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“Knowing is not enough; we must apply. Willing is not enough; we must do.” (Goethe)
Clinical Skills Teaching
Wisnu Barlianto Faculty of Medicine University of Brawijaya Dr. Saiful Anwar General Hospital
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Clinical teacher
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Experienced clinicians
Clinicians Teacher
Good teachers
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Outline What is a clinical skill What are the practical approach Procedural Skills Teaching Bedside Teaching
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What is a clinical skill • Any action by health care practitioner involved in direct patient care which impact on clinical outcome in measureable way (Philip Cachia)
Clinical skill include • Procedural skill • History taking skill • Physical examination skill • Decision making skill • Learning skill • Diagnostic skill
• • • • • •
Communication skill Patient management Investigative skill Documentation skill Critical appraisal skill Leadership skill
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Technical skill • • • • •
History taking Physical examination Communication skill Procedural skill Information management
Non technical skill • • • •
Situational awareness Task management Team communication Decision making
Design the teaching of cilinical skill
Cognitive phase
Associative phase
Autonomous phase
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Approach to technical skill learning session S
T
E
P
S
• Set the foundation of prior learning • Tutor demonstration without commentary • Explanation with repeat demonstration • Practice under supervision • Subsequent deliberate practice encouraged
Approach to non technical skill learning session S
I
S
F
R
• Set the context and identify roles and outcome • Immerse in role and practice for agreed time frame • Intervention to summarize progress • Feedback from self, peers, and tutor • Refined practice building on feedback by reimmersion
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Levels of skill learning and performance achievement
Assessment
Show • OSCE how • OSLER Does
• Mini-Cex • DOPS
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Sesi teaching/tutorial yang bertujuan untuk melatihkan suatu prosedur klinik tertentu.
Educational Objectives
Clinical Skills Communication Skills Clinical Reasoning Practical Procedures Patients Investigation and Management Data Interpretation and Retrieval Professional Skills Transferable Skills Attitude and ethics
Strategies
Procedural Skill Teaching Bedside Teaching Logbooks & Portfolios Task-Based Learning Problem-Based Learning Study Guides
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Definition The American Board of Internal Medicine A procedural skill is the learned skills necessary to perform diagnostic and therapeutic procedures within the domain (of any diciplinary medicine). Procedural skills are not unique to surgical specialities but to most branches of medicine. Broad Categories of Procedural Skills: Essential procedural skills Elective procedural skills Not required & not recommended procedural skills
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Broad Categories of Procedural Skills Essential procedural skills Commonly encountered procedures (intravenous line insertion, lumbar puncture) Life saving procedures (cardio-pulmonary resuscitation) All procedures that every learner should be able to perform flawlessly and competently
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Elective procedural skills Depending on the curricular goals of the program for the given group of learners and available and material resources This skills has increased parallel to the rapid rise in the number of procedures and tendency towards specialization
Not required and recommended procedural skills All procedures that deem to be not suitable and/or not safe enough to teach and learn to the given group of learners Depends on the program goals, specialty requirements and needs of the learners
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Tujuh Prinsip Dasar Procedural Skills Teaching 1. Konseptualisasi 2. Visualisasi 3. Verbalisasi 4. Praktek 5. Koreksi dan umpan balik 6. Penguasaan bagian-bagian ketrampilan 7. Otonomi
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1. Konseptualisasi Mahasiswa harus memahami elemen kognitif dari suatu ketrampilan yang akan dilatihkan: Jenis ketrampilan yang sedang dilatihkan Alasan (reasoning) prosedur harus dilakukan Indikasi dan kontraindikasi Hal-hal yang harus diperhatikan selama melakukan prosedur
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2. Visualisasi Mahasiswa melihat procedure yang didemonstrasikan oleh tutor secara keseluruhan dari awal sampai akhir sehingga mahasiswa memiliki ’model’ tentang bagaimana prosedur tersebut dilaksanakan.
3. Verbalisasi Mahasiswa memiliki kesempatan untuk mendengarkan narasi masing-masing langkah dalam suatu prosedur klinik.
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4. Praktek Memberi kesempatan mahasiswa untuk berlatih, mulai dari bagian-bagian prosedur sampai pelaksanaan procedure secara keseluruhan.
5. Koreksi & Umpan Balik Penerapan prinsip pemberian umpan balik yang positif pada mahasiswa dalam pembelajaran clinical procedure.
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6. Penguasaan (skill mastery) Kemampuan untuk melakukan setiap bagian/tahap clinical procedure yang dilatihkan dalam kondisi sebenarnya tanpa kesalahan.
7. Skill autonomy Kemampuan untuk melakukan secara menyeluruh clinical procedure yang dilatihkan dalam kondisi sebenarnya tanpa kesalahan.
