1. Teaching Procedural Skills Amy S. Oxentenko, MD, FACP, FACG, AGAF Mayo Clinic, Rochester

2. No Disclosures

3. Objectives Create an educational contract with a trainee before an endoscopy session. State the basic features of creating the appropriate learning environment. Describe the stages of conscious competence. Reiterate the 4-step approach to teaching psychomotor skills. List factors for when to take over the scope. Give feedback applying Pendleton’s Rules.

4. Outline of Talk Set-Dialogue-Closure Model Peyton’s Learning Cycle of Competency 4-Step Process of Teaching a Psychomotor Skill Instruction and Communication Performance-Enhancing Feedback Pendleton's Rules Simulator Training

5. If a Colleague was Sick and Coverage Was Needed, Would You Rather… A.Supervise in the fellow continuity clinic? B.Give your canned talk to the med students? C.Perform a few hospital consults? D.Supervise a fellow doing colonoscopy?  During their first week EVER of scoping

6. Why is teaching endoscopy so challenging???

7. Teaching a Procedural Skill: Why Does it Feel so Tough? Many have not had instruction in teaching a procedural skill Many were taught varying ways to do the same thing as trainees, so it is not always clear what is the “best” way It requires a balance of patience, diligence, and removing ourselves from the “expert” stage of competence in order to teach

8. Let’s See How Well We Are Doing? How many of you currently set an agenda with every trainee before an endoscopy shift? How many of you give specific feedback after a procedure shift? How many of you create a learning plan for a trainee for their next procedure shift?

9. Set-Dialogue-Closure Model

10. Set – Period before training begins – Verbal: Assessment of skills, agenda setting, develop an educational contract – Physical: equipment, ergonomics, room set-up, position Dialogue – Delivery of actual training (4-step process) Closure – Summarize and reflect – Performance-enhancing feedback – Define learning objectives for the next session

11. Framework for Endoscopy Training Preparation Assessment Align agendas, set objectives/ground rules Set Clear, consistent, concise, common Performance –enhancing instruction Dual task interference/cognitive overload Dialogue Summary Performance-enhancing feedback Take-home message Closure Educational contract

12. The Set

13. Framework of the Agenda Knowledge Skills Attitudes Pre/post/intraoperatively Awareness of pt needs Endoscopic technique Prioritization Time management Motivation Relationship with team Relationship with pt

14. Setting Learning Objectives: “SMARTER” SSpecific MMeasurable AAchievable RRelevant TTimely EEconomical RReviewed (modified prn)

15. The Dialogue

16. Psychomotor (Bloom’s) Taxonomy for Hierarchy of Skills MasteryDoesShows howKnows howKnows whatAwareness

17. Peyton’s Learning Cycle of Competency Unconscious Competence Unconscious Incompetence Conscious Incompetence Conscious Competence

18. Competency Learning Model Aware that you lack a skill. Working on a skill; requires thought. Not aware that you lack a skill. So skilled you don’t have to think about it. Unconscious Competence Unconscious Incompetence Conscious Incompetence Conscious Competence

19. Competency Learning Model Uh-oh. There’s something I don’t know. I can do this when I am deliberate about it. I don’t know what I don’t know. I can do this without even thinking. Unconscious Competence Unconscious Incompetence Conscious Incompetence Conscious Competence

20. Competency Learning Model TraineeTeacher Early trainee Expert Unconscious Competence Unconscious Incompetence Conscious Incompetence Conscious Competence

21. Competency Learning Model Early trainee Unconscious Competence Unconscious Incompetence Conscious Incompetence Conscious Competence

22. Competency Learning Model Trainee Early trainee Unconscious Competence Unconscious Incompetence Conscious Incompetence Conscious Competence

23. Competency Learning Model Expert Unconscious Competence Unconscious Incompetence Conscious Incompetence Conscious Competence

24. Competency Learning Model Teacher Expert Unconscious Competence Unconscious Incompetence Conscious Incompetence Conscious Competence

25. How to Instruct When Teaching a Psychomotor Skill 1.Trainer perform, trainee observes, with no verbal explanation. 2.Trainer performs, trainee observes, with the trainer explaining the procedure in detail, breaking it down into steps. 3.Trainer performs, and the trainee explains the procedure in detail, breaking it down into steps. 4.The trainee performs the procedure, and verbalizes what they plan to do before they do it.

