Clinical examination skills can be imparted effectively using videos for bedside examination

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By Naresh Kumar

Background & Purpose
Efforts to impart psychomotor skills through IVLE using McGill Videos have been tried since October 2007 at NUS. The post OSCE survey for year 3 and 4 students in academic year 2008-2009 revealed that it was difficult to use the videos in local context. A common observation arose that there was a need for – ‘standardization of clinical examination techniques’. This study was aimed towards developing a standardised clinical examination video for Orthopaedics and also to prove its effectiveness in standardizing the clinical examination techniques for students and examiners.

Methodology

The steps were as follows:
Production of the standardized video
Video workshop demonstrating clinical examination techniques
Post workshop student feedback
Analysis of feedback
Analysis of workshop attendees vs. non attendees performance in the final phase 3 exam

Results
Out of 260 students, 128 students attended the pre-exam video workshop. The post workshop feedback questionnaire had 6 questions per joint/region. The positive response rate per question was: A-94.5%, B-85.5%, C-84.5%, D 90.9%, E- 95.5%, F- 91.8%.
216 students out of 260 students were examined in the Orthopaedic stations in OSCE. Workshop attendee students scored average 74.01% marks. Non-attendees scored 61.88% marks. Out of 128 workshop attendee students - 37.2% students received positive comments, and 9.1% non-attendees received positive examiner comments.

Conclusions
Psychomotor clinical examination skills in Orthopedics are acquired at the bedside and in the classroom. Clinical standardization can only be achieved by having a standardised video which is available over a common platform i.e. IVLE.

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Clinical examination skills can be imparted effectively using videos for bedside examination

