It’s August and as a resident, I sit at the crux of this famous teaching model. I’m still having some of my first “do ones” while daily “teaching one” to the medical students, juniors and interns who have spent the last few years seeing and are ready to “do.” Like many experiences while becoming a doctor, no matter how many times you’ve seen a procedure or practiced on a model, there is nothing quite like the first time.
When it comes to procedure teaching, there are many things to consider besides the “doing,” but the focus of today’s post will be on bedside teaching. I’ve broken the first-time teaching process into three steps, and I’ve tailored my tips accordingly for each step. While these tips speak to the first-time experience, I believe the principles apply to each and every time.
Plan Ahead and Prepare
I first learned this phrase as the primary principle of Leave No Trace, but I think it applies to everything in life, especially procedures. Here are my suggestions for how to plan and prepare before going to the bedside.
Prepare Yourself
- Make sure you are familiar with all the steps of the procedure
- Think about how to describe the steps
- “I just do it like this” doesn’t callout the takeaway specifics, but “Direct the needle towards the clavicle and suprasternal notch keeping your needle parallel to the chest wall while puncturing. Once you hit the clavicle, do not re-angle the needle but use your other hand to press down on the needle to help it traverse under the clavicle” better describes what you’re doing and directs the learner’s focus
- It isn’t cheating to copy how someone else teaches something–watch an online video and listen to the phrases they use, trusting that eventually you will develop your own.
Prepare & Assess Your Learner
- Have them talk you through all the steps. If they don’t know the steps, have them look it up in Roberts and Hedges or watch a video online
- This does two things for you. It lets you assess their knowledge and build a checklist for all of the equipment they need to gather
- To this day, I still walk through the steps of the procedure in my head to gather equipment and then to prepare it bedside before starting
- Explore the equipment with them
- If it is cheap equipment and not a whole sterile kit (like an IV catheter) take one out and show them your tricks and let them play with it before using it on a patient
To the Bedside, or “…to the sea”
William Osler said, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” This is the most important and usually the most challenging part for both the student and the educator. It can also be a rewarding educational experience with the right approach.
Kit Exploration
If you didn’t get a chance to before, do it once sterile. Have them walk through the procedure again and make sure all the equipment is set up and tested
Know When to Shut Up
Leave the learner some room for trial and error and to figure things out
- Remember how nervous you were the first time someone actually let you place a central line? A chest tube? An LP? They usually know they aren’t getting it but are having trouble converting their thoughts into manual dexterity; allow them the space to work it out
- Keeping your mouth shut leaves them room to ask for help or specific advice
- For the learner not doing a procedure for the first time, consider supervising from afar, a.k.a. Get out of the room!
- Some of my best learning came from working out the kinks without an attending leaning over me
Know When to Speak Up
If they are about to harm the patient, by all means, stop them! Open your mouth! Put your hand on theirs!
- If you can do it without alarming the patient, even better, but never let them harm the patient because you were finding a way to slowly and nicely deliver the message
- There are appropriate interjections for effectiveness and style
- Choose wisely: know the difference between a technical correction and a style preference
- Just as we generally crawl before we walk, it is important to help the student be technically correct before offering points of finesse. For example, if they can’t tie a square knot, why move on to teach anything besides an interrupted stitch? But if they have a solid knot, they can move on and learn more advanced stitches
- Some learning points can wait until after the procedure is complete (usually style points fall into this category)
Pick Your Words Wisely
- Always use a calm voice
- Remember the patient. Try to pick vocabulary that positively guides the learner to do something differently and won’t make the patient feel scared that the person with a needle or knife in them doesn’t know what they are doing
- My attending Dr. Schechter, says: “Be patient. When you run out of patience, be more patient”
Keep Your Hands to Yourself
No one ever learned how to do anything by having someone else do it for them
- Honor the phrase “Never touch a leaner’s knot.” It’s a rule I learned when teaching knot tying, and it forces you to use your words to teach, and it lets the learner still be the one tying the knot
- This can be really hard. I like to clasp my hands behind my back as a reminder not to touch, releasing them now and then only to point at things
- Another approach is to always place your hand over the student’s to correct an incorrect action because you don’t want to allow them to build bad muscle memory
- But wait! Those two statements give opposite advice. What do I do?
- I don’t believe that bad muscle memory gets built the first time someone does something, and I think there is more value in allowing the learner to find what the right angle feels like on their own. Keep in mind for the learner who isn’t finding the right angle, even after being given plenty of space to try on their own, it’s likely appropriate to guide them with the help of your hand over theirs
Debrief
I believe that reviewing is just as important as doing when it comes to learning from our experiences. The debrief is the perfect place to revisit some of those teaching moments where you might have been judiciously “shutting up.”
Ask your learner how it went. What went well? What did they have a hard time with? Why do they think they had a hard time?
- Most of the time, the learner is pretty aware and thinks the same things you do about how it went. Often, they just don’t know how to fix where they had trouble or that there are smoother ways to get from A to B
- This is your golden opportunity to share what your past experiences have enabled you to see about their trials and tribulations
- Limit your feedback. Pick 2-3 keys points to prevent information overload
Now, enough of the talking about it–it’s time to get out there and teach! Remember, these tips aren’t hard and fast rules. Let the principles guide you:
- Prepare yourself and prepare the learner -> set them up for success
- Find the balance of how much to say and do -> I think learners get more out of the experience when they have room to explore and learn without a monologue of corrective measures
- Patient safety is number one -> do whatever it takes to protect the patient from harm, bonus points if you can do it without scaring the patient
- Debrief -> It’s the perfect time to review, discuss and teach anything you held back during the procedure
Many thanks to Drs. Jay Khadpe, Joshua Schechter, Teresa Smith and James Willis for offering advice on this piece. To Ms. Sallie Oto, editor extraordinaire. And to Dr. Diane Levine, my constant inspiration as a clinical educator.
Reference:
http://iteachem.net/2014/02/teaching-procedures/
http://www.practicaldoc.ca/teaching/practical-prof/teaching-nuts-bolts/teaching-procedures/
http://www.medscape.com/viewarticle/723631
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Emergency Medicine, PGY 4 • Raised in Berkeley • Schooled in Detroit • Training in Brooklyn
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It’s August and as a resident, I sit at the crux of this famous teaching model. I’m still having some of my first “do ones” while daily “teaching one” to the medical students, juniors and interns who have spent the last few years seeing and are ready to “do.” Like many experiences while becoming a doctor, no matter how many times you’ve seen a procedure or practiced on a model, there is nothing quite like the first time.
Leave the learner some room for trial and error and to figure things out
If they are about to harm the patient, by all means, stop them! Open your mouth! Put your hand on theirs!
1 Comment
TSmith · October 23, 2015 at 7:20 pm
Wonderful! I enjoyed the structure of this article.. the bullet points, then more explanation with the links!. It will make it easier to read on the run..
Strong work,
Teresa