The 4-stage approach to teaching a skill in ATLS: A review of literature

Context

The 4 – and subsequently 5 step model for teaching a skill in ATLS has been around since the ATLS programme began in 1978, and has remained one of the most controversial areas of the now global programme. This paper reviews the history and development of the model, provides previously unacknowledged evidence for its use and proposes ways in which we can better communicate and use the model in our ATLS courses.

Introduction

Time for skill acquisition is severely limited on ATLS courses, and always has been, with priority having been given pre 10^th edition to the dissemination of the knowledge-based areas of the course manual through lectures. The 2019 10^th edition provides a greater emphasis on skills learning through scenario-based discussions, thereby maximising the context of psychomotor skills within simulated practice rather than as an adjunct to the manual chapters. Despite this pedagogical advancement, time is still restricted and instructors may still be privileging lower levels of Bloom’s cognitive taxonomy over the acquisition of higher order evaluative skills and psychomotor competence development. It is acknowledged that the ATLS Provider (student) course is a two-day course with at least three days’ worth of learning crammed into the time available. Current challenges include how much pre course learning can be expected for psychomotor skills and how best to maximise the time on course we do have to practise.

Rationale

This paper will:

·        - Review the nature of and need for psychomotor skill acquisition in the ATLS context;
 - Clarify the psychological processes involved in acquiring a new skill;
 - Reflect on a range of relevant literature;
 - Offer hitherto unacknowledged evidence for the 4-stage method; 

Psychomotor skills– what are they?

Psychomotor skills are described as “the mental and motor activities required to execute a manual task,” according to Foley & Spilansky (1972) in Kovacs (1997) and a concept of “integration of well-adjusted performances, rather than a tying together of mere habits” (Adams, 1987). “Skills are both mental and motor and they are learned,” asserts Adams (ibid). He adds, “any behaviour that has been called skilled involves combinations of cognitive, perceptual and motor processes with different weights” (p.42).

Singer adds to this: “Skilled motor activity is a function of Input (sensory and perceptual function) x Central processing (decision and command functions) x Output (motor functions). The integration of these processes leads to more purposeful behaviour” (Singer, 1978)

To summarise, psychomotor skills, are behaviours that require a combination of cognitive, sensory, perceptual, organisational and motor processes, acquired by novices and practised using all of the above, until they become proficient (Dreyfus & Dreyfus 1986.)

Psychomotor skills – previous research.

There is a dearth of evidence in this field pertaining to the medical field. Procedural medicine has been an “assumed activity...without a formal educational context, living within the cliché: ‘see one, do one, teach one’ for too long” says Kovacs ((1996, p387). This may be due to the preference for randomised control trials over other approaches which have yielded better results in the psychological material. So, we tend not to find studies on experts and novices in skills acquisition, and there is very little work on how we teach and learn psychomotor skills. But that does not mean that because there is no model, and no RCT to support it, we cannot support the approach we have been using for 40 years in ATLS from other, related fields. The domains of sports and physical education have some useful work we can draw on and may well offer a starting point for the much-needed empirical research we need in this area of medicine.

Three psychomotor domains were created during the 1970s – Simpson (1972), Harrow (1972) and Dave (1967). Simpson’s model was the one used by the originators of ATLS, with some adaptation. All three models aimed to describe what happened when people performed a skill, and did not focus on the process to acquire the skill or to transfer a skill from a master to a novice. In short, the 4-stage approach was developed by George and Doto (ibid) as outlined later in their 2001 paper in Family Medicine, by extrapolation from Simpson’s work, but there is little background evidence of what contributed to that model. More recent writers have adopted George and Doto’s original ATLS 4 stage model (1991) model, even being erroneously credited for it (Peyton, 1998). Before dismissing the model, should we not find evidence for its use, and if that is not possible within the medical community, bound as it is by narrow research preferences, then in other areas of research?

What do we know about learning psychomotor skills?

Some of the original work in this area is decades old, and to be found outside of the medical education literature, but with little evidence given for the ATLS 4/5 stage model, this work is offered to clarify how and why the 4/5 stage model has been advocated for so long.

1.Singer and Cauraugh (1985) identify the three elements of learning a skill:

·        acquisition,

·        retention and

·        transfer potential (p104.)

In identifying a model for the acquisition of psychomotor skills in ATLS I suggest we select a model that enables our students to acquire, retain and transfer the skill to their practice. If any of these factors are omitted, the skill will not have been acquired for future use, it will have merely been replicated from the short-term memory. When we debate a model for skill acquisition, we need to be mindful that acquisition is only the first step, and that without retention and transfer the skill has not been learned and cannot thereby be used safely.

Summary: Skills need to be acquired, retained and transferred appropriate to patient need. We need a model that enables this over mere momentary imitation.

