Clinical Skills Training & Simulation Pedagogy

Prof K.R. SethuramanDean – Faculty of Medicine &

Deputy VC – Academic/International Affairs

AIMST University

“That which we must learn to do, we learn by doing.” – Aristotle

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 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)

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.

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

Choice of Learning Activity – Dale’s Cone of Experience

Millers model of competence

Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7.

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Read, Listen Knows

Shows how

Knows how

Does

Performance or “hands on”

Live Demo; Multimedia

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 )

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.

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.

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.

Stages in Competence

• Unconscious Incompetence

• Conscious Incompetence

• Conscious Competence

• Unconscious Competence

Skill Acquisition

Skill Competency

Skill Mastery

Ignorance

http://www.businessballs.com/consciouscompetencelearningmodel.htm

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

• Teacher’s guidance is necessary to achieve correct performance

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

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.

Mastery Learning Model

-Bloom 1968

Phased Training for Competence

Easy Complex

Component of a skill Integrated skills

Isolated Combined

Simulated Real life

II. Simulation for Skill Learning

What is simulation?

Simulate: Aping =

Imitate uncritically and in every aspect

(simia = Ape)

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

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

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.

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)

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)

Key elements in SBE

• 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)

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

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.

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?

Debrief – Things to 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

Three C’s of education

Constructive

Contextual

CollaborativeThese apply well to the debrief sessions

III. Skill Learning through Simulation

Problem Solving Skill Communication skill Physical Examination Skills Integrated Complex Skills

Problem Solving Skill

Simulated Patient Management Problem (S-PMP)

Demo …

Communication skill

TALKING WITH PATIENTS

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

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]

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

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

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"

Simulation for Physical Examination Skills

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

Detecting Errors in Physical Exam for Effective Debriefing

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

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

Procedural Steps &Interpretation

Candidate ID number Gr.total1 2 3 4 5 6 7 8 9 x

Step 1                      

9Step 2                      

8Step 3                      

3Step 4                      

10Step 5                      

5Step 6                      

9Perception & Interpretation

                     

10

Student Score

                     

Procedural Steps &Interpretation

Candidate ID number Gr.total

1 2 3 4 5 6 7 8 9 x

Step 1                      

9Step 2                      

8Step 3                      

9Step 4                      

10Step 5                      

8Step 6                      

9Perception & Interpretation

                     

4

Student Score

                     

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’

Immersive Simulation for Critical Care Skills

Stress of Realistic Simulation without harming patients

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)

Barriers - “Why Change?” Resistance

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

To Sum Up: Education –Teaching – Learning

Education is about learning

Teaching is NOT = Learning&

Education is to achieve learning outcomesSo, Education should be adapted to skill learning

An Enlightened Teacher is -

!

Terima Kasih !