Teaching Musculoskeletal Procedures Sponsored by: STFM Group on Hospital Medicine and Procedural Training

Instructors Steve Roskos – Michigan State University Steve Roskos – Michigan State University Ashok Kumar - University of Texas Health Science Center at San Antonio Ashok Kumar - University of Texas Health Science Center at San Antonio Dale Patterson - Memorial Hospital of South Bend Family Medicine Residency Dale Patterson - Memorial Hospital of South Bend Family Medicine Residency Julie Sicilia – Alaska Family Medicine Residency – Univ. of Washington/WWAMI Julie Sicilia – Alaska Family Medicine Residency – Univ. of Washington/WWAMI Roberta Gebhard – SUNY Buffalo/Niagara Falls Memorial Medical Center Family Medicine Res. Roberta Gebhard – SUNY Buffalo/Niagara Falls Memorial Medical Center Family Medicine Res. Roger Garvin - Oregon Health and Sciences University Roger Garvin - Oregon Health and Sciences University

Objectives At the end of our seminar each participant will be able to: At the end of our seminar each participant will be able to: 1. Teach procedures using principles of effective instruction. 2. Use a certification checklist to evaluate learners’ skills. 3. Give effective feedback to learners while teaching musculoskeletal procedures.

Agenda 1. (30 min) Introduction: Principles of effective instruction Principles of effective instruction Giving Feedback Giving Feedback Evaluating Competency Evaluating Competency 2. (55 min) Role play instruction & feedback: Participants will all have opportunity to play the role of teacher and receive constructive feedback on their teaching techniques. Participants will all have opportunity to play the role of teacher and receive constructive feedback on their teaching techniques. 3. (5 min) Wrap up: questions and answers

Teaching procedures: What is the content? Indications Indications Contraindications Contraindications Equipment Equipment Complications (AKA Risks, Adverse effects) Complications (AKA Risks, Adverse effects) Patient preparation Patient preparation Performing the procedure Performing the procedure Post procedure instructions Post procedure instructions Coding and Billing Coding and Billing

An effective skill lesson Introduction Introduction Core Core Conclusion Conclusion OOMPA ED WASDM PF SIOMT OOMPA ED WASDM PF SIOMT Yelon S. Goal Directed Instructional Design: a Practical Guide for Teachers and Trainers

An effective skill lesson Introduction (OOMPA) Introduction (OOMPA) –Objective –Overview –Motivation –Prerequisites –Agenda

An effective skill lesson Core Core –Explanation/Demonstration (ED) WASDM WASDM –Practice with Feedback (PF)

An effective skill lesson Conclusion (SIOMT) Conclusion (SIOMT) –Summary –Integration –Objective –Motivation –Test

Objective “You will be able to perform this procedure on real patients in the real world” “You will be able to perform this procedure on real patients in the real world” “When presented with a patient who may require a ____________, the learner will be able to determine the need for a ____________ and competently perform a ___________.” OOMPA ED WASDM PF SIOMT

Overview A quick summary of the steps involved. A quick summary of the steps involved. e.g. “We are going to obtain informed consent, prep the area, and inject it with triamcinolone and lidocaine.” e.g. “We are going to obtain informed consent, prep the area, and inject it with triamcinolone and lidocaine.” OOMPA ED WASDM PF SIOMT

Motivation Why should the learner care? Why should the learner care? e.g. “This procedure can benefit lots of patients with osteoarthritis, it provides speedy relief, and the patients thank you!” e.g. “This procedure can benefit lots of patients with osteoarthritis, it provides speedy relief, and the patients thank you!” OOMPA ED WASDM PF SIOMT

Prerequisites Anatomy of the area Anatomy of the area Indications/Contraindications Indications/Contraindications Benefits/Risks Benefits/Risks Equipment needed Equipment needed Steps of the injection Steps of the injection Post-procedure instructions Post-procedure instructions Coding and Billing information Coding and Billing information OOMPA ED WASDM PF SIOMT

Prerequisites “What are the risks of this procedure?” “What are the risks of this procedure?” “Pretend that I am the patient and explain the risks, benefits, and alternatives.” “Pretend that I am the patient and explain the risks, benefits, and alternatives.” Refer them to a resource (e.g. Pfenninger & Fowler’s Procedures for Primary Care) Refer them to a resource (e.g. Pfenninger & Fowler’s Procedures for Primary Care) OOMPA ED WASDM PF SIOMT

Prerequisites Aids (these also add novelty, which aids learning) Aids (these also add novelty, which aids learning) –Videos –Photos –Diagrams –Models OOMPA ED WASDM PF SIOMT

Shoulder anatomy: (Photo removed) (Photo removed) From

Find the spot (Photo removed) (Photo removed) From: medicine.ucsd.edu/clinicalmed

