Prepare to Teach and Learn

Before instructing anyone in the performance of a procedure, it is important to provide an opportunity for the student to prepare to learn that procedure. This phase of learning should occur in a more didactic format, aside from the laboratory or patient bedside where the actual mechanics of the procedure will be performed. The goal of this preparatory time is to ensure that the student understands the large amount of prerequisite information needed to perform procedures appropriately. This information includes a review of the indications and contraindications for the procedure, the instruments and the tools used to perform the procedure, and the expected outcome of the procedure. In addition, learners should take time to review the risks of any procedure they perform, including the possible complications and how to manage them if they occur. A portion of this preparation should focus on the process of obtaining informed consent as well as documentation of the procedure [1, 2].

Whether procedural instruction is a planned activity (e.g., as a cadaver/skills laboratory or simulation session) or an impromptu bedside opportunity, the learner should be asked to be prepared by acquiring information regarding the procedure before its performance. Instructors can use any of several methods to prepare students for procedural learning. Traditionally, learners have been assigned chapters in a textbook to review before an instructional session or a clinical rotation where that procedure is frequently performed. Other approaches include distribution of information packets, computer programs, or videos containing the information they would like the learner to have mastered before the teaching experience. Although these methods of preparation ultimately provide the learner with the information required, they are passive learning. Rather than providing all of this background information directly, instructors can foster interest and more sustained learning if they give students the necessary tools to find this information through their own exploration. Physicians-in-training are often able to uncover and retain more information if they consult multiple sources, including colleagues, texts, nurses, and Web-based media. The prospect of learning and performing a new procedure typically serves as adequate motivation for this active learning to occur. In this case, the instructor’s role is to provide some guidance regarding sources of reliable information and to review the information acquired, leading a discussion regarding what they have learned and highlighting key points. Even when a bedside procedural teaching opportunity arises with little warning, as long as time permits for patient safety, the student can be directed to take a few minutes to review the key components and details of the procedure in a text or video recording before participating in the tactile learning experience. The teacher should maintain an online or readily accessible repository of videos and texts of common procedures for quick reference in these cases [1]. Many teaching institutions have developed and evaluated computer-assisted modules that incorporate images, short video clips, and instructional texts. Ricks and colleagues [3] demonstrated that students with access to computer-assisted material had a significantly better knowledge of the emergency procedures being taught than controls. Professionally developed online educational resources are commercially available, typically with access fees.

While students prepare to learn a procedure, the instructor must prepare to teach it. This involves task analysis, a skill in which the instructor breaks down the procedure into small, more digestible components for teaching purposes. For example, when teaching the placement of a central line, one of the microskills that needs to be acquired before attempting the procedure is the ability to draw back on a syringe using a single-handed method. Without accomplishing this smaller component of the motor skill, the physician will never learn to place a central line independently. As this example demonstrates, instructor preparation can be challenging because many of the microskills required to perform procedures are taken for granted once the procedure is mastered. Therefore, instructors must take the time to deconstruct the components of the procedure in preparation for the learning session and create a task analysis. They should develop a clear and concise order for the process being taught in digestible steps, without taking any previous knowledge or experience for granted [4, 5].

Another component of instructor preparation involves the learning environment itself. Maximization of the learning experience is highly dependent on the setting. As such, when planning to provide procedural instruction at the bedside, instructors must take the time to prepare not only the learner but also the subject. For bedside learning with awake and alert patients, this step is imperative. In addition to informing the patient that a less experienced trainee will be involved in the procedure, it is wise to advise the patient that the procedure will be closely supervised by an experienced teacher and that instructional discussion will occur while it is being performed. This lessens the likelihood that the patient will be surprised or apprehensive when he or she hears the instructions being given. In addition, preparing the patient allows the instructor to choose patients who seem more receptive to participating in the learning environment, thus creating a positive teaching experience for all involved [1].

When the procedural experience involves cadaveric or nonhuman subjects, this phase of the preparation should focus on ensuring that the physical space and environment are conducive to the type of teaching that is planned. Attention is required to ensure the safety of the procedure with respect to communicable diseases and proper disposal of sharp medical tools and biologic materials. Finally, care must be taken to ensure an adequate instructor-to-student ratio. Ideally, there will be fewer than four learners per instructor. In addition, it is imperative that the learners are at the same level of experience to ensure that an appropriate and a consistent amount of guidance is provided.