26. Demonstration of Teaching a Skill

27. Review of Teaching a Psychomotor Skill Explain the 4-step process before beginning Follow the 4-step process Pick a standard case to demonstrate Do not do deliberate errors to prove a point Do not go into lengthy discussions Avoid shortcuts

28. Once In the Endoscopy Suite Where are you standing? – Can you see trainee’s hands and scope? – Can you see monitor? Have you considered the ergonomics? – Wrists, shoulders, back – Table height, scope weight, scope handling, shoes Are you being consistent in your practice? – How to hold and position the scope – How to insert the scope

29. Instruction and Communication During a Procedure Timing of instruction Type of instruction Specific language Teaching vignettes

30. Timing of Instruction Avoid dual-task interference (cognitive overload) – Cannot listen and perform at same time Example: Balance checkbook while someone asks questions – Don’t ask them to provide ongoing commentary Silence is OKAY!!! Occasional words of praise If instruction needed: – Pause and instruct – Ask intermittent questions

31. Types of Instruction – Directive Use more for the inexperienced or when struggling “Deflect the tip up.” – Didactic Use before starting a specific task (polypectomy) – Questioning Use more for the experienced “What do you think is the problem?” “What are your options for this polyp?”

32. Specific Language (12 Terms to Use) 1.Stop 2.Slow down 3.Pull back 4.Advance 5.Blow 6.Suck 7.Tip up 8.Tip down 9.Tip right 10.Tip left 11.Clockwise torque 12.Counter-clockwise torque Using specific terms will avoid more vague or differing ways to describe the same task

33. Teaching Vignettes Can do these before or after the case: Before: – “This patient has diarrhea. Describe what you will be looking for? What do you plan to do if the mucosa looks normal versus abnormal?” After: – “So you removed a small pedunculated polyp with a cold snare. Tell me how you would have remove a polyp if 0.5 cm vs 1 cm vs 2 cm? What if sessile vs pedunculated. Snare or forceps? Hot or cold? Settings?”

34. Before Taking the Scope Away Do you know what the problem is? Are your instructions correct? Are your instructions clear? Are your instructions understood? Were your instructions carried out? Is the technical challenge above skill level? If “yes” for 1-6, then consider taking scope

35. Patient Factors Affecting When to Take the Scope Away Previous experience Team concerns Pain Complications Indications for the case Withdrawal of consent Change in clinical parameters Age Time Pathology found

36. The Closure

37. Feedback During Endoscopy Better defined as: – “Performance-enhancing training” Includes: – Performance-enhancing instruction – Performance-enhancing feedback Follows the rules of giving feedback in general – Decision training – Checking for understanding

38. Example During Colonoscopy “You did that wrong. Next time, turn the dial up and torque to the right.” VERSUS “Let’s talk about what you think happened and what you need to do next time to avoid that same problem.”

39. Pendleton’s Rules 1.Trainer asks trainee what went well 2.Trainer says what he/she thought went well 3.Trainer asks trainee what might be done differently next time 4.Trainer says what he/she thinks should be done differently next time 5.Trainer then does a summary statement for the learner to have a learning plan

40. Simulation Training “Something that is made to look, feel, or behave like something else especially so that it can be studied or used to train people” Merriam Webster Dictionary May allow more rapid progress of skills in the endoscopy suite Can range from videos to patient simulation to animal models to box simulators to advanced simulators

41. Simulation Training Don’t expect to send a trainee alone to practice on a simulator for the 1 st time – Learn incorrect technique – No feedback provided Use simulator to practice a technique once known Simulators should be used at each level of training

42. Questions?

43. Summary Use the Set-Dialogue-Closure Model to format your teaching sessions in endoscopy; never forget to set the agenda! Appreciate that as an expert, you need to transition yourself to the phase of “conscious competence” in order to effectively teach a procedural skill. Use the 4-Step Process of Teaching a Psychomotor Skill when teaching a trainee a new technique. Utilize Pendleton's Rules to give performance- enhancing feedback after a teaching session, and set objectives for the trainee’s next session as well.

44. Thank you! Oxentenko.amy@mayo.edu