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Scenario Training: How to Teach Them and How to Make Sure People Learn From Them

May 29

Posted by Jeff Young, MD in Clinical Teaching, EMS | No Comments

Teaching How to Do Scenarios and How to Learn From Them (BACKGROUND FOR THIS WEEK”S PODCAST)

 

While checklists are good, teaching  people to perform medicine where 100 proscribed motions and words are delineated may or may not be good. While seemingly contradictory to what I’ve said before, here are the reasons:

Memorization sucks from a safety perspective

  • Things are memorized in patterns, when you break the pattern everything shatters to the ground and its very difficult to recover
  • So, memorization is good if you can sit there, clear your mind, concentrate without interruption, and regurgitate the components – rarely happens in an emergency

Memorization is a bad way to teach

  • Things are learned in chunks (5-7 individual items) that are then bonded together by transitions
    • Airway transitions to breathing exam after you do X, breathing to circulation when you do Y
    • That way all you need to remember under pressure are the transitions, the chunks will be there for you if you learned them properly (repetition)
  • People who are not good teachers (or think they are good teachers) teach neophytes by pointing at the list of checkboxes and say “look, dummy you didn’t do this one”. The learner then gets nervous and goes “shoot, I better remember to do that one” this then makes it hard for them to remember the previous step or the one following since they now fixate on the one they missed.
  • Checklists are NOT FOR MEMORIZATION. They are safety tools to be used during, or around the heat of the moment to create a situation where you can collect data, analyze, and implement. When you don’t have to memorize, you can go one level deeper into information gathering and analysis, which is usually good (but could be bad if you are not diligent about going back to your checklist and making sure you got everything).

So if you have a checklist why learn anything?

  • Because you need to understand the physiology, the presentation, the sequence of signs and symptoms, the safety considerations, the techniques for care (IV’s, intubation and such) and you need to learn how to properly rank priorities and form and carry out a treatment or rescue plan that works.
  • The checklist merely allows you to not forget essential safety components

My take on how to teach this:

  • Make certain the learner understands the background on everything (what it looks like, what its components are, etc.)
    • What respiratory failure is
    • What an unsafe environment is
    • What shock is, etc.
  • Next, insure they understand why the steps in the algorithm are where they are?
    • Why is airway first
    • Why do we listen to the lungs
    • Why do we check peripheral pulses first
    • Why do we wear PPE
    • Why is an unsafe scene a problem, even when the patient is dying and needs help right away
  • Next, ONLY practice the individual steps.
    • Do those until you can see the person understands what they need to do and why, and why the algorithm is the way it is..
    • Don’t even think of going to step B until they have a grasp on step A
      • Example: don’t move to breathing evaluation until the learner is checked out on airway, and so on

After learning all the steps (airway, breathing, circulation, vital signs, etc.)

  • Use YOUR experience and knowledge to help them link the steps
    • Everyone does this a little different, and often there is no right way
    • Will go over in podcast

When you are preparing to test, don’t make them go through the whole evolution if they are screwing up – STOP! You must correct them when they muck up a step or a transition

  • How you prepare someone for testing is where your ability as a teacher comes out. It is at this step you can make or break learning and retention
  • Remember, in these sorts of things, if they do it wrong once and their mind grabs that bad process, it will take a lot of work (usually 5 perfect repetitions) to eradicate it
  • Stop, tell them what they did, and go back at least 2 steps, so they need to practice the step, and the transition in the flow of the problem.

Finally, testing probably needs to be less strict

  • I know this is contrary to a lot of what I say, but if someone is getting nervous at the same step in the test over and over again, and they clearly understand the material, and they do everything else right, they probably are competent and shouldn’t be failed. If they are horrible all the way through, get rid of them before they hurt someone.

Medical Decision Making Lecture at Virginia Society for Repisratory Care

May 22

Posted by Jeff Young, MD in Clinical Teaching | No Comments

This is the lecture I gave this past week at the Virginia Society for Respiratory Care in Virginia Beach, VA on May 21. Hope you enjoy it.
Thanks for listening.
JY.

Podcast: Play in new window | Download

Thinking a few steps ahead….

May 5

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, EMS, Hospital | No Comments

As I’ve said in the podcasts and posts, improvising off the top of your head in high risk situations usually doesn’t work out well for anyone. Yet, sometimes you see people respond effortlessly, when circumstances take a rapid turn for the worse, and you think “wow, they can really think on their feet”. There are probably two things going on in experienced people’s minds in those situations.
First, they have been through the situation before, and if you looked at some of the posts, and lectures, you know that when you go through situations multiple times, you create a “model” or “schema” in your head for that situation. That means that your brain goes “ok I’ve been through this, that looks like it did before, that does also, last time I did this and it worked out, I’m going to do that again”. A really experienced person also adds “I’m going to watch out for X, because if that happens, I’m screwing up and I need to change to plan B.”

