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The
Veterinary Clinical Skills Literature Review and Western U-CVM Plan Lara
Marie Rasmussen, DVM The veterinary curriculum needs to ensure that students gain the requisite technical veterinary skills of an entry-level veterinarian. This statement generates two questions that need to be answered: what are these skills and how do we ensure learning of these skills? In today’s veterinary medicine, the breadth of potential clinical skills that a veterinarian may elect to perform is phenomenal-- everything from giving an injection into the tail vein of a mouse to performing a fetotomy. A special report in 1993 addressed this issue with regard to small animal surgery skills 1. A mail survey of private practitioners yielded lists of surgical procedures that were graded with respect to expected proficiency and ranked based on personal expectation of high proficiency. Undoubtedly many veterinary schools conduct their own in-house or local practitioner surveys to better define what is a required skill, and likely these “lists” vary by region, country, and era. Inherent to this question of what is a required skill is the question, Who decides what is a required skill? Is it the boarded specialist, the academician, the private practitioner, the public, a governing body, or a quorum of the aforementioned parties? The Ontario Veterinary College strives to answer these questions with the Professional Competencies of Canadian Veterinarians: A Basis for Curriculum Development. This thorough document establishes general objectives as well as specific tasks in which all entry-level veterinarians should have demonstrable competence. This competence includes the ability “to give or obtain appropriate veterinary attention for all species, in any circumstance, whether or not they (the veterinarian) are able to provide the attention themselves.” 2 In order to meet this ambitious objective, it seems we need to closely evaluate how we accomplish this goal. The
answer to this “how do we do it” question is multifactoral.
First, we as educators must understand what the individual
components of a complex skill actually are.
A skill can be broken down into its composite events.
Ex: riding a bicycle—stand
up, walk over to bicycle, hold bicycle with wheels directed forward, sit
on seat, place feet on pedals, balance, force pedals around axis of gears,
continue to direct front wheel forward.
Each event can be mastered without the confounding factors of all
the remaining events. To ask
someone who has never stood up to master balancing on a bicycle seat seems
ludicrous; they are too concerned with keeping themselves upright! A time-honored method employed in the manufacturing industry might be beneficial analogy in this setting when determining how to teach a skill. Assembly-line efficiency is improved by a method of task analysis; an entire task is observed repeatedly and broken down into its component parts. Then each component part is studied to improve its individual efficiency. Finally, when each component part is mastered on a small scale, the task is “reassembled” and overall efficiency has been shown to improve. 3, 4, 5 I would bargain that every educator has been witness to the scenario of a student faced with a monumental task, repeatedly failing, becoming frustrated, allowing the frustration to complicate the task further, and finally completing the task in a less than ideal manner after repeated attempts. The exemplifies the well developed cognitive domain (“head”) recognizing a poorly developed psychomotor domain (“hand”) and manifesting through an underdeveloped affective domain (“heart”).6 Unless we ensure the student has mastered the preliminary components inherent to a complex skill prior to attempting the complex skill, we set the student up for a frustrating and unrewarding experience. We actually encourage the undesirable qualities of impatience and frustration. Given that we are dealing with a diverse population of students, the outcome of this scenario is varied: for some this experience is an insurmountable roadblock to learning, for others hopefully a lesson in how not to teach if they should ever find themselves in such a position . After this disassembly, we must provide “hands-on” experience and instruction with these basic components of the many complex skills required of entry-level veterinarians. The degree to which we must “revert to the basics” will depend primarily on our audience, the students. General dexterity and common sense will vary immensely within this large, diverse population. Additionally, today when entrance requirements do not demand technical expertise7 and candidates are potentially being admitted earlier in their academic careers, we can not expect entering students to have a high degree of veterinary technical experience. The following is an example of the castration of a dog (skills involved with maintenance of anesthesia have been omitted.) This complex skill is broken down into stages and then each stage is further broken down into individual components or tasks that must be mastered to accomplish the parent skill—castration—properly. When these mastered components are combined with a working knowledge of pertinent anatomy and the “recipe” of a castration, the likelihood of a successful outcome for the student and the animal is high.
