Teaching Procedures- Near Peer
Peter DeBlieux, MD
February 2010
I. Introduction
Objectives –
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Generate qualities and behaviors of effective procedure
instructors.
Demonstrate understanding of the phases of procedure
instruction.
Develop clinical procedure instruction and student feedback skills.
A. Principles of Adult Learning- principles that apply to all learning
environments
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Motivation is established, the material is useful
Assurance that learning is active-not a passive environment
Concepts not facts are taught
Feedback is provided promptly and appropriately
Environment is non-threatening
Material is related to existing knowledge
Learners are treated as individuals
Learning is best when self-paced
B. Procedure Instruction is more than just a motor performance
 Knowledge of the procedure, indications, contraindications
 Skills that are required for success
 Attitudes that promote professionalism
 Behaviors that yield positive results for patients and providers
C. Challenging the History of Procedure Instruction
 See one
 Do one
 Teach one
 Also known as “See one, Do one, Screw one up!”
D. Concept of Accidental Educators-“Just Say No”
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The majority of academic physicians are “accidental educators”there was never a primary career plan for teaching medical students
and residents
If academic physicians are accidental educators then what can be
expected of house officers/students in training? – Perpetuation of
accidental education?
Accidental
Educator
E. The Performance Model
 The concept of “optimal stress”, that level of stress that motivates and
challenges students, but does not bore or threaten them. Too little
stress and too much stress impair learning.
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When considering adult learning, stress and performance are linked.
Developing a need to know is essential in obtaining “buy-in” from the learner.
- “In order to be a teacher of medicine the doctor must always be
a student” – Charles Mayo
Effective Qualities and Behaviors of Procedure Instructors:
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C.
Eye contact
Enthusiasm
Ask and encourage questions
Deliver positive nonverbal feedback
Deliver pertinent oral feedback
Utilize audiovisuals prior to attempts
Review pertinent indications and contraindications
Defined purpose and indication of the subject’s worth
Expert knowledge
Clear explanations
Problem solving emphasis
Student-centered instruction
Permits entire group to observe
Humanistic orientation and patient approach
Group instructional skills
Clinical supervision
Clinical competence
Modeling professional characteristics
Logical stepwise progression for procedure
Utilizes performance check-list
Encouragement of performance visualization
Phases of Procedure Instruction
Phase One – Introductory Phase
Below are listed components of the Introductory Phase of procedure instruction.
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To Know One…
 Cognitive understanding of the procedure – What is required?
 Objectives and expected performance are understood by learner
 Establish a need to know – how is this beneficial to the learner?
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Indications for a given procedure
Contraindications for a given procedure
Resources required
“After focusing on the cognitive aspects of a procedure, what are some the
aspects of demonstrating a procedural skill that might prove helpful?
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To See One…
 Procedural demonstration and psychomotor training– What is required?
 Check list of sequential steps
 Overview of the skills
 Demonstration and verbalization of sequential steps
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Moving from…
Unconsciously Incompetent
Consciously Incompetent
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Unconsciously Incompetent – a starting point when the student does
not know the requirements for competency. Lack of a need to know.
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Consciously Incompetent – student understands the cognitive aspects
of the procedure and has an idea of the required pathway to achieve
competence, but does not manifest competence.
Phase Two – Practice Phase
Below are listed components of the Practice Phase of procedure instruction.
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To Do One…..
 Psychomotor training – What is required?
 Establish ground rules for practice-simulation versus real life
 Identify resources – patients, computers, cadavers, manikins, sim
 Close initial observation and ability to prompt student
 Feedback that is immediate, supportive, constructive, and specific
 Master immediate steps in succession
 Correct motor mistakes immediately
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To Do One Again and Again….
 Allow independent practice time
 Develop a mental image of performing a procedure
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Moving from…
Consciously Incompetent
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Consciously Competent
Consciously Competent – knowing and performing every aspect of a
procedure. Ability to describe and demonstrate a procedure in a stepwise
fashion. The ideal position to teach by being “close” in relationship to the
students – the Near Peer phenomenon.
Phase Three – Perfecting Phase
Below are listed components of the Perfecting Phase of procedure instruction.
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To Do One Again and Again….
 Repetition and practice
 Minimal prompting
 Feedback on fine points
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To Teach One…..
 Generate realistic situations to enhance skill performance
 Focus on the requirements to teach the procedure
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Moving from…
Consciously Competent
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Unconsciously Competent
Unconsciously Competent – ability to perform procedure reflexively.
Unable to adopt the perspective of a novice. No longer “close” to the
student in experience and may not be able to relate as effectively as the
Consciously Competent instructor.
Tell me, I’ll forget
Show me and I may remember.
Involve me and I’ll understand.
-Chinese proverb
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REFERENCES
1.
Thomas H. Teaching Procedural Skills: beyond the “see one-do one.” Academic Emergency
Medicine, 1994.1(4): 398.
2.
Chapman DM. Use of computer-based technologies in teaching emergency procedure skills.
Academic Emergency Medicine, 1994. 1(4):404.
3.
Wainscott MP. The Hands-On Instruction of Procedural Skills. Educational Handout SAEM 1998.
4.
Rodgers KG. Teaching Procedural Skills. Educational Handout, Navigating the Academic Waters
ACEP 1999.
5.
Schwenk, TM, Whitman N. Residents as Teachers: A guide to Educational Practice. Salt Lake
City; University of Utah School of Medicine,1993.
6.
Whitman, N. Essential Hyperteaching: Supervising Medical Students and Residents. Salt Lake
City; University of Utah School of Medicine,1997.
7.
Edwards JC, Marier RL. Clinical Teaching For Medical Residents, Roles, Techniques, and
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8.
Whitman N, Lawrence P. Surgical Teaching : Practice Makes Perfect Stritter. . Salt Lake City;
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9.
Irby DM. “Clinical Teaching Effectiveness in Medicine” Journal of Medical Education
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10.
Apter A, Metzger R, Glassroth J. “Residents’ Perceptions of Their Role as Teachers” Journal of
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11.
Greenberg LW, Goldberg RM, Jewett LS. “Teaching in the Clinical Settings: Factors Influencing
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