Clinical Skills Training

1
Clinical Skills Training Simulation Pedagogy
That which we must learn to do, we learn by
doing. Aristotle

• Prof K.R. Sethuraman
• Dean Faculty of Medicine
• Deputy VC Academic/International Affairs
• AIMST University

2
Objectives for this Session - a

• List the competencies for a health professional
• Discuss the taxonomy of skills and appropriate
  methods for learning them (using the Dales Cone)
  
• Explain simulation pedagogy relevant to skills
  training (using Millers Pyramid of competence)
• Discuss the advantages of using simulation as a
  teaching/learning tool.
• Explain why debriefing and guided reflection are
  part of Simulation Based Education (SBE)

3
Objectives for this Session - b

• Provide exemplars for which simulation could be
  valuable as a learning tool
• Examine current practices and research regarding
  the implementation of simulation
• Is learning by simulation just "simulated
  learning"?
• Discuss some pitfalls and problems with
  simulation based learning.

4
Spectrum of Clinical Competence

• I. CLINICAL
• History, Physical Exam, Management
• II. TECHNOLOGICAL
• Procedural Skills (Diagnosis Therapy)
• III. HUMANISTIC
• Professionalism, Ethical behaviour
• IV. SOCIAL PREVENTIVE
• Team work, Cooperation etc.

• Maheux et al. Acad Med 1990 65 41-5

5
Choice of Learning Activity Dales Cone of
Experience
6
(No Transcript)
7
Millers model of competence
Performance or hands on
Does
Live Demo Multimedia
Shows how
Knows how
Read, Listen
Knows
Miller GE. The assessment of clinical
skills/competence/performance. Academic Medicine
(Supplement) 1990 65 S63-S7.
8
Domains Skills (Bloom)

• Cognitive Skills
• Critical thinking, Problem solving etc.
• Psychomotor Perceptual Skills
• Physical examination,
• Procedural Skills (Diagnosis Therapy)
• Skills of Affective Domain
• Communication Skills
• Other soft skills (Social Preventive )

9
Learning Intellectual Skills

• Learn basic facts, concepts and principles.
• Solve problems under verbal guidance
• Instructional format
• Solve problems with the help of hints.
• Guided practice format
• Solve problems independently.

10
Learning Psychomotor Skills

• Listen or Read about the components of the skill.
• Watch a demonstration of the skill.
• Practise the skill under supervision and
  corrective feedback.
• Practise the skill independently.

11
Learning Communication Skills

• Listen to narratives, orations or inspiring
  anecdotes.
• Watch role play, skill demo, socio-drama, etc.
• Participate in role play-simulation
• Practise under supervision and corrective
  feedback.
• Independent practice.

12
Stages in Competence

• Unconscious Incompetence
• Conscious Incompetence
• Conscious Competence
• Unconscious Competence

http//www.businessballs.com/consciouscompetencele
arningmodel.htm
13
Skill Acquisition

• Skill acquisition represents the initial phase in
  learning a new clinical skill or activity
• One or more practice sessions are needed for
  learning how to perform the required steps and
  the sequence
• Teachers guidance is necessary to achieve
  correct performance

14
Skill Competency

• Skill competency represents an intermediate phase
  in learning a new clinical skill or activity
• The participant can perform the required steps in
  the proper sequence (if necessary) but may not
  progress from step to step efficiently

15
Skill Proficiency

• Skill proficiency represents the final phase in
  learning a new clinical skill or activity.
• The participant efficiently and precisely
  performs the steps in the proper sequence.

16
Mastery Learning Model
-Bloom 1968
17
Phased Training for Competence

• Easy Complex
• Component of a skill Integrated skills
• Isolated Combined
• Simulated Real life

18
II. Simulation for Skill Learning
19
What is simulation?
Simulate Aping Imitate uncritically and in
every aspect (simia Ape)
20
Fidelity of Simulation

• How closely the appearance behaviour of the
  simulation match those of the simulated system
  (reality)
• Physical (Engineering) fidelity refers to the
  fidelity to the physical characteristics of the
  real task (visual, auditory, haptic etc)
• Functional (Psychological) fidelity refers to the
  fidelity to the skills involved in the real task
• (cognitive, perceptual, manipulative or
  behavioural)

N J Maran R J Glavin. Low- to high-fidelity
simulation a continuum of medical education?
Medical Education 200337(Suppl. 1)2228
21
The ADDIE framework for Design of Hi Fi
Simulations

• Analyze Analyze relevant learner characteristics
  and tasks to be learned
• Design Define objectives and outcomes select an
  instructional approach (of Gagne)
• Develop Create the instructional materials
• Implement Deliver the instructional materials
• Evaluate Ensure that the instruction achieved
  the desired goals

22
Simulation Based Education (SBE)

• An educational simulation is
• A sequential decision-making exercise in which
• students fulfill assigned roles to manage
• discipline-specific tasks
• according to guidelines provided by the
  instructor
• in an environment that models reality

• Simulation vs. Game
• In educational simulations there are no elements
  of fantasy.
• Simulations are more fluid and spontaneous.