Castration:
dog Restraint: hand stamina, animal rapport, animal behavior, “inside voice”, +/- coordinated efforts Injection: identifying site, drug calculation, syringe handling IV access: asepsis, catheter handling, fluid set-up, coordinated efforts Induction: drug calculation, syringe handling, catheter handling, titration-to-effect, coordinated efforts, “inside voice” Intubation: judge tube size, multiple hand maneuvers simultaneously, cuff inflation, transfer of responsibility Preparation: asepsis, positioning, skin prep, self-prep, gown/gloving, pack preparation, autoclave management, sterile field maintenence Incision: instrument handling, scalpel blade depth, tissue handling Scrotal ligament: controlled strength Ligate: Instrument handling, suture handling, tissue dissection, controlled strength, emergency preparedness Close: Instrument handling, suture handling, tissue handling Recovery: Transporting animals, +/- restraint, +/- rapid administration of IV/IM drug, clean-up Given this list of individual tasks or skills to master, then how do we as educators accomplish this. The solution for some components are intuitive and measurable: hand stamina—have the student repeatedly exercise the hands in scenarios likely to replicate the actual skill (ex. play tug-o-war for 5 minute intervals with a towel using only one hand positioned in a typical “scruff”-holding position; this would mimic scruffing a difficult dog during administration of premedication.) For some students this training will be unnecessary (even laughable), for others, perhaps essential to their personal safety! Other components have solutions that are less easily visualized: cooperative efforts—require students to work together toward a common goal (ex. a simple example would be to have 2 students alternate stacking blocks and stage a competition judged on speed and accuracy; this would mimic 2 students restraining a dog for IV catheter placement and IV induction.) The students must learn subtle visual and verbal skills to accomplish a desired task efficiently. Likely the most appreciated solutions are those that directly mimic the real environment: sterile field maintenance—make the student aware of their body relative to their surroundings [ex. Have the student prepare themselves in surgical attire, then require them to navigate a replica operating room that is wired to signal (lights, noises) when sterile technique is broken (sterile glove touches non-sterile object); this can be made more challenging by adding in distracters (verbal questions requiring calculations, etc.) as the student continues the navigation of “the maze.” Several
veterinary studies, with a focus on small animal surgery 8-16,
have touched on this issue of teaching the basic components of a complex
skill through repeated practice in a non-threatening environment prior to
attempting the final complex skill. All
studies found that practice, removed from the actual procedure, resulted
in similar and in some aspects superior performance, compared to those
simply attempting the procedure itself.
Once the individual components of a complex skill are mastered, we can then bring them together slowly and appropriately. Concurrent with this “assembly” of the skill, is the integration of the cognitive and affective domains with the psychomotor domain. First, attempt assembly of a simple task in a non-stressful environment where the consequences of failure are minimal to absent. An example would be completing the skill “Intravenous catheterization” on a plastic model or robotic simulator. The mastered manual dexterity components allow smooth transition to the composite skill; the student is neither frustrated nor fearful of moving forward in the learning process. The next step is to increase the complexity of the composite skill in the same non-stressful environment. For example, running a mock surgical procedure on an inanimate model allows the addition of time- and sequence-critical events and multiple minor skills (catheterization, aseptic preparation, etc.) to the milieu. The lack of failure-consequences continues to allow learning and refinement of skills without fear or anger as is often evident from students in highly stressed learning situations. As the students progress and master each assignment, the skills can be offered in arenas with added risks, for example setting-up for and observing a procedure or scrubbing-in and assisting with a surgical procedure. Obviously adhering to the time course from simple procedures to complex procedures makes the most sense. The next leap of learning in clinical skills is doing the procedure oneself with close supervision and strict “safety” guidelines, again with simple to complex skills progressing over time. And the final enormous step in learning is “flying solo”. It has been observed that the percentage of successful “solo flights” when performing certain skills can be increased from 40-50% to 100% with this gradual and patient approach to learning clinical skills. 17 A
final component of the “How to teach” answer is motivation; “cracking
the whip” only goes so far with adult learners.
We as teachers must be the coaches and cheerleaders.
We must show them the road to learning.
Frankly, the key is that we must be the experts in not only
veterinary medicine but education as well.
Johnson and Farmer15 found that through observation and
critique of several clinical skills laboratory settings, the most ideal
and successful structure could be determined.
Factors included clearly stated objectives, obvious clinical
relevance, and appropriate tasks for given levels of skillfulness.
Other components essential to motivating learners in technical
training, as stated by Blackwood, are checklists, procedures, end goals
and adequate materials.
