When medical graduates enter
the frantic and challenging clinical arena, they are called upon to
apply themselves immediately to the direct care of patients. For a
doctor to provide a high level of clinical care, a judicious mix of
knowledge and skill is required with skills being built on the bedrock
of knowledge. Miller’s pyramid of clinical competence reinforces this
concept – the broadest part of the pyramid is ‘Knows’ followed by ‘Knows
how’ [1]. Both of these represent the cognitive domain, upon which are
built ‘Shows how’ and ‘Does’. Though the narrowest part is ‘Does’, it is
at this stage of competence that the learner actually performs as a
doctor by applying in practice all that he has learned. With the current
systems in place, while knowledge is usually gained, skill acquisition
is not invariably assured [2]. Medical educators must adopt appropriate
teaching-learning methods to produce skilled doctors – doctors with the
ability to perform, to ‘do’.
What are Skills?
Taken literally, a skill is an ability that is
acquired through deliberate, systematic, and sustained effort; thus,
training is required before a person can be said to be skilful.
Conventionally, when used in the context of KSA – Knowledge, Skills,
Attitude – the term ‘skill’ refers to psychomotor skills which are
manual, physical skills such as staining a hematology slide, performing
urinary catheterization, suturing a laceration, or drawing a blood
sample. With training, psychomotor skills progress all the way from the
learner observing an expert performing the skill, to the learner
mastering the skill. The progression is commonly defined using a
simplification of Dave’s taxonomy that starts with imitation, moves to
control, and ends with automatism [3]. An example of imitation would be
when the learner observes a trained person draw a blood sample and
copies her; with practice under supervision, the learner gains some
control over sampling until, finally, she is able to do it automatically
and can even adapt it to cover problem situations like an uncooperative
child or a patient in shock.
Over the years, the term ‘skill’ has taken on a
broader definition that includes not only the ability to effectively
draw a blood sample, but also other aspects like the ability to interact
with the patient, obtain consent, and handle complications [4]. Both the
Medical Council of India (MCI) and the Association of American Medical
Colleges (AAMC) mention the need for skill development during
undergraduate medical education; the latter defines a clinical skill as
a discrete, observable task during the provision of care [5,6]. From
that standpoint, clinical skills could include everything from
establishing a professional relationship with the patient, to taking a
clinical history, performing an appropriate examination, recommending
and performing diagnostic tests, and undertaking therapeutic
interventions.
These discrete and observable acts are reflected in
some of the competencies identified by both the MCI and the
Accreditation Council for Graduate Medical Education (ACGME); thus,
‘Clinician’ and ‘Communicator’ roles of an Indian Medical Graduate, and
the ‘Patient Care’ core competency of the ACGME are essentially related
to clinical skill development [5,7].
Types of Clinical Skills
Besides basic, generic clinical skills, there are
problem-based clinical skills, discipline-specific clinical skills, and
continuum-of-care skills [6].
• Basic clinical skills: These are needed
regardless of discipline and setting. They include communication
skills (building the patient-doctor relationship, taking the
history, counseling, reflecting with and teaching the patient);
examination skills (of the anatomy and function of body organs); and
clinical investigating and procedural skills (for basic diagnosis
and therapy).
• Problem-based clinical skills: These
assist in case-based learning and can be learned and practised
through evaluating commonly seen problems like fever, and cough.
• Discipline-specific clinical skills:
These skills are specific to a particular discipline e.g.,
aseptic technique can be repeatedly practiced during a surgical
posting while preventive health skills can be learned during
community visits.
• Continuum-of-care skills: These include
those learned while students rotate through different clinical
settings like the outpatient, inpatient, emergency, intensive care,
and community settings so that they are exposed to the continuum of
care across settings.
Levels of Clinical Skills/Competence
There are various instruments and scales that guide
learners and trainers on the path to acquisition of clinical skills or
competency [8-10]. Table I details Dreyfus’ skill levels.
Individual specialties can define standards applicable to different
stages of training, as detailed previously [11].
TABLE I An Example of Levels of Acquisition of Clinical Skills According to the Dreyfus Model
Dreyfus’ skill Level
|
Description* |
Example
|
Novice |
Learner has minimal knowledge and needs |
Is only able to perform endotracheal intubation if full
|
|
close supervision; he tends to stick to rules |
supervision is provided
|
|
or follow the plan since he lacks the
|
|
|
confidence to innovate. |
|
Advanced Beginner |
Through practice, learner is able to perform |
Can perform intubation with only occasional supervision.