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Lima Langkah Procedur Skill Teaching
Step 5: Practice Step 4: Verbal demonstration by learner Step 3: Verbal demonstration by tutor Step 2: Silent demonstration Step 1: Overview
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Step 1: Overview
Mahasiswa sebaiknya memahami mengapa procedure dibutuhkan & bagaimana penggunaan procedure ini dalam pelayanan pasien ≈ prinsip konseptualisasi Faculty of Medicine Univ ersity of Brawijay a
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Step 1: Overview Steps
Rationale
Preceptor's Task
Step One : Students master cognitive Understanding the components of the necessity of the skills skills such as motivates the learners indication, contraindications and precautions
Teaches the knowledge components of the procedure
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Step 2: Silent demonstration
Memberikan gambaran mental kepada mahasiswa bagaimana procedur dilaksanakan dengan baik dan benar sesuai dengan prinsip visualisasi Faculty of Medicine Univ ersity of Brawijay a
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Step 2: Silent demonstration Steps
Rationale
Step Two : Preceptor demonstrates the Learners develop exact way the visual impression of procedure is done the procedure without verbal description
Preceptor's Task Demonstrates procedure to the learners with or without the help of mannequins
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Step 3: Verbal demonstration by tutor
Tutor mengulang demonstrasi dengan menjelaskan masing-masing langkah mahasiswa dapat bertanya dan meminta klarifikasi sesuai dengan prinsip verbalisasi Faculty of Medicine Univ ersity of Brawijay a
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Step 3: Verbal demonstration by tutor Steps
Rationale
Preceptor's Task
Learners chance of Step Three : success improves if Repeats the procedure Preceptor repeats they are able to again. Narrates the the procedure and narrate the procedure. steps describes each steps Allows learners to clarify their doubts
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Step 4: Verbal demonstration by learner
Mahasiswa mengulang langkah-langkah prosedur secara verbal agar lebih memahami pelaksanaan procedure dan mampu mengingat langkah-langkah yang harus dikerjakan ≈ prinsip verbalisasi & umpan balik Faculty of Medicine Univ ersity of Brawijay a
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Step 4: Verbal demonstration by learner Steps
Rationale
Step Four :
Build up the memory Learners of the procedure. sequentially describe Allows preceptor to the steps to the correct the learner preceptor
Preceptor's Task Listens to the students describing the procedure. Corrects and reinforces if necessary
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Step 5: Practice
Mahasiswa berlatih melakukan procedure, sedangkan tutor melakukan observasi dan memberikan umpan balik ≈ prinsip praktek, koreksi dan umpan balik Faculty of Medicine Univ ersity of Brawijay a
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Step 5: Practice Steps
Rationale
Preceptor's Task
Perceptor observes and provides feedback. Step Five : Learners are ready to Allows the student to Learners perform the demonstrate the repeat the procedure procedure procedure until desired proficiency is achieved
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Barriers to Procedural Skills Teaching
Lack of motivation Wrong images of the procedures Learners inherent inability Difficult to transferring the skills
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Tips on Procedural Skills Teaching Advance from unknown to known as new knowledge and skill are constructed upon pre-existing knowledge and skill Practice & teach safer aspects of the procedure first Allow learner sufficient time to be familiar with the equipments Determine the end points of the each procedure based on students, programs needs & requirements Be cognizant of learner’s ability and needs
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To study the phenomena of disease without books is to sail an uncharted sea To study books without patient is not to go to sea at all (Sir William Osler)
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The process of active clinical learning and teaching in the presence of the patient.
“Bedside teaching is the only site where history taking, physical examination, empathy and a caring attitude can be taught and learnt by example.” (Nair, 1997)
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The clinical tutor demonstrates aspects of the case history and physical examination to the students.
The clinical tutor stands to the side and critiques each student in turn as they enquire into aspects of the history and carry out aspects of the physical examination.
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The clinical tutor distances him- or herself from the student– patient interaction and observes a single student or pair of students in a longer portion of history taking or examination,
Working singly or in pairs, students take a history and examination without supervision and subsequently report back to the tutor in a tutorial room to present the case and receive feedback on content and delivery
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Model Bedside Teaching Session Maintain throughout: ● Patient Centered (avoid technical language, base teaching on that individual) ● Include everyone!
Enter patient’s room
Inside patient’s room
Leave patient’s room
End outside room
Begin outside room
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Model Bedside Teaching Session Begin outside room: Ask patient's permission Establish goals and time limit with the group Assign each group member a role
Enter patient’s room Inside patient’s room:
Introduce everyone & brief overview Diagnose learners & patient: observations & questions Conduct focused teaching: Role model, Practice Discussion and Feedback Ask patient if he/she has questions Genuine, encouraging closure
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Model Bedside Teaching Session..... Leave patient’s room End outside room: Debrief with group Feedback (private) Follow-up with patient
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How to Organize the Bedside Teaching?
Primary obstacle is to get started To start small Limit time to 15-20 minutes Use the material you have Involve the learners in history elicitation, clinical examination and planning the management Review your own physical examination skill Follow a standard book Shadowing may be used for beginners in OP Get the learners involved in selecting and presenting the patients
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Advantages of Bedside Teaching Opportunity to: • gather additional information from the patient • directly observe students' skills • role model skills and attitudes Humanizes care by involving patients Encourages the use of understandable and nonjudgmental language Active learning process in which adults learn best Patients feel activated and part of the learning Improves patients' understanding of their disease and the work-up Faculty of Medicine Univ ersity of Brawijay a
Problems of Bedside Teaching Fear of patient discomfort Lack of privacy, confidentiality Patients are often hard to locate (testing, operating room) Learners do not want to go to bedside Takes more time Teachers feel uncomfortable (may lead to discussion of medicine teacher not familiar with)
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Practice Points Potential barriers to teaching at the bedside include those relating to physician teachers, patients and students Advantages include the ability to directly observe clinical skills, improve patient care and enhance learning Specific bedside teaching strategies can alleviate many of the barriers and include: attending to the patient's comfort, using focused teaching methods and managing group dynamics
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“A good consultant is accessible, approachable and friendly, with the power of a god, the patience of a saint and the sense of humour of an undergraduate.” Lowry 1987
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