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Friday, April 01, 2011
The Page 2 Blog-Education: You Watched, So Now Do It!
The mantra in medical education for teaching psychomotor skills has always been “see one, do one, teach one”. Stop and reflect on this for a minute. Using this time-honored concept, it would reasonably be expected that someone who saw you play the Minute Waltz (reference 1) on the piano today could play it by themselves tomorrow and teach it to another the next day; how presumptuous would it be of the teacher to expect that? Would you choose to be a passenger in a plane I was flying after I had sat in the cockpit and watched a pilot navigate cross-country once? This type of trial and error education, while it may perhaps eventually lead to learning skills, is not tenable; it is unsafe for the patient and unsatisfying for the student! Atul Gawande recognized this problem in his book Complications (reference 2):

The patient needed a central line. “Here’s your chance,” S., the chief resident said. I had never done one before…I had seen S. do two central lines…Now it was my turn to try…I stopped outside my patient’s door and just stood there staring, silently trying to recall the steps…She [S.] let me continue with the next steps, which I bumbled through. (11-15)

So, what do we need to understand better to most effectively teach anesthesiologists the requisite psychomotor skills, including, among others, vascular access, mask ventilation, tracheal intubation, securing the difficult airway, cardiopulmonary resuscitation, peripheral nerve and neuraxial blocks with ultrasound guidance, medication administration via bolus injection and TIVA infusion techniques, administration of blood and blood products and technical management of ventilators and the anesthesia machine?

Teaching psychomotor skills requires, at a minimum, 4 steps (reference 1):

  1. Analyze and separate the skill into its component parts and determine which aspects of the skill are most difficult to perform;
  2. Provide students with a model of the skill they are expected to perform, demonstrated effectively and in its entirety;
  3. Make provisions for students to practice until the expected behavior is mastered;
  4. Provide adequate supervision and an evaluation of final performance.

It sounds simple, doesn’t it? Maybe not…Consider an easy psychomotor skill: starting an IV. Broken down into its component parts, there are >25 steps to starting an IV, including, among many others, washing your hands, cleaning the patient insertion site, securing the vein without contaminating the newly cleansed site, threading the catheter, connecting the infusion line without air entry into the vein, securing the IV catheter and tubing for unobstructed infusion, and regulating proper flow into the vascular tree. A nice video provides a more detailed explanation how to insert an IV.(reference 3) Have you ever dissected the component parts of more difficult psychomotor skills such as ultrasound-guided sciatic nerve catheter insertion for continuous administration of local anesthetic medication or fiberoptic intubation through an intubating LMA? Teachers of anesthesiology must catalogue the steps to accomplish each psychomotor skill for there to be any hope that they will be able to teach them to someone else.

Simulation is now recognized as the way to provide students with a model of the skill to be learned and risk-free practice to perfect safe technique. Simulation enables “no-risk learning”, i.e., there is no risk involved when an inexperienced student “tries” an unfamiliar skill and makes a mistake on a mannequin rather than unsuspecting patient. Read about the American Society of Anesthesiologists' Simulation Education Program, Anesthesiology Residency Review Committee perspective on the place for simulation education in residency education, and American Board of Anesthesiology perspective on simulation education in the MOCA process . See references 4-7 below for some examples of investigative work related to simulation in anesthesiology education.

Establishing a final evaluation of psychomotor skill competency logically flows from explicitly defining the component parts of the skill, explaining them to the student, having the student practice them until proficient, and then testing the student in order to document mastery. How do you best teach psychomotor skills? How detailed are you in defining and prioritizing the component steps as you prepare to educate others to master each skill? How do you offer risk-free skill practice to your residents and fellows? Tell us what your criteria are for calling someone competent at each psychomotor skill.

Reference 1. Foley RP, Smilansky J: Teaching Techniques-A Handbook for Health Professionals. McGraw-Hill, New York, 1980, pp 71-91
Reference 2. Gawande A: Complications : a surgeon's notes on an imperfect science, 1st edition. New York, Metropolitan Books, 2002, pp 269
Reference 3. Ortega R, Sekhar P, Song M, Hansen CJ, Peterson L: Videos in clinical medicine. Peripheral intravenous cannulation. N Engl J Med 2008; 359: e26
Reference 4. Smith HM, Jacob AK, Segura LG, Dilger JA, Torsher LC: Simulation education in anesthesia training: a case report of successful resuscitation of bupivacaine-induced cardiac arrest linked to recent simulation training. Anesth Analg 2008; 106: 1581,4, table of contents
Reference 5. Gordon JA, Wilkerson WM, Shaffer DW, Armstrong EG: "Practicing" medicine without risk: students' and educators' responses to high-fidelity patient simulation. Acad Med 2001; 76: 469-72
Reference 6. Murray DJ, Boulet JR, Kras JF, Woodhouse JA, Cox T, McAllister JD: Acute care skills in anesthesia practice: a simulation-based resident performance assessment. Anesthesiology 2004; 101: 1084-95
Reference 7. Bradley P: The history of simulation in medical education and possible future directions. Med Educ 2006; 40: 254-62

Posted by Alan Jay Schwartz, M.D.,MSEd
Alan Jay Schwartz
About the Author

J. Lance Lichtor, M.D
J. Lance Lichtor, M.D. is a professor of anesthesiology and pediatrics at The University of Massachusetts Medical School. He is the web editor and an associate editor for Anesthesiology.

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