|
|
simple tasks to an acceptable standard,
|
|
|
needing only occasional supervision. |
|
Competent |
Learner demonstrates coordination and |
Performs intubation with ease, unsupervised, and ‘knows
|
|
efficiency in standardised and routine |
how’ to plan for complicated situations
|
|
procedures, and can assess and plan for
|
|
|
complicated situations. |
|
Proficient |
With a deeper understanding of the |
Performs intubation with ease in complicated situations
|
|
theoretical and practical aspects of the skill, |
like a patient with a deformity of the cervical spine |
|
the learner becomes proficient in it, taking
|
|
|
full responsibility and dealing with
|
|
|
complicated situations routinely. |
|
Expert# |
The learner has authoritative knowledge, |
Innovates and trains others in the technique of endotracheal
|
|
intuitively innovates, and trains others in
|
intubation |
|
the skill.
|
|
*Based on Dreyfus [9] and Benner [10]; #Progression occurs as a
gradual transition and does not stop once ‘expert’ level is
achieved; on the contrary, experts must periodically evaluate
themselves and seek opportunities to stay up-to-date. |
Teaching of Clinical Skills
The Challenges
Once the need for training in clinical skills has
been established, the next logical step is to determine effective
methods so that learners can be trained to perform the skills safely and
effectively; however, before that, one must understand the challenges
inherent in the clinical learning environment [12,13].
Invariably, there are time constraints owing to
patient-care, research or administrative responsibilities preventing
active participation in teaching by clinical teachers; patient
priorities must often take precedence over teaching; opportunistic
teaching may result in unpredictability and can sabotage learning
objectives; expectations from learners may be mismatched especially when
there are multiple hierarchies in the same clinic (different semesters
of undergraduate students together, or undergraduate along with
postgraduate students); patient unwilling to allow teaching encounter or
too sick; limited time for immediate feedback or student
self-reflection; shorter in-patient stay precludes learning natural
history of a disease from in-patient follow up; multiple patient
problems may prevent teaching one problem in detail; awkwardness in
pointing out student’s errors, or admitting to consultant’s errors, in
front of the health team.
Models of Clinical Skills Training
We describe some models that are already being used
in a limited sense or can easily be adapted to the Indian context.
See One, Do One, Teach One
SODOTO, as it is popularly referred to, is a method
of learning procedural skills that dates back several generations [14].
Learners observe an expert perform a procedure, then perform it
themselves, and, after practice, they train others to perform it. In
this apprenticeship model of medicine, learners learn by practising on
real patients, which is the most realistic way to learn. The main
disadvantage is that this approach is poorly structured and may fail to
teach the skill properly; for the same reason, assessment may be
difficult. Since it is usually performed on real patients, often without
adequate supervision, patients may be exposed to harm at the hands of
learners who, as yet, lack experience and technical skills.
One way to overcome these disadvantages is to prepare
learners beforehand; thus, learners should read about the steps of the
procedure, observe experts perform it, watch video demonstrations,
practice on manikins, and only when they feel confident should they
perform the procedure on a patient. A clinical skills laboratory can
help achieve clinical skills training without exposing the patient to
trial and error.
Peyton’s Four-step Approach [15]
Skills are learned through practice under the
observation of the trainer who provides feedback. There are four steps:
1. Demonstration: The trainer performs the
task as usual – say an endotracheal intubation - demonstrating it to
the learner without any comments while the learner observes the
procedure.
2. Deconstruction: The trainer repeats the
procedure, but this time he demonstrates the equipment and details
each step of the procedure.
3. Comprehension: The learner takes over
at this stage, explaining each step of the procedure while the
trainer performs it according to the instructions of the learner.
4. Performance: The learner performs the
complete procedure by himself.
The learning session is structured as follows [16]:
• The set – Where the teacher takes into
consideration the learners’ basic knowledge; the learner’s position
(learner watching from the side or from across); and ensures that
the learner can clearly see all the steps.
• The dialogue - The teacher breaks up the
procedure into clear steps; provides positive feedback and corrects
mistakes; keeps dialogue focussed to the task at hand; and considers
another session if the task is complex and requires long
explanations.
• The closure – Here the teacher evaluates
that the learner will be able to perform; and explains how the
procedure may have to be adapted under different circumstances.
In practice, the demonstration (step 1) could be done
on a real patient so that the learner witnesses a real-life, competent
performance, while deconstruction and comprehension (steps 2 and 3) can
be performed away from the patient using only the relevant equipment.
The steps should be repeated in different situations so that the learner
can perform satisfactorily in different scenarios.