The Process of Learning

Although a variety of methods are used for procedural instruction, a process based on the theory of psychomotor learning is often most effective. The long-standing tenet “see one, do one, teach one” does not provide an optimal framework for the learner or the instructor to ensure mastery of a procedure. Instead, a multistep process of learning the procedure and then practicing it with a declining level of supervision and guidance is more effective (Table 6.1).

Table 6.1 Steps in the process of learning a procedure.

Conceptualization—understanding the reasons for performing a procedure, the overall process, the tools involved, and the risks/benefits

Visualization—observing a demonstration of the procedure, performed in a fluid and competent manner by the master teacher

Verbalization—reviewing a verbal deconstruction of the procedure while it is performed by the expert, with opportunity for interruptions and clarifications

Guided practice—performing the sequential steps of the procedure under the supervision of an expert physician

This process starts with conceptualization of the procedure, which entails understanding the reasons for performing the procedure as well as its risks and benefits, as described earlier. Once conceptualization has occurred, the subsequent step is visualization of the procedure. As the instructor models the procedure in its entirety, the learner is a silent observer, taking mental notes of the instructor’s actions. The instructor serves as a silent model during this step of the learning process, demonstrating the expected performance once skill mastery is achieved. Visualization can occur at the bedside, in the cadaver laboratory, or using filmed videos.

It is important to ensure that the learner is positioned to observe the procedure from the same perspective from which he or she will perform the procedure. For example, placing the learner at the patient’s side to observe an endotracheal intubation would be suboptimal. Rather, the learner should be positioned with the same visual orientation as the person performing the procedure in relation to the patient to visually record each step from the perspective in which it is performed. Video-assisted laryngoscopy is an even better example of the significance of the learner and teacher having the same perspective. Ayoub and associates [6] described a study in which students who were trained to intubate using a video-assisted laryngoscope were remarkably more successful at direct laryngoscopy intubation than their cohorts who had been trained with the direct laryngoscopy technique.

Once the basis for the procedure is understood (conceptualization) and the learner has been given a model of the procedure (visualization), the instructor deconstructs the procedure for the student while performing it a second time, verbally noting each step taken and the skills required for it. This process is known as verbalization. Accurate task analysis before the instructional session ensures that the instructor presents the procedure in a clear, coherent, and comprehensible manner. Each portion of the procedure is described verbally and is performed physically simultaneously. This can be accomplished in a face-to-face interaction or using video prepared in advance. During this step, the learner is encouraged to interrupt the procedure to ask questions or make clarifications of the information being communicated. Although a prepared video may allow demonstration of the procedure with verbal cues, the particular components of the procedure are best discussed in a small group or in an individual, face-to-face interaction. Subsequently, the learner can be asked to narrate the procedure while the instructor performs the procedure a second time. This ensures that the learner conceptually understands the actions involved and the order in which they should be performed [2, 7].

Multiple faculty members may be involved in teaching procedural skills to the same group of learners, at the bedside as well as in a simulation or cadaver laboratory, and it is of utmost importance that the procedure is demonstrated and performed consistently. Although clinicians who have mastered clinical procedures often have their own nuances or specific tricks of the trade to offer trainees, these should not be incorporated into this stage of the learning process. Therefore, it is important to be cognizant of the basics of a procedure, as some instructors may have to alter their “usual” method for performing a procedure to deliver a more standardized educational experience. Once the standard method is mastered by the learner, particular variations and shortcuts may be taught, but if taught prematurely, these will only confuse the novice learner and lengthen the time required for motor learning of the procedure [4].

Armed with the visual model of the procedure and the ability to verbalize the steps involved, the learner is then observed performing the procedure on the model. This process is known as guided practice [3]. To decrease learner anxiety, this step is often performed initially on cadavers, simulation models, or a willing volunteer rather than a patient. The learner may be instructed regarding separate steps of the procedure one step at a time or may attempt the entire procedure under guidance. If the instructor chooses to review certain steps of the procedure, they should be reviewed in the order in which they are performed to maximize the motor-based learning involved. Learners should be able to verbalize each step as they perform it and should be observed carefully by the instructor for any errors [4].

