Jennifer is a pediatric emergency medicine fellow. She frequently supervises residents on wound repair procedures. Some wounds are minor and are repaired using simple suturing techniques; other wounds are complex and require advanced techniques that are less frequently performed. How can Jennifer provide residents with opportunities to practice these techniques while ensuring good cosmetic outcomes for patients?
Zak is a pediatric emergency medicine physician. He is responsible for organizing educational sessions for fellows throughout the year. Some procedures such as intubations or chest tube placements are critical procedures that can carry significant morbidity and even mortality. The complexity and low frequency of these procedures can lead to decay of skills over time. How can Zak provide fellows with opportunities to maintain their procedural skills?
rocedural skills are “the mental and motor activities required to execute a manual task”.1 Medical procedures are frequently performed for diagnostic and/or therapeutic purposes. Procedures can be relatively simple (e.g., laceration repair of a minor wound) to complex (e.g., intubation for airway protection). The degree of risk associated with procedures varies greatly; some procedures can result in significant morbidity or even mortality if performed poorly or incorrectly.
Under Bloom’s domains of learning, being able to perform a procedure successfully requires competency in two domains: cognitive and psychomotor. Learners must understand procedural indications and contraindications, proper setup, and how to perform the procedure. Learners should also have proficient technical skills to perform the procedure. Similar to acquiring athletic skills, frequent and deliberate practice is critical to attaining procedural competency.
How do we, as clinicians and educators, provide trainees with opportunities to learn, practice, and maintain procedural skills, while ensuring high standards for patient safety?
What are existing frameworks for procedural education?
The traditional model for procedural teaching has been “see one, do one, teach one.” In this apprenticeship model, novice learners acquire skills through direct patient care. Although this may still have a role in learning simple procedures (e.g., foreign body removal), it is considered suboptimal for procedural education due to patient safety concerns. In contrast, simulation-based medical education has become an important tool for trainees to acquire procedural skills in a safe environment.
Sawyer et al. proposed a simulation-based framework for procedural skill training that includes six steps: learn, see, practice, prove, do, and maintain (Table 1). In this framework, learners use deliberate practice and instructor feedback to achieve procedural competency. A key component included in this framework is simulation-based mastery learning: learners must prove their procedural competency by passing a summative assessment on the simulator.1 An example of this summative assessment in the form of a checklist is included in Sawyer et al.’s article. Although the application of this model in its entirety is likely challenging, it is a helpful framework for educators to consider when designing workshops or curriculums focused on procedural education.
Table 1. Six Step Framework for Procedural Skill Training
|Learn||Learner acquires the background knowledge necessary to perform the procedure.||A resident reads about the indications/contraindications to performing a lumbar puncture (LP), materials required, and steps to performing an LP.|
|See||Instructor demonstrates and models the procedure. This can be done in person or via a video.||A resident watches a video that demonstrates how to perform an LP.|
|Practice||Learner practices the procedure on a simulator using deliberate practice: focused and repetitive practice with formative feedback from instructor to improve technique.||A resident practices performing LP on a simulator while an instructor observes and provides immediate feedback for improvement.|
|Prove||Learner undergoes summative assessment on a simulator, based on a predefined checklist.||A resident performs the LP on a simulator while the instructor assesses the resident's performance based on a checklist.|
|Do||Learner performs the procedure on a patient.||A resident performs the LP on a patient.|
|Maintain||Learner receives ongoing education to maintain procedural skills.||A resident practices performing LP on a simulator throughout the year.|
Another application for simulation-based procedural training is the maintenance of procedural skills. An example is “just-in-time” training (JITT), which is procedural education that occurs immediately prior to performance of the procedure. This serves as a “refresher” and can be useful for advanced techniques or high-risk procedures that are infrequently performed. Although the exact impact of this training on clinical performance is difficult to determine, JITT has been shown to improve trainee procedural knowledge and confidence level.2,3
What are practical tips for teaching procedures?
Now that we have explored the broad framework for procedural education, let’s discuss practical tips and strategies for teaching and supervising procedures in the clinical setting. This can be a challenging task because clinicians have to balance competing demands including trainee education, patient safety, and time constraints. Below are helpful tips to consider before, during, and after the procedure.