Peyton’s four-step approach helps learners, who start
off as "consciously incompetent", become "consciously competent"; thus,
from realising that they cannot perform the skill, they begin to be able
to perform with conscious thought. Further, learners are actively
exposed to professionalism and patient-doctor communication during step
1 which is not usually the case during conventional training [17]. Step
3 is considered the most relevant for learning the skill since it
includes mental representation and vocalisation of the skill. One
disadvantage of this approach is that it is meant for a one-on-one
teacher student interaction; unfortunately, such an ideal
teacher-student ratio is not the norm and this technique may not be
applicable to small group teaching. Educators have attempted to overcome
this disadvantage by sharing videos of steps 1 and 2 with large groups
and having small batches perform steps 3 and 4 [16]. Alternatively, the
teacher can demonstrate steps 1 and 2 to the entire class. This is
followed by step 3 with a single learner (learner 1) while the other
learners are observing the skill. Learner 1 then takes the place of the
teacher and performs step 3 under the instructions of learner 2
and so on until every learner has completed step 3 and moved on to step
4 - all the while getting feedback from a peer as well as from the
teacher [17].
Talk the Talk and Walk the Walk [18]
This literally means that trainers should practice
what they preach i.e. become positive role models, especially for
training in communication, reasoning, empathy and other essential
patient-centered clinical skills.
T= Think out loud: To demonstrate clinical
reasoning, the trainer should vocalise his thoughts as he works towards
a differential diagnosis or choses a particular line of treatment. The
learner is exposed to the process and not merely to the outcome of
clinical reasoning.
A= Activate the learner: Motivate the
learner to engage with patients so as to provide patient-centered care;
promote learner autonomy.
L= Listen smart: This is done so as to
diagnose the learner’s abilities in the clinical environment.
K= Keep it simple: Demonstrate focused
communication and rule-based clinical decision making.
W= Wear gloves: Besides demonstrating the
importance of universal precautions, its true utility lies in the
promotion of a hands-on approach to patient care. The trainer
role-models the physical examination and respectful, healing touch.
A= Adapt enthusiastically: Clinical
medicine is fraught with uncertainty; the trainer should accept
unexpected outcomes and admit mistakes with humility, changing course
when required.
L= Link learning to caring: Demonstrate
empathy and caring for all patients and expect the learner to do the
same.
K= Kindle kindness: Give and expect
kindness routinely to demonstrate that the patient is not the enemy.
Other Techniques to Enhance Clinical Skills Training
Peer-assisted Learning [19,20]
Peer-assisted learning is an educational method where
students function as teachers as well as learners. The peer can be a
fellow student (Student as teacher) or a resident (Resident as teacher)
who works together with the learner to construct new knowledge. It
results in reciprocal learning with the peer and the student learning
together. Peers are better accepted as teachers because they are closer
in experience to the learners and thus are perceived as being friendly,
supportive and less threatening than consultants. They understand the
learning difficulties of their peers and are reported to give useful
feedback, besides being enthusiastic to teach [21]. Peer teachers, being
advanced beginners, are more likely to use a step-wise approach than
consultants, who, over time, have developed an integrated approach to
teaching skills.
Besides cognitive skills, peer-assisted learning
facilitates lifelong learning, teamwork, critical thinking, reflection
and communication. Peer teachers can close the gap between students and
clinical teachers, and make small-group teaching possible in situations
where clinical teachers are over-burdened by large patient loads and
other responsibilities. Peer-teachers may derive academic and career
benefits from their teaching experience. A disadvantage of using
peer-teachers is that they have limited clinical expertise and may not
be as competent as consultants in teaching the cognitive and technical
aspects of complex procedures. Training in pedagogical principles is
required before peers can be recruited for peer-assisted learning
activities.
Clinical Skills Laboratories
These are educational facilities that provide a
protected environment for learners to practice clinical skills before
using them in real settings. Repeated practice in a skills laboratory
not only ensures that students acquire proper, safe techniques, but also
helps them maintain a high level of skill. To achieve skill acquisition,
it is important for institutions to create an authentic environment with
multiple resources, to facilitate student motivation, and to provide
opportunity for repeated practice [22]. Skills laboratories may use a
mix of simulation-based learning using manikins, videos, computers or
virtual reality, and standardized or simulated patients.
Simulation-based Learning
Simulation in medical education means to use an
artificial process to mimic a clinical encounter. Simulators are devices
or tools that replace the actual patient and allow experiential learning
through deliberate practice [23]. Experiential learning is an active
process where the learner adds new knowledge and experience upon
previous knowledge and experience, and thus constructs new learning. In
simulation-based learning, the learner can make mistakes that do not
impact a real patient [24]. Table II shows various ways in
which simulation can be used in clinical skills training. Clinical
semester students can practice increasingly complex skills in
increasingly complex scenarios as they progress through training.