When an error is identified, it is optimal to have the instructor place his or her hand on the trainee’s hand to stop the incorrect action and physically redirect the student to the correct motor action while providing verbal instruction regarding the proper method. It is important that learners be told that this will happen and for them to expect this hand-on-hand contact. One common pitfall is allowing learners to perform procedures with errors and then providing feedback regarding those errors after the procedure has been completed. The idea is to stop the error before it is imprinted in the learner’s motor memory. Therefore, as the instructor places his or her hand on the learner’s hands, redirecting the student to the accurate motor skill, the learner is prevented from incorporating an incorrect movement into his or her motor memory [4].

Guided practice is critical to skill acquisition and mastery. Time should be provided for the student to practice the procedure repeatedly under the guidance of an instructor, who redirects and provides feedback when necessary. As the learner becomes more comfortable with the procedure, demonstrating increased skill competence, the instructor’s involvement in the procedure should decrease until the learner is essentially performing it without assistance. Practice without guidance can precipitate errors and result in imprinting of inappropriate actions, which is dangerous to patients and a disservice to the learner. Immediate feedback, both positive and negative, is invaluable throughout the learning process. More specifically, effective feedback is performance based, highlighting portions of the procedure that were done well and pointing out areas for improvement, with specific tips on how to improve the skill attempted [1, 5].

There will be occasions when the learner fails to perform the entire procedure successfully. It is important to create a positive learning experience in this scenario. One effective way to educate the learner regarding mistakes is a face-to-face debriefing session. It is most beneficial if this discussion takes place immediately after the procedure. In most cases, the learner will have a high level of self-awareness and be able to identify areas for improvement. The instructor should provide feedback in a positive way, first emphasizing the correct steps performed, then providing a constructive critique of any errors in technique, and finally encouraging the learner to reattempt the procedure with guidance. Once a basic procedure is mastered by a learner, the next step in skill acquisition is to present variations on that procedure. It is in this final step that learners can be introduced to the shortcuts or varied methods that instructors use in their daily practice. They should be challenged to apply the procedure in difficult situations and learn alternative techniques to accomplish the desired outcome [7].

Putting Theory Into Practice

In reality, many physicians-in-training are still learning procedures within the framework of the “see one, do one, teach one” model. The transition to a more formalized, effective method for learning key procedural skills is difficult, as it requires more preparation on the part of both the learner and the teacher. In addition, the time required to teach and supervise learners practicing new procedures is considerable. The recommended teaching methods can be implemented in a variety of ways, including computer software models, low fidelity model practice, simulation laboratories, cadaver/animal laboratories, and bedside teaching on patients. Each of these teaching environments, when used within the framework of the teaching theories presented earlier, can provide an opportunity for effective learning.

At the most basic level, simple teaching models are most effective when teaching the core motor activities required for a procedure. These models are often less expensive and more portable than simulators or cadavers, and they carry no risk of errors compared with bedside teaching. As one study conducted by a surgery department demonstrates, using a simple model such as a pig thigh to teach a surgical procedure led to significant improvements in overall performance by residents. The authors of this study noted that because of the constraints of decreasing operating room time and the increasing liability concerns about allowing junior residents to practice on and learn from live patients, residents were not receiving adequate training in certain procedures. Therefore, a brief training session was developed using the model of a pig thigh, with a pre- and postsession evaluation. Residents demonstrated a significant increase in their postsession scores, regardless of their level of training or experience with the procedure. The success of this basic teaching technique was linked primarily to the quality and availability of immediate feedback for the learners as they practiced the procedure during the session. As noted by the authors, a simple tool, such as a pig thigh model, provides an opportunity for new learners to practice a procedure in a safe, inexpensive environment with close mentoring before direct patient contact in the operating room [8].