2.Barnes (1987) emphasises two principles in the teaching and learning of psychomotor skills:

i)           To prevent learners developing faulty initial habits which are then very difficult to unlearn

ii)          Skill retention correlates with the level of initial proficiency – thus requiring that the first time a learner practises a skill it has to be practised accurately.

A similar focus on initial accuracy followed by later practice for speed is outlined by Smith et al (1997) in their work on learning to perform fibre optic nasotracheal intubation.

Summary: Skills need to be performed correctly the first time; if error is permitted retention will be delayed, if achieved at all. We need a model that best enables correct practice first time round.

3.To achieve the three elements in (1) and the two principles in (2), Singer and Cauraugh (ibid) categorise learning and performance strategies as primary and secondary. Primary strategies relate to conducting the skill, (also called associative by Gagne & Briggs, 1974.) Secondary strategies allow the primary strategies to operate more effectively – also called support (Dansereau,1978). A primary strategy may result in little more than copying, whereas a secondary strategy leads to better retention, adaptation to other situations and self-management. I suggest our role as instructors is to equip learners with the secondary strategies so that they can practise ATLS safely without our presence. Models to enable this are discussed subsequently.

Summary: the mechanism of acquiring a skill needs to sustain its practitioner once alone

4.Barnes (1987) who ironically characterises surgery as the “ultimate body contact sport,” pointed to Lippert and Farmer (1984) in reminding us that psychomotor development has to take place alongside cognitive and affective development. Indeed Simpson (1966, 1972), the originator of the work used by the 4 stage approach creators, George and Doto (1991) also characterised behaviour in the psychomotor domain as reflexive of the mental, emotional and physical states of the performer.

Singer & Cauraugh (ibid) acknowledge that: “a great deal of information processing occurs…..when people attempt to learn/perform complex motor activities” (p106) and that one of the “primary differences between the highly skilled and the lesser skilled is the degree and type of conscious involvement prior to, during and following motor performance” (Singer, Garson & Kim, 1979).

Summary: Skills acquisition is cognitive, not just motor. We need a model that allows for cognitive acquisition before, during and alongside the motor acquisition.

5.We need to be aware of the dangers of adapting only an instructional strategy whereby a student acquires a skill quickly, but with no agency over it. Rather we should be using a self-initiated strategy

Whereby the student not only acquires the skill, but develops a self-generating strategy for its future use. (Singer and Cauraugh, ibid, p107)

Summary: Developing a schema that allows future use of the skill is essential

Evidence for the 4-stage model for skills teaching as used in ATLS since 1978.

This is by no means an exhaustive review of the evidence for the 4/5 stage approach. What this selection offers is a perspective on skills acquisition that is to be found outside of the medical field. The domains of physical education and cognitive psychology have been sampled for this purpose.

The following components are considered vital to any effective psychomotor skills teaching and learning approach:

The role of context

“Performance in a discrete, procedural task is forgotten more readily than performance in a continuous task” (Adams & Hufford, 1962; Ammons et al, 1958; Mengelkoch et al, 1971; Neumann & Ammons, 1975).

The role of cognition

The role of cognitive processes has perhaps been ignored by detractors of the 4/5 stage approach. For clarity, “a cognitive process is a control process that is a self-generated, transient, situationally determined, conscious activity a learner uses to organize and regulate received and transmitted information, and ultimately behaviour” (Singer, 1980a). We cannot ignore that people actively seek to control their environments, and are not passive recipients of situational dictates. We need to recognise and utilise this in the process of transferring a skill from an expert to a novice. That means that the learner needs to be an active participant, drawing on their cognitive processes, with support and guidance from their instructor. Learning a psychomotor skill is a cognitive strategy which draws on internal organisation as well as external instruction, both of which govern the learner’s behaviour. A learner imposes a structure on their movement information that ensures it is learned and retrieved more efficiently.

The role of visual input

Vision is the dominant modality in the early stages of learning (Fleishman & Rich, 1963) but gives way to other sensory modalities later on in the learning process.

The role of verbal description

The development of those organisational pathways outlined above can be mediated by the external support of the instructor. This support is enacted largely through language, or verbalisation.

“the ability to succeed in motor performance may very well be related to the ability to apply external and internal words to motor acts” says Singer in O’Neil (1978).

Not only are words spoken by the instructor important but also the words spoken by the learner to guide themselves.  This has been variously termed: verbal mediation, conceptualisation, ideation and thought processing.

There is a long history of recognition of the importance of verbal support for motor skill acquisition. In 1953 McAllister found that verbal learning transferred positively to motor learning, and verbal pre- training transferred to motor responses in visual-motor tasks. In 1955 Goss acknowledged that “verbal mediators were seen as implicit agents contributing to movement regulation.”  However verbal pre-training is a transfer theory, and is a highly empirical domain, not in favour with medical education researchers. Whilst interest in mediation and pre training theory died in the late 1960s and early 1970s, sadly it does not mean that a better theory for the verbal regulation of movement has emerged since (Zivin, 1979). We would benefit form some empirical research in this area.