TABLE II Ways to Use Simulation to Train Students in Pediatrics
Semester
|
Simulation Exercise |
Third and fourth
|
Low to medium fidelity: Normal and abnormal anatomy and
physiology of a child; Anthropometry; use of basic equipment
like the sphygmomanometer |
Sixth and seventh |
Low to medium fidelity: Pharmacological principles in the
pediatric age group;
|
|
High-fidelity: make a clinical diagnosis, elicit signs, perform
and interpret investigations |
Eighth and ninth
|
High-fidelity: Initiate treatment; observe the results of
the treatment on the ‘patient’s’ well-being; perform
resuscitation |
Simulated Patients/Standardized Patients
[25]
A simulated patient (SiP) is an otherwise healthy
actor who has been trained to display different clinical symptoms and
signs. He participates in the history taking and the examination and
communicates sufficiently well so that even an expert may be fooled into
believing he is a patient. A standardized patient (SP), on the other
hand, is usually a real patient who has the history and the clinical
findings of a medical problem. He is tutored to depict a specific
medical case for the specific purpose of training medical students. SPs
display real feelings and emotions.
SiP and SP are useful in teaching communication
skills for history taking, information gathering, for interpersonal
communication, addressing sensitive issues, and counseling patients or
breaking bad news [23]. They also help in improving examination skills
and in honing patient feedback skills in a controlled way. The clinical
scenarios can be matched to the level of training of the student and can
be repeated for every student, allowing uniformity of the learning
experience. SiP and SP need to be trained and compensated; their
performance has to be monitored to ensure reliability and validity; an
SP/SiP ‘bank’ should ideally be set up - thus, expertise and resources
are required.
Assessment of Clinical Skills
Assessment methods must lend themselves to the
measurement of whether skills have been acquired and also how well they
have been learned. Understandably, since a skill is an activity, it has
to be observed. From the standpoint of Miller’s pyramid of clinical
competence [1], the student ‘does’ while the assessor observes. The
ideal place to observe a learner perform is at the workplace – Workplace
Based Assessment (WPBA). Assessment at the workplace should be an
ongoing process (formative assessment) with the learner being given
immediate feedback and multiple opportunities to perform the activity
until he becomes competent at it [11,26]. Directly-observed procedural
skills (DOPS), mini-clinical evaluation exercise (mini-CEX), multisource
feedback (MSF) and mini-peer assessment tool (mini-PAT) are some of the
WPBA methods in use. Many of these have been discussed previously
[11,27,28]. They have in common two critically important aspects –
observations that are recorded on assessment checklists, and feedback.
Objective checklists are used to record what the
learner ‘does’, although subjective assessments are made too. The
inherent bias of a subjective assessment is reduced considerably through
the use of multiple assessors over more than one occasion and in
multiple settings [11]. For the learner to be said to have acquired
competency in a particular skill, his checklist score should preferably
match set criteria (criterion-based) rather than be normative-based;
with the latter, he may not be truly competent in his own right but
merely more competent than other learners.
Feedback is the key that promotes learner progression
and improvement [13,27]. Direct observation of the learner’s performance
followed by immediate feedback helps him understand where to change
practice so as to become competent. Medical teachers hesitate in giving
feedback for a number of reasons, prime being that they don’t want to
hurt the learner’s feelings, fear that he might take it negatively as a
criticism of his actions, or worry that he may disrespect the feedback
and advice given [29]; however, when given constructively, in a safe,
mutually respectful environment, and especially when solicited by the
learner in order to improve his performance, feedback is extremely
useful (Box I). Effective formative feedback is an
important component of assessment for learning and is more likely to
lead to learning [13]. Work-place based feedback does not take too much
of the clinician’s time. When given as part of a regular, ongoing
process, the learner begins to expect and desire feedback rather than
feeling ambushed by it.
Box I Guidelines For Giving And Receiving
Feedback
Guidelines for giving feedback
• Feedback should be given soon after the
performance but away from the patient
• It should be content specific, reflecting
on the current task only.
• Ask the learner to start with what went
well. Stay positive.
• It should focus on behaviors that can be
changed. The teacher could suggest alternative behaviors, but
must do so sensitively. Example: ‘I like the way you listened
patiently to the history. Perhaps next time you could make more
eye contact while the patient is talking. I feel she would have
found it easier to trust you and would have opened up about the
substance abuse much sooner. There’s a good article on
non-verbal communication that I think you should
read...........’
• Questions should be framed such that they
encourage reflection. How do you think the patient felt? What
would you do differently next time?
• Negative feedback should be non-judgmental.
It should be directed to the performance and not the learner’s
personality. Example, ‘what you did was hurried’ and not ‘you
are very impatient’.
• Feedback should be restricted to 2-3 key
messages so as not to overload the learner and should correspond
to the expected learning outcomes of the activity.
• Close by summarizing.
Guidelines for receiving feedback
• Ask for it
• Listen first, without becoming defensive
• Respond gratefully and gracefully, don’t
react
• Use the feedback to change behavior
• Ask for clarifications where required
• Ask for an opportunity to demonstrate changed behavior
|
In conclusion, taking cognizance of the challenges to
clinical skills training in our country, we can use many of the training
models that have shown success in practice and adapt them to the Indian
context.
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