Monday, November 3, 2014

Workshop Title:
Hybrid model for training physical examination and procedural skills

Workshop Synopsis:
The purpose of this workshop is to re-examine physical examination and procedural skills training - by evaluating current educational theory, and empirical best practices; and then proposing a hybrid blended training model; by exploring how the eLearning, simulation, and mastery training paradigms can add value and insights to traditional training curricula. We will use three practical scenarios as illustrations and educational practice examples - abdominal physical examination, suturing, and corneal foreign body removal.

Workshop Website/Interactive digital wall

Workshop Program:
1345 to 1515hrs (90 minutes)


Good morning. There will be three parts to this workshop. Part 1, an individual and table discussion followed by interactive presentation; Part 2, a presentation of one method to think about this teaching and training conundrum; and finally Part 3, an interactive Q and A, followed by reflection and summing up section.

Professor Khan sends his apologies for not being able to attend this workshop due to a late logistical problem, and Gominda will deputise on his behalf, by taking down your responses to each question, writing a summary on the Padlet wall, and playing the role of a "traditionalist" if necessary.

Part 1:

Review of workshop participant feedback to questions (15 minutes)
(posed to workshop participants live, by email beforehand, via online Survey)

Please reflect on the following three questions first individually, for a couple of minutes, write down your answer, and I will then nominate a volunteer from each row to come up to the podium/microphone to share a summary of your responses to the questions with the group.
(Alternative arrangement if room is organised with participants seated around four tables is for a small group discussion to occur after personal reflection, and one or two nominees from each table to present their responses to the questions to the whole group. Please introduce yourself to your fellow educationalists seated at the table in the first minute or two).

A. How do you currently teach physical examination and procedure skills training?
B. What do you feel are the strengths of the current training program?
C. What do you feel are the weaknesses of your current training program? What could be improved? How might you do this?

Interactive presentation and discussion, with each row volunteer, or nominee from each table, presenting their comments to the three questions. 

Q and A interactive discussion.

Part 2:

Lets use a sporting analogy, and reflect on how this is similar to the training process for physical examination and procedural skills.

Consider the desire to play tennis. From a beginner's or novice's point of view, a good amateur player, or aspiring professional tennis player.

How would you learn to play tennis. And perform well.

One process would be to watch videos of a range of tennis players, from good amateurs, to a range of the top professionals. Paying attention to a variety of styles, and strategies. With different competition. On different surfaces. And different playing conditions.

You would get some coaching. Go for lessons.

Your teacher or coach would explain the principles of stroke making, demonstrate the forehand or serve, get you to role play or mimic his or her action/stroke making, and start you first hitting slow balls tossed on same side of court to you, then from across the net (close first, then further), then hit to you. You make half strokes, then 3/4 stroke actions, then full stroke actions. You would hit gently first, staying in one place, then take increaing steps to hit a ball placed further from you, hit to you at greater pace. You would be asked to repeatedly practice forehands, then backhands and so one. You would eventually play with the coach, before moving on to play with a variety of opponents. While the coach constantly gives you feedback, and you reflect on your performance. Good coaches would video tape your performance, and you and your coach would watch these performances, repeatedly, and then go back to the practice court.

This process would repeat itself. You would play progressively better players, longer matches, under tougher conditions, with less rest periods. 

Does this process remind you of teaching and training for physical examination and procedural skills.

You would want to view, and watch competent, proficient, and ideally master clinicians. The very best in their area. Not only how they examine patients, but how a variety of master clinicians perform procedures. Train with the very best. Learn from them. Try to model them. Get them to coach you. And keep giving you feedback. You would repeat this process. Again and again. Under more difficult conditions. 

Travel to see the best.

Watch videos of the best performers.

Practice with coaching and feedback.

Videotape your own performances.

Watch yourself.

Get respected, and master clinicians to give you feedback.

The analogy between sports, in this case learning and training to be a tennis player, and physical examination and procedure skills training in health professions education should be quite clear.

A current model which several of you have shared is a live demonstration, with or without an earlier video demonstration, followed by small group student practice either in a simulation centre, or on volunteers, followed by individual instructor feedback, and then further practice and experience with selected patients, either simulated or actual patients.

What we can learn from the sporting analogy, or a training to be a chef analogy, is repeated iterative practice, using a mastery training model. Where progression to the next stage of training is dependent on demonstrating competency and proficiency of each physical examination and procedural technique. Where any deficiencies in performance are picked up, with the student or trainee coming back for remedial focused practice with feedback. 

We can add exposure to a wide range of different techniques, using digital video demonstrations, to illustrate the breadth and range of physical examination and procedural skills which can be applied in a variety of clinical settings.  This simulates the previous phenomenon where a motivated trainee or student had to search widely, sometimes worldwide, to find and learn from the best practitioners in a field. We can also consider the use of video reviews of clinical examination and procedural performance, with self critique and reflection, as well as instructor feedback, following a coaching paradigm. The process to scale up this process, by the use of senior students, is used by several groups, and is also used in the sporting and other skill training settings.

Interactive Q and A. 

Concluding statements.

Thank you.

Original planned format of workshop below for your reference.


Review of current approaches to training (Junaid Sarfraz Khan) 15 minute presentation

Q and A


Review of how the eLearning and simulation literature and empirical evidence can help refine and improve current training and education programs (Poh-Sun Goh) 15 minute presentation

Q and A


Interactive group discussion (30 minutes) 

Workshop review and closing comments (15 minutes) 



Review of how the eLearning and simulation literature and empirical evidence can help refine and improve current training and education programs (Poh-Sun Goh) 15 minute presentation.

What is the role of comprehensive physical examination when cross sectional imaging is widely available?
Is the role of physical examination to screen, to comprehensively evaluate or to aid decision making (conservative, operate or discharge)?
How can procedural skills training programs take advantage of the literature from simulation and mastery training literature?


What is the purpose/objective of current training and education programs?





***Entrustable professional activities (EPAs)

What teaching methods do we current use to fulfil these educational objectives?

***Knowledge --> Lecture, Interactive tutorial

***Skills --> Demonstrations, practice sessions with feedback (simulation, volunteer, then clinical patients)

***Attitudes --> Case studies, role-modelling, self-reflection exercises



What do we know from the literature?




***eLearning and Simulation

What do we know from our own experience and empirical practice?


***How do we learn?

***What do we observe on a day to day basis?



Lifelong learning?

What are our own successful learning experiences?

***How were we taught in medical school?

***How were we trained (postgraduate)?

***What are our best experiences in later professional practice?

As participants? 

As faculty and program leads?

How can we refine and improve current training programs?

***Keep the best of what we do currently?

***What can we reduce, refine, or add to?

How can eLearning, and simulation augment current training programs?


***Deliberate practice

***Mastery training


***See one, do one, teach one

***On the job training

***Feedback and coaching

***Portfolios and ePortfolios

***Self reflection

***Mentorship and modelling

Video records for self reflection and feedback/coaching