The overhead light is punishingly hot, and my senior resident is sweating as he struggles through a central line placement. It is clear he has no idea where his needle tip is on the ultrasound screen, and I am silently cursing myself for assuming that at this stage in his training, having already done “a few” internal jugular line placements, he would be facile with this crucial step. I resist the urge to nudge him out of the way and do it myself, instead offering guidance and encouragement. We get through it, without harm to the patient, and I vow to do a better job next time.

Sound familiar? In the age of eLearning modules and simulation most trainees come to the bedside with some idea of how to perform a given procedure, but even the best virtual reality training cannot replace supervised experience with patients. Most clinicians receive little or no education on how to be an effective procedural teacher, yet from early in residency we are expected to take on this role. As a result, these interactions can be frustrating and time-consuming for both teacher and learner, and at worst dangerous for the patient.

We propose that procedural teaching is a specific skillset that medical educators can practice and nurture. Supervised procedures can be rich learning experiences that build both skills and confidence, and ensure high quality care for the immediate patient and those our trainees encounter in the future. In today’s blog post we recommend specific strategies to save time, minimize stress and maximize learning in a procedural teaching experience. Even skilled learners who are well on their way to independent performance can benefit from these techniques, which encourage an active approach to self-improvement in future practice.

As with all teaching, procedural supervision benefits from advanced planning. We like to think about these encounters as having three distinct components: a pre-procedure assessment and plan, intra-procedure guidance, and a post-procedure debrief. Experienced teachers will have their own stock phrases and learning objectives for each of these three components; we’ll share some of our favorites below.

 

1. Before the procedure.

For anything other than true emergencies, you will usually have a few minutes to ask your learner some questions, even if it’s just while gathering equipment or donning sterile gear. In order of priority, we try to:

  • Diagnose skill and comfort level. If time is no obstacle, the learner can rehearse the procedure with you using a teaching kit in the team room. If you are pressed for time, a verbal rehearsal provides a good sense of how well they know the steps.
  • Establish an educational focus. Here we hope to inculcate a habit of deliberate practice: to think about the aspect(s) of a given skill one wants to improve, practice the skill, reflect on how well those objectives were met, then practice again. The aphorism often attributed to Vince Lombardi captures this nicely: “practice doesn’t make perfect; perfect practice makes perfect.”

If you are short on time, a useful shortcut is to ask “what part of this procedure do you feel you do really well, and what are you still working on mastering?”

Finally, especially with early learners, it’s worth taking one more step:

  • Alert to the possibility of interruption. Say something to the effect of “if I need to, I’ll step in and help or take over, but I’ll hand it back to you as quickly as I can.” Knowing this beforehand can be a relief to nervous learners, and soften the blow to confidence in learners who thought they were ready to do it on their own.

 

2. During the procedure.

The pre-procedure brief will often give you a sense of how much or how little you will need to actively guide the learner during the procedure itself. If instruction is necessary, use precise language, correct mistakes as they occur, and do this in a way that will not alarm the patient or any family members in the room.

Precisely articulating the movements you want someone else to perform is a skill that requires practice (deliberate practice!) to master: the next time you direct someone to do something, listen for ambiguity and try to eliminate it. For example, before dinner ask your partner not to cut the carrots but to chop them into ½ inch cubes. We recommend using this sparingly as it may be insufferable in real life, but during procedures this precision is invaluable because it conveys your true intention. “Turn right” could mean several things; “rotate clockwise x degrees” is more specific and therefore leaves little doubt as to what you want the learner to do.

While “stop” also has a fairly clear meaning, such words, especially if uttered with urgency, risk alarming an awake patient (and/or the learner). Try alternative phrases like “let’s pause here,” which can be especially effective if combined with an unmistakable but silent physical signal like holding up your hand. Similarly, corrective phrases can be tailored to impart clear meaning without making the patient worried. We are partial to saying “when I see X I like to Y,” as in “when I see a venous pressure of 90, I like to reassess my needle tip location to ensure it’s venous.” To you and your learner, that is a directive comment. To an awake patient, it sounds innocuous.

 

3. After the procedure.

Learners are often their own worst critics. Before offering your own feedback, ask for their thoughts on their performance. You may find they are well aware of their shortcomings, and your most effective role will not be in identifying them, but helping learners think of ways they can improve. Any comments should be honest and specific. Limit yourself to 1-3 items, whether strengths or weaknesses, at least one of which should relate to the educational focus you established in the pre-procedure plan. Ideally, your learner will walk away from a suboptimal performance with a plan of action to improve. Even a highly skilled learner can identify new goals to perfect their technique, or perhaps an intention to develop their future role as a procedural teacher themself.

Finally (item number 4!), don’t forget to perform a post-procedure debrief with yourself. This needn’t be burdensome, but a quick check-in on your teaching skills will reinforce your own habits of deliberate practice. After the incident described at the beginning of this blog, I (AEM) formed an intention to perform a more careful pre-procedure assessment of any learner I supervise. More precisely, I always ask how many procedures they have successfully performed, and I no longer accept “a few” in response.

 

Resources

Sawyer T, White M, Zaveri P, Chang T, Ades A, French H, et al. Learn, See, Practice, Prove, Do, Maintain: An Evidence-Based Pedagogical Framework for Procedural Skill Training in Medicine. Acad Med. 2015;90(8):1025–33.

Roberts NK, Williams RG, Kim MJ, Dunnington GL. The Briefing, Intraoperative Teaching, Debriefing Model for Teaching in the Operating Room. J Am Coll Surg. 2009;208(2):299-303

Patton K, Morris A, Çoruh B, Kross E, Carlbom D, Thronson L. Teaching to teach procedures: a simulation-based curriculum for senior residents or fellows. MedEdPORTAL. 2015;11:9997. https://doi.org/10.15766/mep_2374-8265.9997

 

Amy E. Morris, MD is an Associate Professor of Medicine in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Washington in Seattle, WA. She attends on the Medical and Oncology Bone Marrow Transplant ICUs and pulmonary consult services. She is originally from Alaska, and after 20 years is still adjusting to city life in the Lower 48 so tries to get outside with her family as much as possible, rain, shine, or especially snow: skiing, hiking, biking, paddling. Her special talent is embarrassing her preteen children by demonstrating enthusiasm for anything, and using terms like “deliberate practice” in front of their friends.
Rosemary Adamson, MBBS’s passion is improving the quality of medical education to improve patient care. She loves taking care of patients, supervising trainees, teaching medicine, and teaching about teaching. She particularly loves that everything she learns about teaching helps her parent her kids and everything she learns about parenting helps in her work! She’s a pulmonary and critical care physician at the Veterans Affairs Puget Sound Healthcare System and an assistant professor at the University of Washington.