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Teaching Procedural Skills. Amy S. Oxentenko, MD, FACP, FACG, AGAF Mayo 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.

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teaching procedural skills

Teaching Procedural Skills

Amy S. Oxentenko, MD, FACP, FACG, AGAF

Mayo Clinic, Rochester

objectives
Objectives
  • Create an educational contract with a trainee before an endoscopy session.
  • Statethe 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
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
If a Colleague was Sick and Coverage Was Needed, Would You Rather…
  • Supervise in the fellow continuity clinic?
  • Give your canned talk to the med students?
  • Perform a few hospital consults?
  • Supervise a fellow doing colonoscopy?
    • During their first week EVER of scoping
teaching a procedural skill why does it feel so tough
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
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 model1
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
setting learning objectives smarter
Setting Learning Objectives:“SMARTER”
  • S Specific
  • M Measurable
  • A Achievable
  • R Relevant
  • T Timely
  • E Economical
  • R Reviewed (modified prn)
how to instruct when teaching a psychomotor skill
How to Instruct When Teaching a Psychomotor Skill
  • Trainer perform, trainee observes, with no verbal explanation.
  • Trainer performs, trainee observes, with the trainer explaining the procedure in detail, breaking it down into steps.
  • Trainer performs, and the trainee explains the procedure in detail, breaking it down into steps.
  • The trainee performs the procedure, and verbalizes what they plan to do before they do it.
review of teaching a psychomotor 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
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
Instruction and Communication During a Procedure
  • Timing of instruction
  • Type of instruction
  • Specific language
  • Teaching vignettes
timing of instruction
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
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
Specific Language(12 Terms to Use)
  • Stop
  • Slow down
  • Pull back
  • Advance
  • Blow
  • Suck
  • Tip up
  • Tip down
  • Tip right
  • Tip left
  • Clockwise torque
  • Counter-clockwise torque

Using specific terms will avoid more vague

or differing ways to describe the same task

teaching vignettes
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
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
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
feedback during endoscopy
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
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
Pendleton’s Rules
  • Trainer asks trainee what went well
  • Trainer says what he/she thought went well
  • Trainer asks trainee what might be done differently next time
  • Trainer says what he/she thinks should be done differently next time
  • Trainer then does a summary statement for the learner to have a learning plan
simulation training
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 training1
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
summary
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

Thank you!

Oxentenko.amy@mayo.edu