14. Introduction • This quote emphasizes the important point that the desire to learn a skill does not equate to proficiency in performing a skill. • Mastering skills includes performing the task flawlessly under normal conditions and also being able to respond appropriately in the event of complications or equipment failure.

15. Introduction • Mastering a skill may take many attempts of performing it both correctly and incorrectly. • Evidence suggests that perfecting even basic skills may take at least 24 or more performances to master the skill.

16. Reflect when you first learned a particular physical exam or procedural skill from a resident, attending or other teacher. Introduction

17. Introduction • What on this list did the “teacher” do well in order to help you learn that skill?

18. Introduction • In your reflection, your teacher probably demonstrated some and hopefully most of the characteristics of a good teacher listed in the previous table. • Each of these characteristics is essential to teaching psychomotor skills. • Organizing your teaching • Effective communication throughout • Assessing the learner’s skill level • Demonstrating and providing guidance • Allowing for reflection and providing immediate feedback • Assuring patient safety • Teaching in a professional manner

19. Introduction • Many times you are asked to teach a skill that you may not have mastered yourself. The old“see one, do one, teach one” is a myth. • It is an unrealistic expectation to believe that you can master or correctly teach a skill after performing it only once. But the model of watching an expert, attempting under their guidance and practicing is a much better model to use for your teaching and learning.

20. Introduction • If you take this model and put it to use, you are more likely to become and expert and you will be better suited for teaching the same skill to learners. • Some procedures are fairly easy and with low risk to patients. A fundoscopic exam and blood pressure are examples. These can certainly be attempted by an inexperienced learner with little harm to a patient.

21. Introduction • For more challenging or risky procedures, it is extremely important for you to reflect on how comfortable you are with that procedure so that you know when you should ask for help. • The more experience you have, the more comfortable you will feel. Recall, it may require more than twenty times of performing a skill before you are comfortable. So allow yourself to feel comfortable before you teach complex skills.

22. Introduction • That’s why Reznick et al in his 2006 NEJM article states that: • “Sheer volume of exposure… is the current hallmark in surgical training.” • ~Reznick et al. NEJM 2006 • Thus repetition and practice are key to performing and teaching psychomotor skills.

23. Definition • What is a psychomotor skill? • Psychomotor skills are skills that require a physical or muscular movement in an appropriate series of steps to complete the task accurately. • Psychomotor skills can be lumped into physical exams (PE) or procedure skills (p-skills).

24. Definition • Examples of psychomotor skills include: • Doing a physical exam of any body part: • Fundoscopic exam of the eye • Auscultation the heart or lungs • Range of motion for a joint • Palpation of the liver and spleen • Doing any procedure from gram staining sputum to performing a heart transplant.

25. Review – Irby’s Model • There are several elements that are necessary to achieve a positive and effective teaching experience. • Recall Module 2 -Teaching 101, what are some ways to create a safe learning environment?

26. Review – Irby’s Model • You can create a safe learning environment by setting ground rules, communicating effectively, and organizing your teaching. Organizing your teaching into three stages helps you teach efficiently and effectively. • What are the three phases of organized teaching?

27. Review – Irby’s Model • The three phases of organized teaching are: preparation, teaching and reflection. • We will use Irby’s model of clinical teaching to demonstrate how to organize teaching encounters for physical exams and procedures. • Using this model will help you be a more effective and efficient teacher.

28. ReviewThree Stages of Clinical Teaching by Irby: Preparation Teaching Reflection Before During After Adapted from: David Irby, How attending physicians make instructional decisions when conducting teaching rounds. Acad. Med., 1992; 67(10):630-638.

29. Preparation Reflection Teaching Before During After Teaching PE & P-Skills • The first thing to do before embarking on a teaching session is to prepare. Can you recall the 4 key components of the preparation phase? Click here for the answer

30. Preparation Preparation • 4 Key Components: • Teacher (self) • Learner • Patient • Context

31. Preparation Preparation-Teacher • In preparation, you prepare yourself as the teacher first, then prepare the learner, the patient and the teaching context (or environment). • As the teacher, you should feel prepared to teach the skill by enhancing your knowledge of the steps involved in the skill, its indications & contraindications, risks & benefits, materials & equipment, potential complications, and cost/system issues.

32. Preparation Preparation-Teacher • This means you may have to read more, talk with consultants, and practice before performing the skill on a patient. • If you do not feel comfortable with the knowledge or the steps to perform for a particular skill, you can and should seek the assistance of someone who is “expert” – e.g.: chief residents, fellows, attending physicians, nurses, etc.

33. Preparation Preparation-Teacher • Make sure you feel confident in your knowledge and skill level before attempting any invasive procedures that may be harmful to the patient. This critical step helps to prevent harming our patients. • Today we have simulations, videos, plastic modules, web modules, etc. to help enhance skills.