The need for closed loop learning (Adams, 1971)

A closed loop system has feedback from the response, error detection and error correction.  Central to closed loop theory is the student acquisition of capacity to detect and correct errors, and the growth in this process is central to the learning process.  It rejects Thorndike’s behavioural and unconscious view of learning which posits that skills are merely habits to be acquired without agent consciousness. The axiom underpinning this is that motor learning is at heart a perceptual process. The use of error information and the feedback -perceptual trace comparison is a verbal and cognitive activity. Feedback ‘in-situ’ is vital to this process.

The role of Feedback in-situ

Feedback (auditory, proprioceptive and visual) is an integral part of motor control. The identification and correction of motor errors is highly dependent on it (Keele, 1982.) Closed loop learning without feedback in the moment, is not effective. Error detection and auto correction is essential to closed loop learning. Furthermore, if we use secondary strategies within the closed loop learning system, we show that an internal reference for judgment of error develops. Students become over time, their own self corrector.

Kovacs (1997) acknowledges that “although ‘correction and reinforcement’ is listed as a separate stage, in his work, and is often seen as the fifth stage in the ATLS model,  it should be incorporated into each of the preceding steps because it provides a form of feedback for knowledge of results.” (p390).  We consider the role of in-situ feedback to be an inherent and essential part of stages 3 and 4, and not a separate stage.

Early evidence of the 4-stage approach

    1)   Hall 1978

Perhaps the earliest evidence of the 4-stage approach can be found in Hall’s work (1978) which suggests students need to:

     

•    Think about or imagine motor responses or movement patterns in particular situations.
•      Attach verbal labels to each of a series of movements
•      Selectively attend to relevant components of the task
•      Verbally rehearse a sequence

   2)     Singer & Suwanthada, 1984

This model was intended for self-paced skills – those which are proactive, not reactive:

•      Readying – obtaining an optimal mental – emotional state for task and situation
•      Imaging – the role of self talk
•      Focusing – excluding extraneous information
•      Executing – using the self talk to guide practice and focus.

   3)      Kovacs (1997) 

Kovacs acknowledges the need to divide the skills acquisition process into two stages:

(i)         A cognitive one whereby the learner conceptualises the “broader context of the skills” (p390) which relate to both the visual stage 1 of George and Doto’s (1991) model and the verbal stage 2.

(ii)        A more active, motor stage whereby learners both verbalise and perform the procedure from start to finish, which relate to stages 3 and 4.

It is not difficult to see where the 4-stage approach to teaching a skill had its roots. 

There is a dearth of evidence in the medical literature or the medical education literature, but that does not mean that we should not look to other areas of professional expertise for clarification. This review is only the beginning of a process that is long overdue.

References

Adams, JA (1971) A Closed-Loop Theory of Motor Learning.  Journal of Motor Behaviour 3. 111 - 149

Adams, JA (1987) Historical review and appraisal of research on the learning retention and transfer of human motor skills. Psychological Bulletin 101. 41-74

Adams, JA & Hufford, LE (1962) Contributions of a part-task trainer to the learning and re-learning of a time-shared flight manoeuvre, Human Factors 4. 159-170

Ammons, RB., Farr, RG., Bloch, E., Neumann, E., Dey, M., Marion, R., Ammons, CH., (1958) Long term retention of perceptual motor skills. Journal of Experimental Psychology 55. 318 - 328

ATLS https://www.facs.org/quality-programs/trauma/atls  accessed 4 July 2019

Barnes, RW (1987) Surgical Handicraft – teaching and learning surgical skills. American Journal of Surgery. 153 (5) 422 - 427

Bloom, B (1977) Taxonomy of Educational Objective: handbook 1: Cognitive Domain. New York. Lagman Publishers.

Dansereau, DF (1978) The Development of a Learning Strategies Curriculum in O’Neil, HF (Ed) Learning Strategies, New York. Academic Press

Dave, R. H. (1967). Psychomotor domain. Presented at the International Conference of Educational Testing, Berlin.