23
Simulations for SBE

• Written simulations
• Three-dimensional or static models
• Audio based
• Video-based
• Computer-based clinical simulation
• Animal models
• Human cadavers

• Peer to Peer
• Standardized patients
• Task-specific simulators Designed to teach a
  specific skill or task
• Immersive simulation
• Virtual reality (VR)
• High Fidelity (Robotic)

24
Advantages of SBE

• Training can be tailored to individuals/teams
• Chronic diseases can be simulated in its entirety
  
• Bridges the classroom bedside gap
• Intimate examination can be practised and
  learnt by every student (e.g. Rectal exam)

• Risks to patients and learners are avoided
• Undesirable interference is reduced
• Scenarios can be created as per need
• Skills can be practised repeatedly
• Retention and accuracy are increased

25
Key elements in SBE

• Simulation based Education (SBE) has four key
  elements
• Create motivation a priori (briefing)
• Active learner, not passive recipient of info
• Individualized and paced for each learner
• Prompt feedback on success and error (debriefing)

26
Rationale for Teacher in SBE Objectivism vs.
Constructivism

• Objectivist view
• the real world can be described and structured in
  terms of objects
• a well-structured experience will result all the
  learners acquiring an identical perspective on
  knowledge

• Constructivist view
• each learner projects his or her own reality onto
  the world.
• the world does not exist independently as a
  consistently objective component
• identical perspective on knowledge is a naïve
  notion

27
Role of the Teacher in SBE

• Not all experiences are equally educative (Dewey)
• A teacher has to assist the learner in
  understanding the simulated process
• guide the student through critical thinking
  processes to-

• help the students
• differentiate between reliable and unreliable
  facts
• to look for patterns within these bits of
  information
• to construct new knowledge from the experience.

28
Debrief Consolidates Learning

• Often the real learning takes place in the
  debrief session
• Debrief goals are
• What did the students experience?
• What did they learn?
• How can they apply that learning to future
  experiences and learning?

29
Debrief Things to avoid

• Dont Lecture
• Dont provide your analysis before listening to
  the team
• Dont create the sense of an interrogation
• Avoid a rigid agenda let them construct the
  learning outcomes
• Dont interrupt team discussion unless needed

30
Three Cs of education
These apply well to the debrief sessions
31
III. Skill Learning through Simulation

• Problem Solving Skill
• Communication skill
• Physical Examination Skills
• Integrated Complex Skills

32
Problem Solving Skill
I

• Simulated Patient Management Problem (S-PMP)
• Demo

33
Communication skill TALKING WITH PATIENTS
II
34
Talking with Patients Value of

• In primary care, about 86 of the Diagnostic
  value is from historical data
• Ref - Hampton JR et al. BMJ 19752 486-9

35
Learning to Elicit History

• Role play simulation!
• Let them play Doctor-Patient roles and learn

There is no cement like interest no stimulus
like the hint of practical consideration." A
Flexner-1910
36
Role Play Simulation The Method

• Triad of Doctor Patient Observer
• Assigned a problem, e.g. headache to elicit
  history
• Each "patient" is individually coached on an
  entity - e.g., migraine, tension headache, etc -
  totally 4 or 5
• Next day, every Patient is assigned to a "Doc"
  and an observer 4 or 5 groups
• They interact for about 30 minutes in any
  mutually acceptable language

37
Role Play Simulation The Method contd..

• Observer (3rd in the triad) monitors for
• Realism in interview, and
• Any use of medical jargon in lieu of lay-words
• In the plenary session, systematic debriefing is
  done on
• History Analysis of the history
• Lay medical words if unknown or unclear

38
Role Play Simulation FEEDBACK

• Students were mostly appreciative
• "Felt like Sherlock Holmes"
• "Fun way to learn boring history"
• "Never knew so many conditions exist in which
  patients are physically normal"
• "Since student-patient gap is bypassed, I could
  realise the value of eliciting history"

39
Simulation for Physical Examination Skills
III
40
Peer Physical Examination (PPE)

• Students act as models for each other to learn
  the skills.
• PPE has high acceptability, but poses some
  challenges.
• PPE may be less acceptable among culturally and
  linguistically diverse students.

Suzanne Outram and Balakrishnan R Nair. Peer
physical examination time to revisit? MJA 2008
189 (5) 274-276
41
Detecting Errors in Physical Exam for Effective
Debriefing
42
Physical Exam Skills

• MISSION
• Every student must perform the core 'must do'
  skills
• Observe each one perform give corrective
  feedback
• Try and eliminate all learning errors

43
Types of Learning Errors

• Type A
• Omission or poor technique of performing a step
• Type B
• Failure to perceive or to correctly interpret a
  clinical sign

44
Type A
45
Type B
46
Corrective Strategies

• Type A Error inadequate understanding or
  inadequate practice of the procedural steps
• Can be corrected by effective demo during feedback

• Type B Error poor perceptual concepts and
  inability to discriminate between normal Vs
  abnormal
• Corrective Learning by Concept Attainment Model

47
Immersive Simulation for Critical Care Skills
IV
Stress of Realistic Simulation without harming
patients
48
Barriers to the Widespread Use of SBE for Skill
Learning

• The cost of equipment, personnel, maintenance and
  training.
• the initial cost of a simulation center
  approximates RM 0.5 to 1 million.
• The lack of valid and reliable assessment tools
  for simulation learning (esp. predictive
  validity).
• The lack of academic recognition for the time
  spent in developing simulation scenarios
  (compared with publishing scholarly work)

49
Barriers - Why Change? Resistance

• We have always done it this way
• We, the products of traditional method are OK
• Why should we change?

50
To Sum Up Education Teaching Learning
Education is about learning
51
An Enlightened Teacher is -
52
Terima Kasih !
!