A factor that she finds critical to achieving self-directed
learning in mandated programs is that of making sure the learner is fully
aware of the benefits of the skills training, negative and positive,
tangible and intangible. Also,
allowing multiple forms of delivery, offered at all hours, with easy
access to students will create situations where students may practice a
skill simply because it is in easy reach.18 Our plans for technical skills curricular development here at Western University of Health Sciences include seven steps. First we will establish the list of mandatory skills required of a 3rd year student entering clinical practice and of a graduate veterinarian. (See attached checklists). Second, we must critically analyze these skills to break them down into their essential components/individual tasks. Third, we will develop means and methods with which to train students. The goal is to have these methods take on a variety of forms to satisfy the needs of a diverse population of students and skills. Fourth, we must develop means by which to test or confirm mastery of these mandatory skills to protect the individual, the public and the profession from incompetence. Fifth, we must critically evaluate the training methods to ensure that they will indeed meet the objectives. Sixth, we must adequately train the trainers in the topics to be covered and the realistic expectations they should have for the students. Seventh, we must develop and institute curricular outcomes assessments for the short term (year to year) and long term (class to class, new graduates, etc.) The first two years will be dedicated to mastering the majority of the mandatory skills. A major player in this skills curriculum, the Psychomotor Proficiency (PMP) Facility, will be a dynamic, innovative learning center with extensive student availability (open 18-24 hours/day.) The colloquial name will be the Town PuMP relying on the historical connotation of the central, daily meeting place for a community. The goal will be to create an exciting, fun, interactive, comfortable, yet demanding and intellectually stimulating environment. In keeping with our goal of learner-centered learning, the skills curriculum will be largely self-directed. Given that these skills are mandatory, there will be an academic infrastructure and established expectations within which students make choices on how they learn these required skills. The content of the skills curriculum will change frequently to coincide with the Problem Based Learning cases and live-animal experiences. After achieving a designated level of mastery in a given skill, a student will move on to application of this skill to the live animal where appropriate. This skills training program will by dynamic, relying on education data, outcomes assessments, student critiques, and practitioner critiques, etc. to spur evolution within the curriculum. The supporting evidence for individual portions of this curricular design is strong within veterinary medicine and without. What remains is a “clinical trial” of the hypothesis that this veterinary clinical skills curriculum, integrated with the unique PBL format of learning, will effectively “produce” veterinary graduates adept in the mandated skills. “Whenever introduced, a new technologic advance has been initially rejected or feared: rejected because of the belief that it could not work as well as existing devices; feared because of the suspicion that it might.” -- Feinstein Bibliography 1. Johnson, A.L., Greenfield, C.L., Klippert, L., Hungerford, L.L., Farmer, J.A., Siegel, A.: Frequency of procedure and proficiency expected of new veterinary school graduated with regard to small animal surgical procedures in private practice. JAVMA 202(7); 1068-107, 1993. 2. Professional Competencies of Canadian Veterinarians: A Basis for Curriculum Development. DVM 2000. Ontario Veterinary College. University of Guelph. 1996. 3. Schroeder, R.G.: Operations Management: Decision Making in the Operations Function. pp. 467-488. McGraw-Hill Book Co., New York. 1981. 4. Rice, R.S.: Survey of Work Measurement and Wage Incentives. Industrial Engineering 9(7): 18-31, 1977. 5. Yelle, L.E.: The Learning Curve: Historical Review and Comprehensive Survey. Decision Sciences 10(2): 102-105, 1979. 6. Lippert F.B., Farmer J.A.: Psychomotor Skills in Orthopedic Surgery. Williams and Wilkins, Baltimore, Maryland, 1984. 7. Veterinary Medical School Admission Requirements in the United States and Canada. Association of American Veterinary Medical Colleges. Purdue University Press, West Lafayette, Indiana, 1999. 8. Greenfield, C.L., Johnson, A.L., Schaeffer, D.J., Hungerford, L.L.: Comparison of surgical skills of veterinary students trained using models or live animals. J Am Vet Med Assoc 206(12): 1840-1845, 1995. 9. Holmberg, D.L., Cockshutt, J.R., Basher, A.W.P.: Use of a dog abdominal surrogate for teaching surgery. J Vet Med Ed 20(2): 61-62, 1993. 10. Van Camp, S.D., Hunt, E.L., Whitacre, M.D.: Teaching with a standing bovine cadaver: An alternative approach. J Vet Med Ed 15(2): 56-57, 1988. 11. DeYoung, D.J., Richardson, D.C.: Teaching the principles of internal fixation of fractures with plastic bone models. J Vet Med Ed 14(1): 30-31, 1987. 12. Pavletic, M.M., Schwartz, A., Berg, J., Knapp, D.: An assessment of the outcome of the alternative medical and surgical laboratory program at Tufts University. J Am Vet Med Assoc 205(1): 97-100, 1994. 13. Olsen, D., Bauer, M.S., Seim, H.B., Salman, M.D.: Evaluation of a hemostasis model for teaching basic surgical skills. Vet Surg 25: 49-58, 1996. 14. Smeak, D.D., Hill, L.N., Beck, M.L., Shaffer, C.A., Birchard, S.J.: Evaluation of an auto-tutorial-simulator program for instruction of hollow organ closure. Vet Surg 23: 519-528, 1994. 15. Johnson, A.L., Farmer, J.A.: Evaluation of traditional and alternative models in psychomotor laboratories for veterinary surgery. J Vet Med Ed 16(1): 11-14, 1989. 16. Bauer, M.S., Glickman, N., Glickman, L., Toombs, J.P., Bill, P.: Evaluation of the effectiveness of a cadaver laboratory during a 4th-year veterinary surgery rotation. J Vet Med Ed 19(3): 77-84, 1992. 17.
Personal communication.
Walshaw, S.O. University
Laboratory Animal Resources. Michigan State University.
East Lansing, MI. 18.
Blackwood, C.C.:
Applying self-directed learning principles in the technical
training of a high-risk industry. Eds.
Hiemstra, R. and Brockett, R.G. Overcoming
Resistance to Self-Direction in Adult Learning.
New directions for adult and continuing education
No. 64. Jossey-Bass
Publishers. San Francisco,
California, 1994. pp47-54.
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