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![Talking with Patients – Value of
In primary care,
about 86% of the
Diagnostic value is
from historical data
[ Ref - Hampton JR et al.
BMJ 1975;2: 486-9]
History
Exam Lab](https://image.slidesharecdn.com/4003b361-f067-4fc4-b946-aebd89dfbc75-150719172246-lva1-app6892/75/Clinical-Skills-Training-and-Simulation-Pedagogy-33-2048.jpg)
![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]](https://image.slidesharecdn.com/4003b361-f067-4fc4-b946-aebd89dfbc75-150719172246-lva1-app6892/75/Clinical-Skills-Training-and-Simulation-Pedagogy-34-2048.jpg)
Uploaded byK Raman Sethuraman
Clinical Skills Training and Simulation Pedagogy
This document discusses clinical skills training and simulation pedagogy. It outlines various objectives of the session which include listing competencies for health professionals, discussing taxonomy of skills and methods for learning them using Dale's Cone model. It also explains simulation pedagogy using Miller's Pyramid of competence and discusses advantages of using simulation as a teaching tool, including how debriefing and reflection are important parts of simulation-based education. The document provides examples of skills that can be taught via simulation and examines research on implementing simulation effectively in learning.
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Clinical Skills Training and Simulation Pedagogy
- 1. Clinical Skills Training& Simulation Pedagogy Prof K.R. Sethuraman Dean – Faculty of Medicine & Deputy VC – Academic/International Affairs AIMST University “That which we must learn to do, we learn by doing.” – Aristotle
- 2. Objectives for thisSession - a • List the competencies for a health professional • Discuss the taxonomy of skills and appropriate methods for learning them (using the Dale’s 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 thisSession - 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 ClinicalCompetence • 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 LearningActivity – Dale’s Cone of Experience
- 6. Millers model ofcompetence Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7. ProfessionalauthenticityProfessionalauthenticity Read, Listen Knows Shows how Knows how Does Performance or “hands on” Live Demo; Multimedia
- 7. 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 )
- 8. 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.
- 9. 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.
- 10. 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.
- 11. Stages in Competence •Unconscious Incompetence • Conscious Incompetence • Conscious Competence • Unconscious Competence Skill Acquisition Skill Competency Skill Mastery Ignorance http://www.businessballs.com/consciouscompetencelearningmodel.htm
- 12. Skill Acquisition • Skillacquisition 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 • Teacher’s guidance is necessary to achieve correct performance
- 13. Skill Competency • Skillcompetency 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
- 14. Skill Proficiency • Skillproficiency represents the final phase in learning a new clinical skill or activity. • The participant efficiently and precisely performs the steps in the proper sequence.
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- 16. Phased Training forCompetence Easy Complex Component of a skill Integrated skills Isolated Combined Simulated Real life
- 17. II. Simulation for SkillLearning
- 18. What is simulation? Simulate:Aping = Imitate uncritically and in every aspect (simia = Ape)
- 19. 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 2003;37(Suppl. 1):22–28
- 20. The ‘ADDIE’ frameworkfor 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
- 21. 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.
- 22. 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)
- 23. Advantages of SBE •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 • 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)
- 24. Key elements inSBE • Simulation based Education (SBE) has four key elements – 1. Create motivation a priori (briefing) 2. Active learner, not passive recipient of info 3. Individualized and paced for each learner 4. Prompt feedback on success and error (debriefing)
- 25. Rationale for Teacherin 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
- 26. Role of theTeacher 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.
- 27. 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?
- 28. Debrief – Thingsto avoid – Don’t Lecture – Don’t provide your analysis before listening to the team – Don’t create the sense of an interrogation – Avoid a rigid agenda; let them construct the learning outcomes – Don’t interrupt team discussion unless needed
- 29. Three C’s ofeducation Constructive Contextual Collaborative These apply well to the debrief sessions
- 30. III. Skill Learningthrough Simulation Problem Solving Skill Communication skill Physical Examination Skills Integrated Complex Skills
- 31. Problem Solving Skill SimulatedPatient Management Problem (S-PMP) Demo …
- 32. Communication skill TALKING WITHPATIENTS
- 33. Talking with Patients– Value of In primary care, about 86% of the Diagnostic value is from historical data [ Ref - Hampton JR et al. BMJ 1975;2: 486-9] History Exam Lab
- 34. 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]
- 35. 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
- 36. 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
- 37. 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"
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- 39. 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
- 40. Detecting Errors inPhysical Exam for Effective Debriefing
- 41. 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
- 42. Types of LearningErrors Type A Omission or poor technique of performing a step Type B Failure to perceive or to correctly interpret a clinical sign
- 43. Procedural Steps & Interpretation Candidate IDnumber Gr. tot al1 2 3 4 5 6 7 8 9 x Step 1 9 Step 2 8 Step 3 3 Step 4 10 Step 5 5 Step 6 9 Perception & Interpretation 10 Student Score
- 44. Procedural Steps & Interpretation Candidate IDnumber Gr. total 1 2 3 4 5 6 7 8 9 x Step 1 9 Step 2 8 Step 3 9 Step 4 10 Step 5 8 Step 6 9 Perception & Interpretation 4 Student Score
- 45. Corrective Strategies • TypeA 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’
- 46. Immersive Simulation for CriticalCare Skills Stress of Realistic Simulation without harming patients
- 47. Barriers to theWidespread 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)
- 48. Barriers - “WhyChange?” Resistance • We have always done it this way… • We, the products of traditional method are OK… • Why should we change?
- 49. To Sum Up: Education–Teaching – Learning Education is about learning Teaching is NOT = Learning & Education is to achieve learning outcomes So, Education should be adapted to skill learning
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