1. Teaching Procedural Skills UCSF Faculty Development Workshop January 21, 2014 Diane Sliwka, MD Kirsten Greene, MD Darren Fiore, MD

2. Workshop Objectives Develop a process for teaching a procedure. Describe how the theory of deliberate practice guides the steps for teaching a procedure. Practice providing feedback that will enhance performance. Analyze obstacles to the teaching of procedures.

3. Small Group Activity 1 Goal: How would you teach someone to make an easy origami heart (procedure)? -4 groups -Practice making a heart -Identify steps for teaching a procedure -Present steps to large group http://www.origami-instructions.com/easy-origami- heart.html

4. Deliberate Practice All practice is not equal Practice makes permanent Deliberate practice makes perfect Unproductive (mindless) practice vs. Deliberate (mindful) practice

5. Deliberate Practice K. Anders Ericsson Expertise: more to do with how one practices than with performing a skill many times Repetitive, goal-directed practice Targeted feedback Reflection on performance

6. Practice Observed Performance Targeted Feedback Goals LEADS TO ALLOWS FOR GUIDES FURTHER DIRECT HELP US EVALUATE SHAPE

7. Framework for Teaching A Procedure Identify a skill Know your learner Define specific goals Devise an exercise Practice the skill Provide feedback Problem Identification Needs Assessment Goals and Objectives Educational Strategies Implementation Evaluation

8. Steps of Procedural Teaching Preparation Task analysis Conceptualization Visualization Verbalization Guided deliberate practice with feedback

9. Small Group Activity 2 Goal: Learn and teach a complex origami heart (procedure). -2 groups practice blossom heart -2 groups practice beating heart -Work in pairs to teach each other your heart -Self-assessment of teaching http://www.origami-instructions.com/easy-origami- heart.html

10. Feedback

11. Be respectful and sensitive Be specific Temporally close to event Optimal Losada ratio reinforcing: corrective 5.6:1

12. ARTful Feedback Ask Respond Tell

13. Feedback What do you think you would like to KEEP doing? (reinforce) What do you think you would like to STOP doing? (correct) What do you think you would like to START doing? (next steps)

14. Feedback What did you do well? What do you think did not go well? What do you want to work on next time?

15. What is hard about teaching procedures?

16. Patience Give the learner a set period of TIME Give the learner a set number of TRIALS Give the learner a set number of STEPS

17. Communication Give clear directions Don’t scare the patient Don’t scare the learner Use similes, think creatively about how to describe things

18. Safety Do not teach a procedure you can’t do yourself Do not let the learner get into trouble you can’t bail them out of Choose the correct level of learner for your OWN experience level Choose the correct patient for your OWN experience level

19. Challenging Scenario 1 Chris is a surgery intern who has been having a hard year. His evaluations haven’t been good on any rotation this year. Faculty report that he is lazy, has poor technical skills, lacks time management, and still can’t prioritize what is important vs. what is trivial. You know that he has gotten a lot of negative feedback this year. He seems demoralized and less responsive when attendings point out errors compared to a few months ago. Today you are supervising him placing a central line. In the past, he has had trouble with this according to your colleagues although you have never worked with him. What is your approach?

20. Challenging Scenario 2 You are supervising a resident doing a lumbar puncture for his 3 rd time. He has been attempting to get the LP for ~20 minutes, and has not been successful despite your attempts to give suggestions. The patient is awake and is becoming increasingly anxious, expressing concerns about how long the procedure is taking. The patient asks whether the resident knows what he’s doing. What do you do as the supervising physician?

21. Challenging Scenario 3 A new nurse has been training for about 4 weeks to place PICC lines. Her teacher is an experienced PICC nurse. The trainee observed her teacher for a week and has had supervised practice for 3 weeks. She has been successful nearly 80% of the time, but doesn’t know why she’s not yet at 100%. She seems to find and access the vein easily, but sometimes has difficulty using a guide wire and manipulating the equipment. How might her teacher approach this situation?

22. Summary Teaching a procedure takes time and involves helping learner: prepare, analyze the task, understand, observe, verbalize the steps, then practice with feedback. Deliberate practice is repetitive and goal- directed with targeted feedback and reflection. Procedural teaching parallels the steps of curriculum development. Feedback is critical to improve performance.