That works well for people with lots of experience who have worked their way through a lot of situations, what do you do if that’s not you? The key is “mental war gaming” and thinking a few steps ahead, and thinking “what if this is going on?”. Ran a call with the firefighters recently where a child was not responsive after a seizure. I felt the child was OK, but my brain immediately said “check the pupils, check the oxygen sats, and keep a close eye on the breathing” because I’ve been in situations where children have looked OK, but 10 seconds later their lips are blue and they are in respiratory arrest. So if the pupils are equal, the breathing is steady, and the sats are OK, I relax a little. But I also said to myself “what if he stops breathing, or his sats are 80%?” and I began looking for where the bag mask, and peds mask are, where the airway equipment is, and when the transport unit is getting to the scene. You also start playing in your head “if he’s not breathing, what am I going to grab first, are we going to try to ventilate him where we are, or move to a better spot, are we going to let the incoming unit know?, what if we cant bag mask the patient?”, etc.

I was thinking those things, but later I was mad at myself because I was lazy. As soon as I saw that the patient was unresponsive, I should have found the airway equipment, and had it in my or the medic’s hands. I should done that because I also know that if something bad happens, it’s a lot easier to have the stuff you need right in front of you, rather than just thinking “I know what bag that’s in”. This is especially true in the trauma bay since it takes someone else to get the equipment and set it up, leading to an even longer delay. It’s always better in the bay to have the equipment out, on a table, with everything you will need already pulled. Then when you need it you just need to open the packinging and get to work.

Clinical brain training makes you a better provider. Its easy to do on any call or hospital situation, and provides you with constant mental training for when a big situation hits.

Clinical War Games Cases

Apr 19

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion | No Comments

In our training program, simulated cases were the key element. The cases were moderated by the “instructor” and the student responded to the data as it was presented. The data that was given to the student is written out in the case spreadsheet, as well as the score for each element in the case. The score for the case was the percent of possible points scored by the student. This allowed us to provide scores and measurement of real improvement (for more information see the how-to manual in an older post).
I have included several cases for you to look at and get familiar with. I encourage you to print them out, and carry out sessions with your students, or with your colleagues. I will also attach a link to several written transcripts of these sessions, so you can get an idea of how the cases flow.
JY
PE
Narcotic overdose
Hypotensive blunt trauma
Asthmatic
AMI

Mental muscle memory…

Apr 5

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital, Information | No Comments

Mental muscle memory is one the most important things to cultivate when you are learning clinical medicine. It is the process of training yourself to respond in certain ways to certain stimuli. Even if you are facing a completely novel situation, mental training will allow you to carry out the essential tasks in the evaluation without wasting mental energy, that way you can devote all your attention to the novel signs, symptoms, and hazards that you are encountering.
Fire and EMS often do this much better than we do in the hospital. It is rare that a medical student or intern is taught “here are the five things you need to do every time you are in a clinical encounter”, or “when placing a femoral line these are the seven steps you need to carry out to do this safely”. Often in medicine, we tell novices to “watch this a few times”, and then “give it a shot”. If the mentor is good, they will talk about all the steps they are taking to carry out the procedure or encounter, and make certain that the novice understands all the steps. The next step is often not taken, and that is then asking the novice to “talk through” the entire procedure by themselves before they move onto another task. This last step is essential to creating muscle memory, and essential to learning, and it is often not done.
It is puzzling that these educational exercises are not an intrinsic part of the educational process for physicians, and I think if we are going to move to a safer medical culture, they will need to be. In many ways, physicians often have an irrational resistance to any attempt to “cookbook” medical care. I think for many physicians that trained in the 70’s and 80’s they may be a lost cause at this point, since these attitudes are pretty ingrained. But we need to make certain we do not allow these attitudes to gain a foothold in younger physicians.
Here are some muscle memory exercises, and I will put a bunch together for a Kindle offering soon;
1. Step by step account of how to move from recognition of respiratory arrest, to placement of a secure airway. This is probably a 20 step evolution and will often take place under high pressure, therefore it is vitally important to embed these steps.
2. Step by step account of resuscitating a patient with severe medical hypotension. What orders? What labs? Fluids? Antibiotics? Cultures? Etc.
3. Step by step evolution of placing a thoracostomy tube, or a central line