1. Prior to the procedure
Learners should have a solid foundation in the cognitive aspects of the procedure. There are numerous online resources or textbooks that can be accessed to establish baseline knowledge (Table 2). It is important for learners to demonstrate comprehension of the procedure. You can achieve this by having learners describe the procedure step-by-step or ask specific questions to identify gaps in understanding. If you have access to a “just-in-time” training room or cart, this is a great time for learners to demonstrate how they would perform the procedure on a simulator.
An important part of any procedure is patient or parental consent. Novice learners should observe the instructor provide consent to understand what components are included. As the instructor, it is important to explain to the patient and family ahead of time what the roles will be during a procedure and address questions. For example, prior to an LP, you can explain that the learner will be performing the LP, the instructor will supervise, and the nurse will assist with patient positioning and comfort.
Proper set-up is also important to the success of performing any procedure. This includes having the correct equipment and materials, optimal positioning of the patient, and local anesthesia or sedation for patient comfort. Novice learners should be involved as much as possible in the preparation of a procedure while advanced learners should demonstrate competency by independently setting up for the procedure.
Table 2. Resources for Establishing Baseline Knowledge
|Closing the Gap||Website with videos on wound repair techniques|
|INSPIRE||Infant lumbar puncture video|
|New England Journal of Medicine||Repository of procedural videos|
|Canadian Family Physician video series||Repository of procedural videos|
|MedEdPORTAL||Repository of curricula, including procedural modules and workshops|
2. During the procedure
There are many different ways to supervise a procedure, based on complexity, learner experience and comfort level. If you’re supervising a novice learner, you may have the learner observe and perform parts of the procedure. For example, during a complex wound repair, you can perform deep dermal sutures while the learner observes, and then have the learner perform simple sutures to close the wound. This is a great way for trainees to learn advanced techniques while practicing techniques they are already familiar with.
Another approach is to provide step-by-step verbal instruction to the learner performing the procedure. This allows learners to perform the procedure from start to finish while receiving immediate feedback on their technique. If the learner is struggling during a particular step, despite verbal feedback, the instructor may need to intervene to perform that step, and then hand the procedure back to the learner once it’s safe. For example, if the learner is struggling to insert the LP needle, the instructor can reposition the LP needle for successful insertion, then allow the learner to collect the cerebral spinal fluid and complete the procedure.
3. Post procedure
It is important to provide feedback to the learner and answer questions. If the procedure was successful, you could discuss possible pitfalls and ways to troubleshoot.
What is the future of procedural education?
As certain critical procedures become less frequently performed, especially in pediatrics, it is crucial for educators to closely examine our current approach to procedural education and identify areas for improvement.
We need to hold procedural competency to the same standards that professional athletes are held to during their performance. As such, we should engage in frequent dialogue and discussion about best practices so that trainees graduate with full competency in their required procedural skills.
Let’s return to our cases.
To make sure learners can “refresh” their advanced suturing techniques prior to performing on patients, Jennifer used a “just-in-time” suturing cart where learners practice different types of sutures on a training suture pad. This cart was created by Mike, a pediatric emergency medicine physician, who previously encountered the same challenge. She has received excellent feedback from learners and frequently utilizes this cart prior to supervising residents performing wound repair on patients.
Zak has incorporated simulation-based training into procedural workshops. He organized workshops facilitated by faculty throughout the year where fellows practice critical procedural skills on simulators. These procedures include intubations, chest tube placements, needle cricothyroidotomy, and central line placements. He has received feedback from fellows that it has allowed them to maintain certain skills that are not frequently performed clinically.
1. Sawyer T, White M, Zaveri P, et al. Learn, See, Practice, Prove, Do, Maintain: An
Evidence-Based Pedagogical Framework for Procedural Skill Training in Medicine. Acad Med. 2015;90(8):1025-1033. doi:10.1097/ACM.0000000000000734
2. Itoh T, Lee-Jayaram J, Fang R, Hong T, Berg B. Just-in-Time Training for Intraosseous Needle Placement and Defibrillator Use in a Pediatric Emergency Department. Pediatr Emerg Care. 2019;35(10):712-715. doi:10.1097/PEC.0000000000001516
3. Thomas AA, Uspal NG, Oron AP, Klein EJ. Perceptions on the Impact of a Just-in-Time Room on Trainees and Supervising Physicians in a Pediatric Emergency Department. J Grad Med Educ. 2016;8(5):754-758. doi:10.4300/JGME-D-15-00730.1