Teaching medical procedures at your workplace

Learn

This step is also known as cognitive conceptualization. In this part of training the learner should obtain not only an understanding of the technical steps to perform the procedure, but also the rationale for the procedure. This includes learning the indications, contraindications, possible complications, risks, and benefits of the procedure, as well as the alternatives to the procedure. Although it might appear to be a simple step, it is frequently overlooked as an important component of teaching procedural skills. Without this knowledge the learner will not be able to correctly explain the procedure to the patient or obtain adequate informed consent. Further, without this knowledge erroneous therapeutic decisions can be made.

A didactic session provided by postgraduate programs can be the ideal approach to completing this part of the learning. If these sessions have been provided to residents, the community family physician will be able to easily build on this previous knowledge. If such an instructional session has not been provided, the teacher must ensure the knowledge is obtained before the resident has contact with the patient.

Practical tips: Ensure residents read about the procedure to be performed. Having books available at your clinic that describe procedures is useful, but it is also convenient to have written summaries prepared in advance that can be quickly read during clinic time. Such written material could include summary sheets, procedure descriptions, comprehensive informed consent forms, and patient questionnaires that can be used by the resident to lead informative conversations.

Ensure residents check the patient schedule in advance in order to prepare for the procedures.

There are resources available for procedural teaching; online medical education repositories such as MedEdPORTAL (Box 1) provide such teaching resources for various procedures.

See

This step involves demonstrating the procedure to impart procedural knowledge. The teacher can achieve this by using videos or by direct demonstration when a class session has not been completed. In either case, the demonstration should include specification of correct and incorrect techniques to obtain clear understanding.

Comprehensive instructional videos that use principles for designing e-learning materials might be better than simple demonstrative videos that are available on the Internet.

Practical tips: If you are demonstrating the procedure, make a conscious effort to individualize each step. At the same time, provide explanations to articulate the different parts of the procedure. Do not forget to use adequate terminology for the resident’s level of training; for example, for a resident who is naïve to the procedure, avoid technical jargon such as “Because the wound is under tension, just do 3 far-far, near-near vertical mattress suture stitches to secure closure.”

Have videos or links to videos that describe and demonstrate the procedures available at your clinic, either on your smartphone or tablet or on a desktop computer. Academic videos are available on various websites (Box 2).

Practise

In this step, psychomotor skills are acquired. Ideally this step should be done before patient contact, but commonly it is performed on real patients if no academic session has been completed. The ideal method for this step is simulation, which can be done in the office setting. It is very important to include feedback in this part of the training; feedback is more useful when it is direct and immediate. Many studies have shown that expert feedback enhances the learner experience and leads to better performance.

Practical tips: Take time to obtain simulation materials that can be on hand at any time in your office. There are easily available devices that can be used (eg, any threads or laces to practise surgical knots; fabric or cloth materials to practise stitching). You can obtain simulation kits and simple anatomical demonstration models for specific procedures (eg, intrauterine device insertion) from manufacturing companies. You can obtain demonstrator devices from donations from altruistic societies (eg, breast or prostate models). Use various types of fruit as simulation devices (papayas for gynecologic procedures; bananas for toenail resections; oranges for punch, shave, and excisional biopsies). Borrow simulation devices from postgraduate programs or manufacturing companies (eg, limb simulators for joint injections).

Keep in mind residents’ different learning styles and their natural abilities, as well as the challenges to learning procedures. For example, sometimes the learner should be on the same side of the surgical table to understand the steps, as 10% of the population learns by spatial orientation and muscle memory (kinesthetic approach).

Prove

It is important to demonstrate a resident’s comprehension of the procedure. Before performing the procedure, the resident should be able to verbalize and describe its different steps. It is useful to challenge the learner with questions.

Practical tips: Here are some examples of questions to prove a resident comprehends various aspects of the procedure.

• Basic knowledge: What are the anatomical landmarks for the shoulder injection you plan to perform?

• Specific technical points: What number scalpel blade do you use for this procedure?

• Interaction with the patient: What alternatives to the procedure do you plan to discuss with the patient?

Do

This includes the learner’s performance of the procedure in the practice setting with patients. During a discussion with the resident before the procedure, the teacher can assess the resident’s level of understanding of the procedure and can focus teaching on specific needs. There are several things the teacher needs to determine: if he or she should demonstrate the procedure to the resident again; if the resident should be allowed to provide only surgical assistance; if the resident should be allowed to perform parts of the procedure; and whether to assist the resident while he or she performs the procedure. Given that it is more difficult to correct wrong techniques once they have been learned, the resident should always be closely observed to avoid learning incorrect techniques.

Practical tips: Always add positive or invitational comments about the procedure to increase motivation (eg, “Removing a sebaceous cyst will offer you specific challenges, as an adequate removal should be performed without breaking the capsule”).

Maintain

It is of great importance to teach learners to maintain competence in the skills they have acquired or to acquire additional training in new procedures that are part of new standards of care (eg, botulinum toxin injections for migraines, dermoscopy).

Practical tips: Provide information to learners about simulation sources available to maintain skills competence (eg, conferences with procedural workshops such as Family Medicine Forum, annual scientific assemblies, St Paul’s Hospital Continuing Medical Education, local activities).