I am not going to write out these steps right now, because people will transfer their disagreement to the steps that I write out, while what I want is for people to realize that the broad concept of consistent clinical thinking is the key, not the individual steps.
JY

Fast and slow thinking…

Mar 10

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital, Information | No Comments

Everyone interested in learning how we learn, should read Daniel Kahneman’s recent book “Thinking Fast and Slow”. I have read a great deal of his work before, and I find it amazing to read something that actually explains the way that your brain works. It makes some sense that you can improve the way you make decisions by understand the way you decide.
The book and the generally accepted concept is that we think in two ways, System 1:intuitive (fast) and System 2: slow and deliberate. Much fast thinking occurs without our awareness of the process. This includes deciding someone in the lane next to you on the highway is about to do something stupid, realizing someone on the phone with you is angry, etc. Slow thinking is the reasoning and weighing of options that we traditionally associate with decision making. In medicine, problems occur when people learn to make bad decisions intuitively, leading to cascades of errors that often leave the person cleaning up with few options.
This is why it is so important to do the following with novice care providers:
1. Make sure you and they agree on the importance of a few basic principles. While it is possible to drill this into someone’s head, even if they don’t accept the reasoning, that is sub-optimal, and that knowledge will probably break down under pressure. Think of anything you have “learned” but that you never really understood (string theory, financial accounting, differential equations, the loop of Henle) and you know that you might be able to figure out the right answer to a question about one of those subjects, but your knowledge is shallow and can get confused very easily. If students don’t understand why airway should come first, it can be dangerous, especially if bad decision processes get ingrained.
2. Practice, practice, practice – you need to bring that intuitive decision making up in the light of day and look at it. The only way is to make people to think fast, and the only way to do that is to put them in situations or simulations that make them think under pressure. We all know it is rare for someone to function effectively in their first high pressure situation, but unfortunately that first high pressure situation may occur with someone’s health and recovery at stake. So its imperative when training to try to determine if your students really “get” it. If they don’t get it, try to figure out why, go through it again, and then look them in the eyes and say “got it now?” and then test them on it one more time. In essence this is what we do on rounds every day, first people do things because we tell them to, then they grudgingly realize that what we say to do makes sense, and then they understand it and teach those things to the next group.
This is also another reason why unneeded variability is so counter-productive. If you do things different ways for no valid reason, people will get confused and think that the process is essentially random. If they get that in their head, it can be difficult to break. We can’t standardize everything, but we should standardize the first 10-15 steps in any algorithm. That way things can get going along a solid path.

Uncertainty

Mar 8

Posted by Jeff Young, MD in Clinical Teaching, Discussion, EMS, Hospital, Information, Misc | No Comments

It continues to astound me that a vocation that has been around as long as medicine has, continues to have so many unknowns. We don’t know the best way to teach new clinicians, the best way to measure quality, the best way to measure outcomes, or even a viable consistent method to compare clinical care between practitioners and institutions.
This is certainly not from lack of effort, but it does exemplify the incredible complexity of medical care, and the difficulties inherent in trying to teach people to effectively deliver a service with consistent results.
A big part of the issue is that “optimal” care is such a moving target. Optimal care both in and out of the hospital has changed so many times for several conditions that it really makes you wonder if what we are doing now will not be found to be detrimental in the future. ACLS and BLS are great examples of entities taught with absolute certainty 20 years ago, that now have almost entirely different care processes in 2012.
I think this is a very strong reason for decreasing the amount of factual information we ask our students to learn, and increasing the amount of tactical thinking they do. I think there is about a 0% chance that any medical textbook’s information will not be changed significantly in the next 10 years. So drilling that information into student’s heads will lead to knowledge with a potentially very short half life. However, running students through scenarios where they can identify their knowledge gaps, and then fill them, I believe, will lead to better clinicians in the future.
I did research in education for several years, and was amazed at how much was known about learning that had not made it into medical education. Only in the past 1-2 years have many medical schools begun to embrace some of this information, but we still have no good data to know if those changes are helpful.
Textbooks and multiple choice tests work well for teachers and schools because they allow teachers to give standardized tests, with standardized responses, that generate a bell curve of apparent competence. However, as the military and aviation learned, you cant have someone who knows 85% of what to do and pronounce them competent. 85% of the knowledge of how to land a plane will not work out well. Those domains demand their students to demonstrate 100% mastery of the process 100% of the time, and we should as well.
As students, it is vital that you learn to question the medical knowledge you possess. With the tremendous information access at your disposal, there is no good reason why you couldn’t Google the last 10 peer reviewed papers on diverticulitis within an hour of seeing a patient with that condition. You should then have an intelligent discussion with your teacher about why you are doing things the way you are doing, as long as it doesn’t delay emergent care. In emergent situations, following protocols is vital, but afterwards you should make certain you understand why you did what you did. Any teacher who says “this is the way we do it, because I said so” is not a good teacher, and likely not a very good clinician. Anyone who thinks they can write a care guideline that will be optimal for more than a year is probably deluding themselves. Also, be aware that national guidelines are really the “best guess” of a group of smart and experienced people. That guideline should be where you start learning and understanding what to do, not the end of it.