Dreyfus, SE (1986) The Five-Stage Model of Adult Skill Acquisition. Bulletin of Science Technology & Society 2004 24: 177

Fleishman, ES., Rich, D (1963) Role of Kinaesthetic and Spatial-Visual Abilities in Perceptual Motor Learning. Journal of Experimental Psychology 66. 6-11

Foley, RP & Spilansky, J (1972) Teaching Techniques – a handbook for health professionals. New York. McGraw Hill 1980 71-91

George & Doto (1991) A Simple Five Step Method for Teaching Clinical Skills. Family Medicine  33(8):577-8 · October 2001

Goss, AE (1955) Stimulus Response Analysis of the Interaction of Cue Producing in Instrumental Responses. Psychological Review 62. 20-31

Hall, CR (1978) A Review of Encoding Processes in Verbal and motor Memory. Canadian Journal of Applied Sport Sceinces

Harrow, AJ (1972) A Taxonomy of the Psychomotor Domain. New York. David McKay

Keele, SW (1982) Component Analysis and Conceptions of Skill in Kelso, JAS (Ed) Human Motor Beahviour: an introduction. Hilsdale, New jersey. Erlbaum

Kovacs, G (1971) Procedural skills in medicine: linking theory to practice. Journal of Emergency Medicine 15 (3) 387 - 391

Lippert, FGI and Farmer, JA (1984) Psychomotor Skills in Orthopaedic Surgery. Williams and Wilkins, Baltimore

McAllister, DE (1953) The Effects of Various Kinds of Relevant Verbal pre Training on Subsequent motor Performance. Journal of Experimental Psychology 46. 329 - 336

Mengelkoch, RF., Adams, JA., Gainer, CA (1971) The Forgetting of Instrument flying Skills. Human Factors 13, 379 – 405

Neumann, E., Ammons, RB., (1957) Acquisition and Long term Retention of a Simple Serial perceptual Motor Skill. Journal of Experimental Psychology. 53. 159 – 161

O’Neil, HF (Ed) (1978) Learning Strategies. New York. Academic Press

Peyton JW. Teaching and Learning in Medical Practice. Heronsgate Rickmansworth, Herts.: Manticore Europe Ltd; 1998.

Simpson, EJ (1972) The Classification of Educational Objectives in the Psychomotor Domain in National Specific Media institute (ed) The Psychomotor Domain: A resource book for media specialists. Washington DC. Gryphon House

Singer, RN., (1978) Psychomotor domain in O’Neil, HF (1978) Learning Strategies, Academic Press Inc., London, UK.

Singer, RN., Garson, RF., Kim, K (1979) Information Processing Capabilities in performers Differing in Levels of Motor Skills. Tech. Rep. Tr-79-A4, Motor Behaviour Resources Centre, Florida State University, Tallahassee

Singer, RN., Stelmach, GE., Requin, J (eds)(1980) Motor Beahviour and the Role of Cognitive Processes and Learners Strategies in Tutorials in Motor Beahviour. Amsterdam, Netherlands

Singer, RN., Cauraugh (1985) The Generalizability Effect of Learning Strategies for categories of Psychomotor Skills. QUEST. 37. 103 - 119

Smith. JE., Jackson, APP., Hurdely, J., Clifton, PJM (1997) Learning Curves for Fibreoptics nasotracheal intubation when using endoscopic video camera. Anaesthesia 52 (2) 101-106

Zivin, G (Ed) (1979) The Development of Self Regulation through Speech. New York. Wiley

Leadership in the NHS - who is responsible?

I heard a story last week that made me reel.

A loyal clinician was given a token as recognition of service over fifteen years. A group of colleagues gathered and a manager presented a pen, in a box. The recipient opened the box, took  the pen and tried to write with it, to find it contained no ink.

“Typical!” was the response. “They give me a pen, but there’s no ink in it. What good is a pen without any ink? Typical NHS. Scrimping and saving, undervaluing us. I am not even worth the ink to go in my pen.”

Within ten minutes, the gathered group had dispersed to carry on with their work. As each of the group met another colleague they repeated the story of the pen until the latest urban myth was established.

I say 'urban myth' because after the comment about the lack of ink, the manager picked up the discarded pen, opened the box, lifted the false bottom to the box and found the ink refill. Looking up to find an empty room, it was already too late to run after everyone and shout, “There is ink! They did give ink. We are worth the ink in the pen!”

There is so much to say about this story. The dismissive attitude of  the recognition of loyal service. The institutional cynicism. The externalisation of motivation which leads to transactional rather than transformational working. But it is from a leadership perspective I wish to look at this tale more closely.

A week after I heard this story I read an article on “hittability.” The author is a healthcare leadership expert in the USA who teaches and writes extensively on the topic. His thesis in this article is that hittability relates to whether we see a leadership challenge as solvable. He says that hittability is a  “function of our framing lenses – a person’s beliefs, values and worldviews” (Souba, 2016:1) that frames the way we see a leadership challenge and that this is in turn influenced by the way we perceive the future. I would add to this the level of personal responsibility we feel for such challenges, our sense of self efficacy and our desire to act to change the future.

The first thing that Souba highlights is the difference between technical expertise – our fund of knowledge and skills, and what I call transformational expertise – the ability to “see” beyond the restrictions of the challenge. Souba says that what marks out exceptional leaders is that they “see, understand and deal with leadership challenges differently” (ibid) to most people. They are able to separate the facts of the challenge from the various narratives that are constructed by the stakeholders.