34. Preparation Preparation-Teacher • Such tools are helpful for preparing both teacher and learner for both basic and more difficult procedures. • Simulation helps to reduce the risk to patients and allows the learner to practice and gain proficiency. Here is a list of other teaching tools that can be used to prepare both teacher and learner.

35. Mini-didactics Readings Role plays Draw diagrams Practice sessions/simulations Web/computer sources Delegation of teaching Checklists Round Robin Questions Brainstorming Site visits Handouts Demonstrations Games AV/TV/Audio/Video-tapes Preparation Preparation-Teacher Toolbox of Teaching Techniques

36. Preparation Preparation-Teacher • Those items listed on the left hand side are very useful for preparing to teach PE skills & procedures. Which of these have you used and which will you plan to add to your teaching activities? • Try role plays, drawings, checklists, and observations. These can be fun and improve learning. We’ve provided and example of a check list later in this module.

37. Preparation Preparation-Learner • Another very important element of the preparation phase is assessing & preparing the learner. You want to know how competent they are or are not in the skills they are trying to perform. • You want to make sure the learner is ready to perform a skill or procedure on a patient. Thus, as the teacher, you must assess the learner’s stage of competency.

38. Preparation Preparation-Learner • When first learning procedures, we all start at the unconsciously incompetent stage and move to the unconsciously competent stage. Thus we move from novice to expert. • The diagram on the next slide shows the stages of competency starting at novice at the bottom (unconsciously incompetent) to expert at the top (unconsciously competent).

39. Preparation Stages of Competence Un- consciously competent Expert Consciously competent Consciously incompetent Unconsciously incompetent Novice

40. Preparation Preparation-Learner • It may take years to get to the top of the pyramid or to the unconsciously competent stage, but continued practice is the key to getting there. • Stage 1 – unconsciously incompetent can be defined as those early learners who are unaware of what they should know. • Stage 2 – consciously incompetent are those who have the knowledge or cognition to know what they are doing but lack the skill.

41. Preparation Preparation-Learner • Stage 3 – the consciously competent are those who have knowledge and are able to perform the skill in usual situations. Their skills are fixed. • Stage 4 – those who are unconsciously competent – they perform procures almost automatically without thinking about the knowledge or steps and can generally adjust to unusual situations or complications.

42. Preparation Preparation-Learner • For beginners, you first try to move them from the level of being unaware to the level where they have knowledge. Ask them to read up on the procedure or watch videos and experts. This provided the knowledge they need. • Then you try to move them from knowledge to being able to perform the skill. This is where allowing them to watch you and then try it under your watchful eye is key.

43. Preparation Preparation-Learner • Lastly, allow them opportunity to practice. They now have knowledge and skill at this level but need continued practice to improve and perfect their skills. With more practice, experience, time and guidance, they become more competent and move to an automatic performance level. • This can be demonstrated with another diagram. Here an expert is at autonomous performance – basically “auto pilot.”

44. Preparation Stages of Competence Autonomous Performance Expert Fixation Cognition Unaware Novice

45. Preparation Preparation-Learner • Learners need to know the basics about the procedure as well as the steps to the procedure. Allow your learners to learn on their own. • Think outside the box to find ways to help learners gain knowledge by self learning. Suggest different formats of gaining basic knowledge of procedures using the tool box for teaching.

46. Preparation Preparation-Learner • This helps them be more prepared while you can focus on other tasks. Remember we want to be efficient in our teaching but we also want to keep the learner involved. • Think back to your toolbox and select a way for students to learn on their own. You can click below to review the tool box or skip tool box. Review Tool Box Skip Tool Box

47. Mini-didactics Readings Role plays Draw diagrams Practice sessions/simulations Web/computer sources Delegation of teaching Checklists Round Robin Questions Brainstorming Site visits Handouts Demonstrations Games AV/TV/Audio/Video-tapes Preparation Preparation-Teacher Toolbox of Teaching Techniques

48. Examples of Some Tools • Delegate teaching – the more someone teaches something the better they learn it. • Round robin questions – a method to elicit everyone’s responses in order to make everyone feel part of the group and to avoid embarrassing one learner – e.g.: ask everyone in the group to give their best guest at what is going on or to state their thoughts about something. • Site visits – take them to the cath lab, pharmacy or radiology to learn about what goes on there. • Games – create games – they are fun and learners like doing them – e.g.: scavenger hunts for learners using uptodate pages • *remember to keep it focused on the patient case

49. Preparation ~Confucius 450 BC

50. Preparation Preparation-Learner • Confucius understood that adult learners need to be involved in order to retain more information. So involve learners and help them understand the following for each procedure: • Why learn the procedure? • What tools are involved? • What are the indications? Contraindications? • What are the risks? Benefits? • What are the potential complications? • Are there alternatives?