The history and physical examination and their place in the world of error-free medicine….

Mar 1

Posted by Jeff Young, MD in Clinical Teaching, Discussion | No Comments

For years, older doctors have lamented the loss of history and physical examination skills by current doctors. They will point to the large number of labs and tests that are now ordered that could have all been avoided with a good history and physical examination. I say, be careful with that sort of attitude.
History and physical examination provide qualitative data, not quantitative data. That means that the person doing the exam has a great effect on the findings. If you had ten physicians take a history and examine someone with abdominal pain, you would likely get three different diagnoses and plans. Now that’s pretty good actually, at least you are not getting 10 different diagnoses and plans, so I will say the H&P has some discriminatory value. But if you were to draw 10 blood samples from the same patient over an hour, its very unlikely you would see any significant variation, and if you did, it would be a results of something wrong with the analyzer, not the person drawing the labs.
The H&P are wonderful for finding out about a patients medical and surgical history, allergies, medications, and general physical condition, but it has definite limits. Despite all the time spent in medical school on listening and identifying murmurs, no cardiologist in the US would make a definitive valve diagnosis based on what they heard with their stethoscope. They would obtain further confirmatory tests. And certainly no cardiac surgeon would replace a valve based on a physical exam. The purpose of the exam in most patients is to function as a screen. I think most of us can elicit pain fairly well, can identify abnormal skin lesions, identify gross nerve deficits, etc. But would I ever open someone’s abdomen based on a physical exam? Only in two cases, where a wound has traversed the abdominal wall and omentum or bowel is hanging out, or a gunshot wound that has clearly traversed the abdomen. Otherwise we usually get either a FAST or CT. When patients are hypotensive, we have a lower threshold for going to the OR based on the exam, but we still like to see fluid in the abdomen on ultrasound or CT.
Why is this so? Because in previous decades, we accepted a certain error rate as part of medical care. You knew that you couldn’t get tests on everyone so you used the H&P to stratify risk. If the risk was very low on exam, you knew it was likely the patient did not have something life threatening going on, and would return if things got worse (hopefully). In this day and age, missing a major diagnosis and hoping the patient comes back before they suffer irreparable harm is just too risky. We set the bar much lower for getting quantitative (laboratory) and semi-quantitative (radiology) data to make certain nothing is going on. If you have the philosophy that “you need to prove the patient is OK, its not the patient’s job to prove to you they are sick” then you will need to obtain tests to “rule out” conditions frequently. Also, because life threatening problems are rare among your average 1,000 ED patients, your tests are often going to be negative and you will be scolded for wasting money.
We need to get a better handle on what is wasteful testing and what is appropriate. Most of the studies in this area are not good, mostly due to the difficulty in studying this problem. It is also very important to know that physical exam and history taking skills are very user dependent and experience dependent. So a person with 1-2 years of medical experience will not be able to differentiate issues that someone with 10 years experience possibly could.
So be careful, if you think the patient doesn’t look right, or there is disagreement about the physical exam and history findings, get more data.
JY

Here is the lecture on Tactical Decision Making I give to the medical students:

Feb 27

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital, Information, Misc | No Comments

This is the lecture I give to the medical students here. I usually have to run through it pretty quickly so I thought I’d post it here so you could look at it at your leisure.

New_War_Games_Lecture_1a

JY

Clinical Brain Training How-To Manual

Feb 21

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital, Information, Misc | No Comments

Here is the manual that shows you how to set up simulation sessions similar to what we ran for over 700 students and residents.
The how-to manual tells you the learning objectives, how we construct and present the cases, how to grade responses, and how to provide feedback. Click on the link below and then the same link on the page that comes up to get the PDF file.

Clinical_Brain_Training_How_To_Manual[1]

The entire manual is also available for Kindle for $1 to offset the costs of putting up the website and podcast, but I’m certain you would rather get it for free by clicking the link above. If you want to pay a dollar and get the manual for the kindle, just click on the link below:
Clinical Brain Training How-To Manual
JY