Souba identifies a ‘Prevailing paradigm’ which emphasises what is known, and focuses on skills, know-how, competence and expertise and an ‘Emerging paradigm’ which emphasises what is seen. This paradigm suggests that leadership is largely a function of the  hittability of leadership challenges and that effective leaders reframe situations so they can see them as hittable.

If we return to the pen story, we can see that the prevailing narrative, which was quickly adopted, was that the NHS as an employer did not value its workers. This narrative ignores the fact that the clinician was given a pen in the first place and focuses on the perceived lack of ink (which was also factually wrong) to perpetuate the prevailing narrative. That the narrative was further and immediately amplified by those who had been in the room, and those who had been told the tale, suggests that not only was the narrative  a familiar one but also very popular with the majority of the group who spread it. With such a strong and pervasive narrative, one wonders how a leader can re frame this?

If we look at the prevailing paradigm, we can see that narratives about the lack of ink and its representative lack of value of the clinician betray an attitude  of helplessness. The recipient framed himself as worthless, and powerless in the face of a huge, faceless power called “They.”

However the manager, who looked under the false bottom of the pen box adopted an attitude of curiosity, assuming that there might be some ink, not dismissing a solution out of hand before a period of investigation. This reframed the situation, placing the employer in a more positive light and more importantly placing herself as an active, enquiring agent.

An alternative interpretation might have been that the recipient, on finding no ink, accepted the situation and resolved to buy some ink on the way home, thus reframing the employer in a neutral context and himself as a responsible agent of his own destiny.

So, in order to be able to face leadership challenges with autonomy and self respect, we need to learn to reframe the challenges we face. Seeing challenges   as “hittable” depends on us and our ability to reframe the lenses through which we view such challenges.

“Great leaders don't just listen carefully; they also recognise that their framing lenses and their listening are inseparable…..Listening from the place of ‘this person has something important to say’ and listening for the future she or he is committed to constitutes a very different framing lens than listening from a place of ‘this conversation is a waste of my time’ and listening for the first chance to end it” (Souba, 2016:2).

How often do we listen with a mindset that has already decided there is nothing worth hearing? Who crafts our lenses? With what are they smeared? Because we look through our lenses rather than at them, they are often imperceptible to us, says Souba. But what would happen if we took some time to look at our lenses, to ask whether  they are the lenses we chose for ourselves, those we most need, for our own benefit and that of the work we do? How often do we just accept without scrutiny the lenses we have had thrust upon us by the prevailing culture in which we work?

Souba suggests that by not making a conscious choice about our lenses, we are being schooled to accept the lenses of others around us. Our view of the future is in itself a lens which frames the present for us. But if we could make a choice about the future, would we really choose the one we have been enculturated into? Ask any clinician if they are happy with the current situation and they will say no; ask what they think the future holds and they will shudder in despair. But Souba says “having a clear picture of the future you want to create is critical because it acts as an inspiration that alters your ways of being and acting right now” (Ibid), which in turn brings the desired future into the present. Committing to a positive future makes challenges more hittable.

The act of reframing is not just about the challenges we face, it is also about us and the people we are. This is what makes it essential if we are to continue. Souba’s key question is twofold: how do we reframe our healthcare challenges so they show up as hittable, and how do we reframe ourselves so we show up for ourselves as able and confident?

If we are not interested in doing it for the greater good, we should be motivated to do it for our own good. Clinicians are asking for resilience  training, not realising that only they hold the power to develop what they need. Giving up at the first hurdle (“there’s no ink in my pen”) and blaming it on the organisation is self sabotage. Saying to oneself, “I am honoured to be recognised beyond my pay packet, and here is a token of that - a pen, in a box, with even some ink in there,” reveals a happier, more resilient professional, who has a stake in his or her own future, and the agency to create it.

Souba, W. Hittability: The Leader's Edge. Academic Medicine. Nov 2016

doi: 10.1097/ACM.0000000000001498

'Delivering Teaching' - what does that mean?

Those who work with me will know that I have a dislike of the word ‘delivery’ being used to describe education. In the medical world many clinicians talk about ‘delivering lectures,’  or ‘delivering teaching.’ I hear this as a transactional description of the educational process which implies a commodity based concept of learning, whereby the teacher (the expert) gives, bestows upon or hands over the knowledge, skills or even attitudes to be taken up by the learner. Freire (1972) called this the ‘banking method’ and wrote extensively about the damage such a view of education can cause.

Notice, while I am on the subject, the number of times the word ‘teaching’ is used when learning is what is meant. Junior doctors leave the clinical setting of the ward or theatre to attend ‘teaching’ but it is not they who are doing this teaching. People say, “I was at some teaching the other day..” when they were there to learn.  What is it about the distinction between the two words that causes discomfort to me and confusion to others?