A more costly, but increasingly popular tool for teaching multiple aspects of medicine, including procedural education, is the simulator model. Benefits of using this model versus a human model include increased safety, the ability to practice the same procedure multiple times in a single session, and the option of exploring the consequences of errors without the risk of harm to a patient. Although cadavers may provide the best approximation of the tactile and visual cues of a human-based procedure, technologic advances in materials sciences and computer-based models have provided a close approximation in many cases. In addition, the interactive capability of a simulator model allows the instructor to create increasingly challenging circumstances for the learner. For example, a new learner may initially gain mentored practice by placing a central line in a perfectly still, sedated simulator model. As the learner becomes more proficient, the simulator may be manipulated to present a patient with low blood volume and easily collapsible veins to present a realistic challenge to the learner, thereby encouraging advanced skill acquisition. As with any other teaching model, the key component that results in successful skill acquisition is guided, consistent practice with a decreasing role of the instructor in the actual performance of the procedure as the learner becomes more proficient [9].

Similarly, the cadaver laboratory provides an opportunity to learn and practice invasive procedures without posing any threat to the patient. The limitations of this modality include the availability of human cadavers and the expense involved. Use of cadavers provides accurate human anatomy with all the natural variations. Palpation of landmarks and subtle anatomic differences provides a more realistic experience for the learner. At times, complications that cannot be recreated in a simulator model lead to better education. Examples include the inability to advance a guidewire in a cannulated vein and the need to suction an airway while teaching direct laryngoscopy. There are also disadvantages to the anatomic and pathologic differences among cadavers. For example, venous thromboses can prevent flashback in central line access attempts and pleural adhesions can complicate placement of chest tubes. These variations can result in inconsistent learning among a cohort of students. Finally, the safety of all participants must be ensured by screening donors for communicable infections.

An alternative to using human cadavers, especially if there are cultural barriers to their use, is the animal laboratory. Small domesticated animals such as sheep and pigs have historically been used to teach invasive procedures. The animals are anesthetized during the procedures and subsequently euthanized. The advantage of this laboratory is that blood is circulating, and therefore, the physiologic response to the procedure is real. Conversely, the high cost, logistics of caring for the animals, and legal restraints regarding the use of animals for this purpose can be prohibitive. Furthermore, zoonotic disease processes need to be considered. Table 6.2 lists invasive procedures that can be performed on human cadavers or domesticated animals. In many cases, only an animal part such as a rib cage for chest tube placement or trachea for cricothyrotomy is required.

Table 6.2 Examples of invasive procedures that can be performed on human cadaver or domesticated animals.

Procedure	Special instructions	Instruments
Lateral canthotomy	Simulate proptosis by injecting fluid in the retrobulbar space using a small needle and syringe	Suture kit
Retrograde intubation	Feed the wire from a central line kit from membrane to nose/mouth and intubate over the wire	Central line kit and ET tube
Cricothyrotomy	Simulate bleeding by pouring red paint onto the surgical site during the procedure	Scalpel, gum-elastic bougie, and ET tube
ET intubation	Use direct and video-assisted laryngoscopes. Use cricothyrotomy hole to confirm placement.	Laryngoscope/ET tube
Central venous access	Internal jugular, subclavian, and femoral access in human cadavers; landmarks will not work in animals	Central line kit
Pericardiocentesis	Pericardium can be filled with fluid and food coloring after thoracotomy	Central line kit and ultrasound
Tube thoracostomy	Multiple chest tubes can be placed on each side	Chest tube tray
Thoracotomy	Demonstrate cardiac massage, locating phrenic nerve, performing pericardial window, clamping of descending aorta	Thoracotomy tray
Diagnostic peritoneal lavage	Red food color fluid can be injected into the cavity prior to the procedure	DPL tray
Suprapubic catheter	Fill and distend bladder with a Foley catheter	Central line kit and ultrasound
Arthrocentesis	Multiple joints can be injected with yellow food coloring	Needle and syringe

Videos of many of these procedures can be found at www.umem.org/res_video_procedures.php.

ET, endotracheal; DPL, diagnostic peritoneal lavage.