  1. 1. Clinical examination skills can be imparted effectively using Videos for Bedside Examination <ul><li>A/P Dr Naresh Kumar </li></ul><ul><li>MBBS, MS, DNB, FRCS Ed., </li></ul><ul><li>FRCS (Trauma & Orth), DM (Orth – Spinal Surgery) </li></ul><ul><li>Senior Consultant Orthopaedics & Spine Surgeon </li></ul><ul><li>National University of Singapore </li></ul>
  2. 2. Acknowledgements & Grants <ul><li>TEG (Teaching Enhancement Grant) 2010 – 11 </li></ul><ul><li>Mr. Manuel (Noli) Gamboa & Team </li></ul><ul><ul><li>Assoc Director, CIT </li></ul></ul><ul><ul><li>NUS. </li></ul></ul><ul><li>Dr Deepti Nayak </li></ul><ul><ul><li>Research Asssistant, </li></ul></ul><ul><ul><li>Appointed for NIG (NMRC Grant) </li></ul></ul>
  3. 3. Introduction <ul><li>Docere - means ‘teach’ in latin Doctor </li></ul><ul><li>Medicine like other sciences is in forefront of science & research </li></ul><ul><li>Medical teaching is an evolving field </li></ul><ul><li>Handover of medical knowledge to newer generations needs to be efficient </li></ul>
  4. 4. Evolution of Medical Teaching & Learning <ul><li>Totally Self Directed Learning = No teaching </li></ul><ul><li> </li></ul><ul><li>Learning by Shaming = Limited Teaching </li></ul><ul><li> </li></ul><ul><li>Didactic Teaching = Effortless Teaching </li></ul>
  5. 5. Evolution of Medical Teaching & Learning <ul><li>Problem Based Learning </li></ul><ul><li>& </li></ul><ul><li>Teaching Aids; Simulation </li></ul><ul><li>Teaching _ Effort </li></ul><ul><li> </li></ul><ul><li>Spoon Feeding </li></ul>
  6. 6. Evolution of Medical Teaching & Learning <ul><li>More of Problem Based Learning </li></ul><ul><li>& </li></ul><ul><li>Teaching Aids; Simulation </li></ul><ul><li>Teaching _ Superhuman Effort </li></ul><ul><li> </li></ul><ul><li>Breast Feeding </li></ul>
  7. 7. Medical Learning <ul><li>What is Unique about learning in Medicine? </li></ul><ul><ul><li>basic step of gaining knowledge </li></ul></ul><ul><ul><li>practical skills acquisition for clinical examination </li></ul></ul><ul><ul><li>learning requires visual, auditory & tactile faculties </li></ul></ul><ul><ul><li>demonstrate expertise requires practise </li></ul></ul><ul><ul><li>Objective Structured Clinical Examination (OSCE) for Assessment of Orthopaedic Clinical Examination Skills. </li></ul></ul><ul><ul><li>APMEC 2008 Poster </li></ul></ul>
  8. 8. Orthopaedic Learning <ul><li>What is Unique about learning in Medicine? </li></ul><ul><ul><li>practical skills acquisition for clinical examination </li></ul></ul><ul><ul><li>pschomotor learning requires </li></ul></ul><ul><ul><ul><li>visual & tactile faculties </li></ul></ul></ul><ul><ul><li>Variability in the experts do & assess </li></ul></ul><ul><ul><li>demonstrate expertise requires practise </li></ul></ul><ul><ul><li>performance in exam requires predictability </li></ul></ul><ul><ul><li>Objective Structured Clinical Examination (OSCE) for Assessment of Orthopaedic Clinical Examination Skills. </li></ul></ul><ul><ul><li>APMEC 2009 Poster </li></ul></ul>
  9. 9. Bloom ’s Cognitive Ladder Knowledge Comprehension Application Analysis Synthesis Evaluation
  10. 10. Millers Triangle Performance Competence
  11. 11. Orthopaedic Clinical Teaching in NUS? <ul><li>Clinical skills are always imparted bedside </li></ul><ul><li>From October 2007 </li></ul><ul><ul><li>efforts to impart psychomotor skills </li></ul></ul><ul><ul><li>via IVLE using McGill Videos </li></ul></ul><ul><li>Not useful in local context </li></ul><ul><li>Need for- ‘ standardization of clinical examination techniques ’ </li></ul><ul><ul><li>Objective Structured Clinical Examination (OSCE) for Assessment of Orthopaedic Clinical Examination Skills. </li></ul></ul><ul><ul><li>APMEC 2008 Poster </li></ul></ul>
  12. 12. Mc Gill Video CLip
  13. 13. Solution <ul><li>‘ Standardization of clinical examination techniques ’ </li></ul><ul><ul><li>Development of teaching tool to match the bedside teaching </li></ul></ul><ul><ul><li>Adequate bite size to match attention span of local students </li></ul></ul><ul><ul><li>Use of local experts for them to implement standardisation </li></ul></ul><ul><ul><li>To be effective & have usage in local system </li></ul></ul><ul><ul><li>Predictors of performance in an Objective Structured Clinical Examination (OSCE) for psychomotor skills in musculoskeletal examination </li></ul></ul><ul><ul><li>APMEC 2009 Poster </li></ul></ul><ul><ul><li>Does performance in an OSCE depend on the use of Integrated Virtual Learning Environment (IVLE)? </li></ul></ul><ul><ul><li>APMEC 2009 Poster </li></ul></ul>
  14. 14. Methodology <ul><li>Production of the standardized video </li></ul><ul><li>Video workshop demonstrating clinical examination techniques </li></ul><ul><li>Post workshop student feedback </li></ul><ul><li>Analysis of feedback </li></ul><ul><li>Analysis of workshop attendees vs. non attendees performance in the final phase 3 exam </li></ul>
  15. 15. Production of the Standardized Video Knee Spine Shoulder Hip Hand Foot & Ankle 11 Dec 2010 5 Feb 2011 Editing of rough cuts of video
  16. 16. Behind the scene Production of the Standardized Video
  17. 17. Production of the Standardized Video
  18. 18. Video workshop demonstrating clinical examination techniques
  19. 19. Post workshop student feedback <ul><li>Question A : Based on your experience, this video presentation will help standardize the teaching of <Joint/Region> amongst the various hospitals? </li></ul><ul><li>Question B: This video presentation has helped increase my understanding of the common clinical conditions in <Joint/Region>? </li></ul><ul><li>Question C: This video presentation has helped conceptualize (organize & extrapolate) my knowledge of the common clinical conditions <Joint/Region>? </li></ul><ul><li>Question D: This video presentation is relevant to our curriculum & assessments? </li></ul><ul><li>Question E: This video presentation was clear and concise? </li></ul><ul><li>Question F: If this video presentation was available to you at the beginning of your Orthopaedic Surg. posting, you think it would improve your overall performance? </li></ul>
  20. 20. Post workshop student feedback <ul><li>Questions A-E were marked by students on the Likert scale as follows: </li></ul><ul><li>Question F was marked YES/NO </li></ul>1-Strongly Agree 2-Agree 3-Neutral 4-Disagree 5-Strongly Disagree
  21. 21. Analysis of feedback Analysis of workshop attendees vs. non attendees performance in the final phase 3 exam
  22. 22. Results <ul><li>Did the developed video find favour with medical students? </li></ul><ul><li>The video will help standardize teaching amongst the various hospitals? 94.5% agreed </li></ul><ul><li>The video increased understanding of the common clinical conditions ? 85.5% agreed </li></ul><ul><li>The video helps to conceptualize knowledge of the common clinical conditions? 84.5% agreed </li></ul><ul><li>The video is relevant to our curriculum and assessments? 90.9% agreed </li></ul><ul><li>The video was clear and concise? 95.5% agreed </li></ul><ul><li>If it was available earlier, do you think it would improve your overall performance? 91.8% </li></ul>
  23. 23. Results Combined positive response rate per question Table 1: Positive response rate per joint/region per question (A) (B) (C ) (D) (E) (F) SPINE 94.5% 65.5% 76.4% 99.1% 97.3% 95.5% SHOULDER 95.5% 84.5% 84.5% 96.4% 96.4% 94.5% HIP 92.7% 70.9% 71.8% 94.5% 96.4% 92.7% KNEE 94.5% 79.1% 78.2% 92.7% 97.3% 92.7% HAND 95.5% 93.6% 91.8% 96.4% 87.3% 93.6% FOOT & ANKLE 94.5% 85.5% 84.5% 90.9% 95.5% 91.8% A B C D E F 94.5% 85.5% 84.5% 90.9% 95.5% 91.8%
  24. 24. Examination Performance <ul><li>Examiner comments on the overall performance of students (workshop attendee and workshop non attendees combined) in the phase 3 end of year exam. </li></ul>
  25. 25. Examination Performance <ul><li>Examiner comments on performance of workshop attendee students </li></ul>
  26. 26. Examination Performance <ul><li>Examiner comments on performance of workshop non-attendee students </li></ul>
  27. 27. Comparison
  28. 28. Results <ul><li>Marks obtained by students who attended workshop vs those who did not attend </li></ul>
  29. 29. Conclusion <ul><li>Psychomotor skills for clinical examination in Orthopedics are acquired at the bedside and in the classroom. </li></ul><ul><li>Clinical standardization can only be achieved by having a standardised video which is available over a common platform i.e. IVLE. </li></ul>
  30. 30. Thank You!!

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