Some languages have the same word for ‘teaching’ and ‘learning’ and some of those languages differentiate between the two by the use of the passive or the active voice – teaching being the active part of the verb (as though learning is not active!)

I have looked at the etymology of some of the words used to explain the actions of those who are engaged in the learning process. To ‘deliver’ means to bring, hand over, provide, or to surrender something. It comes from the Latin ‘de’ meaning away and ‘librere’ to set free. So to deliver teaching is to bring along something that is handed over, or surrendered to the learners, which in my interpretation means that it is then relinquished by the teacher who can walk away from the process, responsibility discharged. Where, I ask, is the reflexivity in that? What role does the interrelationships between teacher and learner, teacher and material and learner and material play? Very little it would seem.

So would ‘provide’ be a better word?  ‘Provide’ means to make available for use, to supply, to make adequate preparation for or to allow or cater for, to present or to yield. It comes form the Latin ‘providere’ meaning to foresee or to attend to; ‘pro’ meaning before and ‘videre’ meaning to see. So to provide means to preview.  Is this what happens in education? Maybe. But do we provide teaching or learning?

I tend to use the words ‘facilitate learning’ to explain what I hope will result through the organised activities I set up. To facilitate comes from the French ‘faciliter,’ meaning to make easy. I am not sure that the learners I work with would all agree that I make things easy for them, but it is certainly my intention when preparing for the educational episodes in which I will be involved. Facilitate also refers to smoothing the way, to helping to cause something and that is what I hope that my educational endeavours result in; the causation of something new, be that understanding or practice.

So next time you use the words ‘delivery’ or ‘teaching’ just stop and think what kind of message you wish to convey about the education you propose. 

Freire, P., (1972) Pedagogy of the Oppressed  London: Penguin

Just read this interesting blogpost:

http://www.mededworld.org/reflections/reflection-items/January-2014/Bedside-Teaching-Matters.aspx?utm_source=MedEdWorld+Select&utm_campaign=64a6a4c43e-MedEdWorld_Select1&utm_medium=email&utm_term=0_f4cea42140-64a6a4c43e-242088125

I have been concerned for sometime about the disconnect between what we teach and how we teach, and this paper raises questions for faculty development as well as for bedside teaching. No wonder there are constant questions raised about the tension between service and training on faculty development courses. 

One way of looking at workplace based learning which has been much espoused in medical education of late is that of Anna Sfard's two metaphors: 

http://www.colorado.edu/physics/phys4810/phys4810_fa08/4810_readings/Sfard.pdf 

This reminds us of the need to integrate training into the very service being provided. Shared participation in workplace based practices calls for the kind of bedside consultation valued by Ramani, both clinically and educationally.

Acquisition	Participation
Classroom teaching	Engagement in shared activity
Teaching between patients	Talking to patient at bedside
Knowledge based	Integrated competences
Teacher as expert	Teacher as facilitator
Learner as sponge	Learner as co - participant
Telling how to	Showing how
Learning off the job	Learning doing the job
Tutorials	Case based discussions
Vertical relationships	Horizontal relationships

Whilst much of my work involves working with trainers and trainees in classrooms, I do expect to be able to promote a move towards much more integrated educational support for both in the more situated context of the workplace. This is an area we need to focus on imminently.

Module - Reflective Practice for clinicians

I recently wrote an e module for clinicians in reflective practice for the London Deanery Professional Support Unit. This module combines information about reflection for those looking to learn more about it, with a walk through hands on approach to doing reflection.

Access the page link below and click on the pdf picture of the module on the right of the page to go to the whole module.

http://www.londondeanery.ac.uk/professional-development/professional-support-unit/learning-development-and-personal-effectiveness-resources/reflective-writing-skills

Do let me know what you think of it.

Reflective Practice - some examples

Having worked recently on an e learning module on Reflective Practice, and with some superb trainee doctors in producing pieces of reflective writing, I wanted to share some of those with you.

There are three pieces of writing demonstrating the DEBRIEF guide for writing up reflections on clinical practice. I want to thank the trainees involved for their hard work and for being willing to share these pieces in various quarters.

Reflection 1:Massive haematemesis

Situation-ITU resident on night shift.

The case (Describe what happened)

We had a fifty one year old gentleman with NASH who had presented with haematemesis on our ITU outreach list. He had presented on the Friday with a litre of haematemesis witnessed in A&E. There was no gastro on call over the weekend so he was waiting for his scope on Monday. Soon after starting my night shift, I was asked by the med reg to come and see him as he had just had another episode of haematemesis of about 1L.