Agenda What can the learner expect? What can the learner expect? –If a workshop, tell them what you are going to teach them –If informal, tell them what you are going to teach them! OOMPA ED WASDM PF SIOMT

Explanation & Demonstration W - ”You Will perform this procedure” W - ”You Will perform this procedure” A - ”Attend to these steps as I demonstrate them” A - ”Attend to these steps as I demonstrate them” SD – “Say each step before doing it” SD – “Say each step before doing it” M – Have the learner Memorize the steps and recall them M – Have the learner Memorize the steps and recall them OOMPA ED WASDM PF SIOMT

Subacromial Bursa Injection Steps 1. Mark the site 2. Sterile Prep 3. Anesthesia (optional) 4. Insert the needle 5. Aspirate 6. Inject 7. Remove the needle 8. Pressure 9. Dispose of sharp 10. Band-aid

Show Video

Practice with Feedback Real patients Real patients Simulated patients Simulated patients Make sure the learner says the steps as they do them (say then do – SD) Make sure the learner says the steps as they do them (say then do – SD) OOMPA ED WASDM PF SIOMT

Practice with Feedback Simulated patients for musculoskeletal injections: Simulated patients for musculoskeletal injections: –Fruit (e.g. a ripe peach) –Models Sawbones Sawbones Limbs & Things Limbs & Things OOMPA ED WASDM PF SIOMT

A ripe peach? (Photo removed) (Photo removed)

Feedback Information you provide to learners about their clinical performance that is intended to guide their future clinical performance. Information you provide to learners about their clinical performance that is intended to guide their future clinical performance. Anderson WA. “Providing Constructive Feedback”. Lecture presented at the Primary Care Faculty Development Fellowship,

Constructive Feedback A combination of positive and negative feedback along with a description of how to improve next time. A combination of positive and negative feedback along with a description of how to improve next time.

Why Feedback? 1. Learners need to know what they are doing right and/or wrong 2. Learners need to be praised for their accomplishments. 3. Adult Learners Want and Need Feedback!

Practice with Feedback Feedback during the practice Feedback during the practice Feedback after the practice Feedback after the practice OOMPA ED WASDM PF SIOMT

During the Practice Make the situation Pleasant! Make the situation Pleasant! –Avoid pressure & stress –Be encouraging OOMPA ED WASDM PF SIOMT Hewson MG, Little ML. Giving Feedback in Medical Education. JGIM 1998;13:11-116

During the Practice Observe & Prompt Observe & Prompt –Mention what’s right: “You are keeping the needle nice and steady” “You are keeping the needle nice and steady” –Ask, don’t tell: “Are entering at a 90 degree angle to the skin?” “Are entering at a 90 degree angle to the skin?” “Stop a second, now what are you forgetting?” “Stop a second, now what are you forgetting?” OOMPA ED WASDM PF SIOMT

After the practice Prepare the learner: “I’d like to give you some feedback now” Prepare the learner: “I’d like to give you some feedback now” Ask, don’t tell: Ask, don’t tell: –How do you think you did? –What do you think went well? –What do you think you could improve?

The Feedback Sandwich What was done right What was done right What was done incorrectly What was done incorrectly What to do next time (what was done right) What to do next time (what was done right)

Review Check for understanding: Check for understanding: –“What questions do you have?” Improvement plan: Improvement plan: –“What will you work on for next time?”

Characteristics of Constructive Feedback 1. Descriptive, not judgmental 2. Specific, not general 3. Focused on issues the learner can control 4. Well-timed 5. Limited in amount 6. Asked of the learner Hewson MG, Little ML. Giving Feedback in Medical Education. JGIM 1998;13:11-116

Guidelines for Giving Feedback Teacher and Trainee are allies Teacher and Trainee are allies Measured against well defined goals Measured against well defined goals Offer subjective data, labeled as such Offer subjective data, labeled as such Deal with decisions & actions, not assumed intentions or interpretations Deal with decisions & actions, not assumed intentions or interpretations Ende J. Feedback in Clinical Medical Education. JAMA 1983;25:

Conclusion S - Summary: Review the Steps S - Summary: Review the Steps I – Integration: How does this procedure fit with the rest of a treatment plan I – Integration: How does this procedure fit with the rest of a treatment plan O – Objective – review it O – Objective – review it M – Motivation – review it M – Motivation – review it T – Test – assess competency T – Test – assess competency OOMPA ED WASDM PF SIOMT

Assessing Competency Faculty observation Faculty observation Performed on a real patient Performed on a real patient Performed on a simulated patient Performed on a simulated patient General Impression General Impression Global Evaluation Global Evaluation Criterion Checklist Criterion Checklist

Certification Checklist (excerpt)

Now for some practice! With Feedback!