Teaching Procedural Skills
Amy S. Oxentenko, MD, FACP, FACG, AGAF
Mayo Clinic, Rochester
No Disclosures
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.
Outline of Talk
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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
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
Why is teaching endoscopy so
challenging???
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
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?
Set-Dialogue-Closure
Model
Set-Dialogue-Closure Model
• 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
Framework for Endoscopy Training
Set
Dialogue
Closure
Educational
contract
• Preparation
• Assessment
• Align agendas, set objectives/ground rules
• Clear, consistent, concise, common
• Performance –enhancing instruction
• Dual task interference/cognitive overload
• Summary
• Performance-enhancing feedback
• Take-home message
The Set
Framework of the Agenda
Knowledge
• Pre/post/intraoperatively
• Awareness of pt needs
Skills
• Endoscopic technique
• Prioritization
• Time management
Attitudes
• Motivation
• Relationship with team
• Relationship with pt
Setting Learning Objectives:
“SMARTER”
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S
M
A
R
T
E
R
Specific
Measurable
Achievable
Relevant
Timely
Economical
Reviewed (modified prn)
The Dialogue
Psychomotor (Bloom’s) Taxonomy for
Hierarchy of Skills
Mastery
Does
Shows how
Knows how
Knows what
Awareness
Peyton’s Learning Cycle of
Competency
Unconscious
Competence
Unconscious
Incompetence
Conscious
Competence
Conscious
Incompetence
Competency Learning Model
• So skilled
you don’t
have to think
about it.
• Working on
a skill;
requires
thought.
• Not aware
that you lack
a skill.
Unconscious
Competence
Unconscious
Incompetence
Conscious
Competence
Conscious
Incompetence
• Aware that
you lack a
skill.
Competency Learning Model
• I can do this
without
even
thinking.
• I can do this
when I am
deliberate
about it.
• I don’t know
what I don’t
know.
Unconscious
Competence
Unconscious
Incompetence
Conscious
Competence
Conscious
Incompetence
• Uh-oh.
There’s
something I
don’t know.
Competency Learning Model
• Expert
• Teacher
• Early
trainee
Unconscious
Competence
Unconscious
Incompetence
Conscious
Competence
Conscious
Incompetence
• Trainee
Competency Learning Model
• Early
trainee
Unconscious
Competence
Unconscious
Incompetence
Conscious
Competence
Conscious
Incompetence
Competency Learning Model
• Early
trainee
Unconscious
Competence
Unconscious
Incompetence
Conscious
Competence
Conscious
Incompetence
• Trainee
Competency Learning Model
• Expert
Unconscious
Competence
Unconscious
Incompetence
Conscious
Competence
Conscious
Incompetence
Competency Learning Model
• Expert
• Teacher
Unconscious
Competence
Unconscious
Incompetence
Conscious
Competence
Conscious
Incompetence
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.
Demonstration of Teaching a Skill
Review of Teaching a Psychomotor Skill
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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
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
Instruction and Communication
During a Procedure
• Timing of instruction
• Type of instruction
• Specific language
• Teaching vignettes
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
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?”
Specific Language
(12 Terms to Use)
1.
2.
3.
4.
5.
6.
Stop
Slow down
Pull back
Advance
Blow
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
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?”
Before Taking the Scope Away
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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
Patient Factors Affecting When to Take
the Scope Away
• Withdrawal of consent
• Change in clinical
parameters
• Age
• Previous experience
• Time
• Team concerns
• Pathology found
• Pain
• Complications
• Indications for the case
The Closure
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
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.”
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
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
Simulation Training
• Don’t expect to send a trainee alone to practice on
a simulator for the 1st time
– Learn incorrect technique
– No feedback provided
• Use simulator to practice a technique once known
• Simulators should be used at each level of training
Questions?
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 performanceenhancing feedback after a teaching session, and set
objectives for the trainee’s next session as well.
Thank you!
Oxentenko.amy@mayo.edu