When I got there, he had just been reviewed by the surgical registrar and looked unwell. As I went to examine him, he vomited again- about 1.5L over my shoes and on to the floor. I asked for help, assessed what kind of IV access he had and squeezed the bag of blood that was up. A nurse soon arrived and the surgical reg. I asked them to fast bleep the anaesthetist on call and someone went to look for a Sengstaken-Blackemore tube.

The SB tube was put down which stopped the bleeding and more blood was ordered. The plan was to take the patient to theatre and do an OGD. I left the patient with the surgical registrar and the anaesthetists and went back to the unit. They would contact me if there was any deterioration and we made a bed available for the patient post-theatre.

A few hours later, I was called by the medical registrar on call to say that they were in the process of trying to get the patient transferred to the tertiary centre Liver ITU. The SB tube balloon had been pulled out and the surgeons on call could not band varices and there were no gastroenterologists available. I went back to the ward to assess the situation.

The patient now had an arterial line and a CVP line. The SB tube was back in place. The patient was still receiving blood and blood products. I spoke to the tertiary centre  and they accepted the patient for transfer. It was decided that the patient should be intubated for transfer and that it was best to do this on the ward rather than transferring him up to the unit first. The surgical registrar, medical registrar, anaesthetic SHO and registrar and the ITU consultant (over the phone) were all involved in this decision.

There was delay in intubation so that after the SB tube had been removed, the patient vomited blood again and then arrested (PEA). It was a difficult intubation but successful and the SB tube was then re-sited. The patient received 3 cycles of CPR with adrenalin and atropine with return of spontaneous circulation. The initial BP was 100 systolic. The patient’s daughter arrived soon after the start of the resuscitation but did not stay for long to observe.

The situation was again discussed with the tertiary centre  and consultants at home (anaesthetic, medical, ITU) and with the staff present (anaesthetists, surgical reg, medical reg, site managers, nurses) and it was felt that although the patient was unstable, transfer to a unit with staff to do oesophageal banding was the only option that offered some chance of survival. There were conflicting opinions about this but this was the consensus that was reached.

The patient however was not able to maintain his BP, despite boluses of adrenalin and ongoing transfusion. The BP was barely maintained at 70 systolic. The situation was re-assessed and it was decided that transfer was no longer an option. The family had not yet been spoken to. I was nominated to speak to family, with the medical registrar.

The family (wife, daughter, son) understood that the situation was serious and that we had tried to get the patient stable enough for transfer to a specialist unit but that this had not been possible. They wanted active treatment but understood that this was likely to be futile. I explained that the patient could either be brought up to ITU for ongoing support but that the outcome was likely to be poor. The alternative was to keep the patient comfortable on the ward. The family decided that they wanted the patient to be kept comfortable on the ward.

The situation was then again discussed with the members of staff present and with consultants over the phone. The consensus was that treatment should be stopped and the patient kept on the ward. He died soon thereafter with his family at the bedside.

My evaluation (E)

Things that went well: good communication between different members of staff, good decision making process, patient’s best interests always foremost, dignified death at the end.

Areas for improvement: awareness of ward nursing staff of seriousness of situation, hospital logistics (availability of SB tube), delay in intubation, out of hours gastroenterology availability.

Feelings (Bring out feelings, values, beliefs, assumptions etc)

This case left me with a feeling of slight unease; whilst I knew we had done all we could – and we had facilitated a clam and dignified death at the end of the process, I just felt like we could have been slicker in our management. I was frustrated by the nursing staff who did not seem to grasp how ill the patient was. I could feel myself getting angry with the lack of availability of the equipment and the out of hours gastro cover system. I felt like I was doing my very best for this patient but around me the staff and the hospital infrastructure were taking it all at a much more casual pace. We work hard and intensively and when that is not matched by the system or other colleagues it can be infuriating.

Review (Review in light of previous experience; how would someone else have acted?)
 

I have treated patients with similar problems before and have also been with patients at the end of their life. I think the reason this case affected me was because I felt overpowered not just by the inevitability of the patient’s death, but also by the small inefficiencies of the hospital system.

Identify learning points (I)

Communication between everyone involved in case is vital - staff present but also other centres and consultants over the phone, consensus in decision making is important and not easy, but sometimes we cannot always offer patients the care they need or we would like to offer.

Establish follow up actions (E)

The equipment issue is something I can do something about so I intend to do process mapping on such essential pieces of kit, and ensure that there is a system in place to have all kit kept fully stocked and up to date for future cases.

Further reading/ study: STEP Case of the month: http://estepcore.rcseng.ac.uk/secure/cotm/view_case_html?case_id=55

Feedback (Feedback on actions)

I have spoken to my consultant about the equipment project and he suggested I could submit the results as a Quality improvement Project to the next QIP conference the Deanery run.