All the aforementioned settings are effective precursors to bedside procedural learning. As the optimal setting for the advanced learner, bedside teaching provides the opportunity for one-on-one instruction with a master in the procedure on a live patient. Although performance of the procedure can be guided by the expert, it is preferable when the learner feels comfortable with the basic steps of the procedure and has performed it in other settings before performing it at the bedside. Immediate feedback can be provided by both the educator and the patient. Although performing a procedure at the bedside should be reserved for learners who have already been instructed regarding the procedure and practiced it in a more structured setting, other phases of procedural learning can occur at the bedside as well. For example, a medical student who has only read about a procedure can accomplish the visualization phase of learning at the bedside by observing the teacher performing the procedure in a fluid manner from start to finish. Those who have observed the procedure once or twice can be asked to verbalize the procedure and prompt the expert performing the procedure regarding the next step to be taken and how it is to be done. In addition, the learner who has practiced a procedure in laboratory can be guided to assist with certain steps of the procedure, whereas the overall performance is primarily by the teacher. As learners gain experience at the bedside, the number of steps that they perform can be increased until they are able to attempt the entire procedure under direct guidance. In this manner, the bedside can be a suitable environment for a variety of levels of learning procedural skills. The key is to recognize the stage of the learner and create the appropriate, safe experience based on that stage of learning.

Creating a Procedural Education Elective for Preclinical Medical Students

Many educators and clinicians have commented that medical school is the optimal time in physician training to teach basic procedural skills. Because medical students have less direct patient care responsibilities and more time to spend practicing acquired skills, many emergency medicine clerkships have designated space within their curricula for procedural education. Beyond the basic skills learned at the bedside, specific procedural skills sessions using cadavers and simulators are now an increasingly popular way to provide exposure to clinical procedures for the new learners within a safe, well-supervised environment. Even outside the framework of a rotation in emergency medicine, many medical schools employ the skills of emergency physicians when planning preclinical procedural education sessions for rising second- and third-year medical students.

One inventive approach to this has been demonstrated at the Stanford University in the form of a popular preclinical elective known as Essential Procedures in Emergency Medicine (EPEM). The structure of this course is modeled on the principles of motor-based learning presented in the chapter. In summary, educational sessions of 2 hours’ duration twice weekly throughout a quarter expose these students to procedural education before their clinical rotations. For each procedure there is a presession reading assignment, an interactive didactic session, followed by a demonstration of the procedure by an instructor, and then guided practice of the procedure. Each student spends a set number of hours in the emergency department under the guidance of physicians and nurses performing procedures on live patients. Finally, in a cadaver laboratory session, more invasive and rare procedures, such as cricothyrotomy, tube thoracostomy, and central venous access, are practiced with expert assistance and supervision [10].

Student evaluation includes a written examination regarding the basic indications, materials, contraindications, and steps for a given procedure, as well as a practical examination in which the student performs certain procedures in front of an instructor while responding to questions regarding that procedure. To evaluate the effectiveness of this course, EPEM students’ performance in their clinical rotations was compared with that of their classmates who did not participate in this elective. EPEM students had significantly higher scores on procedural performance during their emergency medicine and internal medicine clinical rotations. In addition, enrolment in the elective exceeded expectations during the years studied, demonstrating that preclinical medical students are very interested in having this type of experience before their clinical rotations. Overall, this course presents a successful example of procedural education for early learners that takes into account the educational theory of motor skills acquisition and uses multiple models for guided practice and learning with feedback. It provides a venue for students to learn basic procedures in a prescribed sequence from master teachers, rather than in the unstructured and often inexperienced hands of residents during their clinical rotations [10].

Assessing Competence

There is ample evidence that self-assessment in procedure competency by physicians-in-training is unreliable. Barnsley et al. [11] demonstrated a poor correlation between observed competence and self-reported confidence in junior physicians. Many facets of competence need to be assessed, ranging from understanding the indications and contraindications for the procedure to its potential complications to the actual technical skill required to confirm its successful completion. Some authorities advocate the development of checklists that are comprehensive and universal and that can be used during an observation on an actual patient or a model [12]. Such checklists mimic the task analysis described in the chapter. Conroy et al. [13] demonstrated the utility of a critical action list in assessment of skill retention of a task trainer following lumbar puncture training. Ultimately, competence will be ensured by providing ample opportunity for guided practice with appropriate feedback.

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