Practical Tips for Teaching Clinical Skills

4-6 Minutes

Author: Julpohng Vilai, MD and Judy Hanrahan, JD, MA

Purpose

Teaching medical students and residents involves both ensuring that learners acquire the requisite knowledge and the psychomotor skills required for competent medical practice.

Learning Objectives

1. Define ‘simple’ versus ‘complex’ clinical skills;

2. Describe an evidence-based approach for teaching simple clinical skills;

3. Differentiate between immediate error correction and feedback when teaching clinical skills; and

4. Describe two best practices for providing immediate error correction and feedback.

In medicine, “see one, do one, teach one,” is a familiar refrain about teaching and learning procedural skills. While not completely accurate, “see one, do one, teach one” is often not far from the reality of learning skills in the often rapid-paced, high-stakes clinical environment. Clinical educators can improve their teaching of psychomotor skills by distinguishing between simpler (seven or fewer steps) and more complex (greater than seven steps) skills and by focusing feedback appropriately.  

Simple Skills 

Widely used models for teaching clinical procedures rely on motor learning theories proposed in the 1960s, which posit that psychomotor skills are best learned by dissecting skills into concrete, sequential tasks.(1,2) One popular model in medical education is Peyton’s four-step approach. This approach includes educator demonstration, educator deconstruction, learner description (formulation) during educator demonstration, and learner performance.(3) This approach has been shown to enhance simple skill development such as suturing.(4)

Peyton’s Four-Step Approach 

1. Demonstration: Educator demonstrates the skill at normal speed and without additional comments. 

2. Deconstruction: Educator demonstrates the skill by breaking it down into simple steps, while describing each step. 

3. Formulation: Educator demonstrates the skill while being talked through the steps by the learner. 

4. Performance: Learner demonstrates the skill, while describing each step. 

Step one in Peyton’s approach is notable in that the clinical educator is silent while demonstrating the skill. Nicholls et al explain, “Adopting this instructional technique enables the learner’s visual neural tract to focus on the motor movements linked to the skill, without the brain processing additional sensory information, such as auditory or tactile data”.(5)  

Using the Peyton method “see one, do one, teach one” looks more like: 

1. See one – educator quietly demonstrating without comment,  

2. See one – educator verbalizes steps,  

3. See one/describe one – learner describes steps as educator is performing the skill,  

4. Do one/describe one – learner describes steps in advance of performing each step,  

And, the unspoken fifth step – do many!

It is important to recognize, however, that these models work better for simple procedures and may have limited utility for teaching complex skills.(6) 

Complex Skills

Nicholls et al provide a framework for teaching complex psychomotor clinical skills which shares characteristics with Peyton’s approach, including a silent demonstration of the particular skill and the learner verbalizing the steps that they are taking while performing the skill, but it differs in important ways. Nichols et al urge clinical educators to do some important pre-work before teaching these complex psychomotor clinical skills. Namely, the educator should divide the complex skills into smaller chunks and assess the learner’s existing knowledge and skill level before diving into teaching.

Divide complex skills into smaller chunks

Recognizing that there is a point at which cognitive overload impairs learning, the clinician should divide a task into manageable parts.(5) Each part, in turn, should be further parsed into several sequential steps.(5) Ideally, there should be no more than nine steps in any single teaching session such that multiple sessions may be necessary for a given complex task.(5) For an incision and drainage, for example, it may be helpful to break down the task into three parts: preparation (i.e., gathering materials and supplies, positioning the patient, preparing the sterile field, anesthetizing the area of interest, etc.), I & D (i.e., performing the incision, drainage of the abscess, addressing areas of loculation or fistulae), and conclusion (i.e., packing the area with gauze, taking a wound culture, dressing the wound, addressing antimicrobial therapy and pain management, etc.).  Fractionating the task into several parts, each with discrete steps, allows the learner to minimize a steep learning curve and the cognitive demands on working memory.(5) 

Assess learner’s existing knowledge and skill level 

Another helpful clinician pre-work task is to assess a learner’s existing knowledge and skill level.(5) It is important that this be done prior to teaching a clinical skill as it will benefit both learner and educator in maximizing useful educational time and avoid repetition and potential cognitive dissociation from the task.(5) As an example, a senior resident trainee will enter the educational environment with more background and experience than a first-year medical student. Taking the time to describe to the resident the reasons for chest tube insertion or central line placement may not enhance their educational experience, whereas this may be critical for a novice student to understand. 

Learner Feedback 

Error correction—both during the rehearsal and execution stages of learning—is essential for skills acquisition.(5) Immediate error correction allows learners to reinforce knowledge and prevent an incorrectly learned skill to be practiced and stored in long term memory.(5)  

Finally, feedback is one of the most influential teaching practices in learning motor skills.(5) This differs from error correction, which is intended to redirect processes that, if learned incorrectly, can lead to morbidity and mortality. Feedback about errors that may not necessarily affect outcome for the patient, such as not recapping a needle, may be deferred until the completion of the procedure.(5)  

Pendleton provides a feedback model that is especially useful as it encourages learner self-reflection.(7) This method incorporates the perspectives of both learner and educator: first, ask the learner what went well; second, tell the learner what went well; third, ask the learner what could be improved; and finally, tell the learner what could be improved. Progressive iterations of skill practice and feedback can greatly aid in motor skills learning. ■

References

(1) Fitts PM. Factors in complex skill training. In Glaser R (ed) Training Research and Education. University of Pittsburg Press; 1962. Pp. 177-197.  

(2) Fitts PM, Posner MI. Human performance. Brooks/Cole; 1967.  

(3) Walker M, Peyton JWR. Teaching in theatre. In Peyton JWR (ed). Teaching and learning in medical practice. Manticore Europe Limited; 1998. pp. 171-80.  

(4) Wang T, et al. An education theory-based method to teach a procedural skill. Arch Dermatol. 2004;140:1357-61. 

(5) Nicholls D, Sweet L, Muller A, Hyett J. Teaching psychomotor skills in the twenty-first century: Revisiting and reviewing instructional approaches through the lens of contemporary literature. Med Teach. 2016; 38(10):1056-63. 

(6) Krautter M, et al. Effects of Peyton’s Four-Step Approach on Objective Performance Measures in Technical Skills Training: A Controlled Trial. Teach Learn Med. 2011;23(3):244-50. 

(7) Pendleton D, Schofield T, Tate P, Havelock P. The consultation: an approach to learning and teaching. Oxford University Press; 1984.