 Reflection 2: A&E

Describe events

During a night shift on call I was in theatre with a locum SpR assisting with a laparoscopic appendicectomy. The trauma bleep went off and it was announced that the call was a code red - meaning that there was an unstable patient. I left theatre and went to A&E. On arriving in resus, I found the rest of the trauma team (A&E consultant, orthopaedic SpR and nurses) with a 19yr old male who was intubated and ventilated, who had been transferred from another Hospital, following stabs to the left arm, chest, buttock and thigh. He had a systolic blood pressure of 60 and a tachycardia of 152 bpm and the A&E consultant asked me to insert a chest drain, which I did. As I had missed the primary survey (because I was in theatre), and the patient was unstable I reviewed it for myself and then suggested that a stab check was done - on removing the left arm bandage I noticed that the patient was exsanguinating from a lacerated brachial artery, and he had blood going through a cannulae distal to this in his left forearm which was why he was not responding to fluids. I applied a pressure dressing and asked the A&E consultant to call the surgical Trauma Consultant on call and ask him to attend. The consultant was there in 20 minutes and a tourniquet was applied and the patient went for a CT angiogram and then straight to theatre.

Evaluation

On reflection, I think the team worked well and quickly together once we had realised what the problem was. There was clear communication between each member of the team and life threatening issues were dealt with quickly and efficiently, even though we only had limited staff available.

Bring out emotions etc; Review in light of previous experience

Given my previous experience of trauma I quickly knew that the patient was unwell and I realised that if we didn't quickly find the cause for the hypotension he would arrest and would need a clamshell thoracotomy, which I had never performed alone before and without the support of my SpR or consultant this would have been terrifying. I was aware of how afraid I was about the possibility of having to do a thoracotomy if the patient arrested.

Identify learning points

I learnt the importance of reviewing the primary survey if the patient remains unstable and as in this case it was easily reversible with re-siting the cannulae into a different arm. I am also glad that I did not hesitate to call in my consultant as the patient went straight from A&E to theatre for repair of his brachial artery to save his left arm. Also, I found that being in such a stressful situation as a junior SHO can be emotionally quite challenging and I continued to replay the sequence of events over again in my mind to see if there was anything I could have done differently. I realise now that if that had been necessary I could have called upon the A&E consultant.

Establish follow up actions

Following the incident, I reflected with my consultant and the A&E consultant and suggestions for improvement included applying a tourniquet earlier to the left arm, rather than a pressure dressing. I had considered this at the time, but I was not sure why I hesitated. Next time, if I think of applying a tourniquet I will just put one on and make a note of the time of application. I think that discussing the case with consultants and colleagues afterwards helped me to feel more confident and identified important learning points. The follow day I did some reading about thoracotomies.

Feedback on those actions

I intend to follow up this learning by linking this case to a future case which either covers similar clinical ground or in which there is the question of calling for senior help.

 

Reflection 3: Paediatric patient

Case (D)

A failed kidney transplant patient, he had spent large part of his life in and out of hospital even though he was only seven. He knew all about doctors and nurses, blood tests and operations. He did not like being in hospital and he did not like being told what to do.

On the morning in question, I needed to take a blood sample from him. I introduced myself as I had not met him before. He looked at me suspiciously and told me he wanted to eat his lunch first. I thought this was a reasonable request and said I would come back.

When I came back he said he did not want his blood taken. I explained why it had to be done. There then followed every excuse he could think of as to why he should not have his blood taken then. He wanted to play some more first. He wanted his mum to have her blood taken first. He wanted another doctor to do it. He wanted to go to the toilet first. I dealt with each argument but he became more and more distressed. He swore and shouted and cried and tried running away.His mother said we should go ahead. The minute the needle touched his skin, he was quiet. He stopped crying and calmly watched the blood enter the specimen tube.

I asked him why he had been so distressed. He said he had to make a fuss ‘so that I would be careful’. I said I could understand his logic but that perhaps in future he did not need to make quite so much fuss.
 

I thought I dealt with this situation well by letting the patient eat his lunch and coming back later and I was glad that I asked him why he had been so distressed, because I learned something from that. However, I could feel myself getting angry with him and only just managed to control that. (Evaluation)

I was very busy that shift and could have done without this, but something made me curious about this child’s behavior. I have to say I admired him in a way for his strategy. (B)

When I thought back over this case later that evening, I recalled talking to a parent of a sick child a few months ago and she said how much she hated her powerlessness. She said she felt as though she and her daughter were victims in the machinery of the healthcare system. That comment stayed with me, and I wondered today if this child’s behaviour over the blood sample was driven by the need to exert some power over what was being done to him. (R)

I realized that we would do well to remember how vulnerable patients feel, and that we need to earn our patient’s trust and it is often best to tread carefully at the start. (I)

When I am working with patients in future, I will endeavour to give them as much choice as possible over their care, even down to when I take their blood. (Establish Actions) I would like to look at the patient feedback forms and see whether there is scope to ask them about choices in their care. (F)