How to teach clinical skills

David GoldbergInstitute of PsychiatryKing’s College, London

Advanced Course for Young Psychiatrists; Paris

December 2002

1. Traditional – modelling

2. Modelling on videotape

3. Special procedures on videotape

- psychotherapy

- neuropsychiatry

4. Role play - each trainee

- group method

5. Real interviews – each trainee

- group method

6. “My difficult patients”

- Role play by doctor

- Recordings

Two kinds of use of TV

Previously prepared videotapes; use role played patients

[always best if you make these; yourselves… own language, culture]

“Disposable TV”: real patients, recordings not kept

Previously prepared videotapesModelling on videotape

Special procedures on videotape

- psychotherapy

- neuropsychiatry

Role play - each trainee

- group method

Real interviews – each trainee

- group method

“My most difficult patients”

- Role play by doctor

- Recordings

Disposable televisionModelling on videotape

Special procedures on videotape

- psychotherapy

- neuropsychiatry

Role play - each trainee

- group method

Real interviews – each trainee

- group method

“My most difficult patients”

- Role play by doctor

- Recordings

Modelling

The traditional learning method

OK provided your teacher is any good

Probably slower than it need be

You may not see a wide enough range

Modelling on videotape

If there is a procedure that is difficult, but you have an excellent teacher, he or she can model it for many students – past and future!

Let us see an example of this – the neuropsychiatric examination, demonstrated by Professor Alwyn Lishman

The same learning package contains rare

syndromes:• Semantic dementia• anosagnosia of illness• Broca’s dysphasia• reduplicative para-amnesia• frontal lobe seizures• anosodiaphoria• prosopagnosia

Modelling on videotape

Psychotherapy is a complex procedure, that typically takes a long time to learn.

If the basic techniques – as microskills – are demonstrated for them, they can be persuaded to take on a case for supervision quickly after they start in psychiatry

Let’s see a therapeutic skill being modelled:

Problem solvingThis is a skill which we teach to GPs – and it is as good as antidepressants in mild depression. But it is also quite useful for young psychiatrists.

(This particular GP is fairly “directive” in her use of the technique)

Problem Solving Ask the patient to identify their MAIN problem

Ask them to think of possible solutions

Suggest any you can think of they haven’t mentioned

Prioritise the list; allow them to strike out impossible solutions

List advantages and disadvantages of each solution

Settle on their preferred solution: break it down into steps

They are to work on the first step of their preferred solution and report progress to you

Teaching Mental IllnessSkills to GPs

GPs need clinical skills not taught in Medical School

how to deal with u.s.s.

how to assess depression

how to assess early dementia

how to help chronic fatigue

……..and so on

Teaching Mental IllnessSkills to GPs

Let’s see an example of “Making the Link” between physical symptoms and life events

The PaperGoldberg, Gask & Sartorius ; 2002

• Why is a course necessary?

• Methods of teaching

• Planning your own course

Headings:

Knowledge deficits; unhelpful attitudes; skill lack

Modelling; role play; using videos; micro-skills

Managerial; course content; training teachers

The VideotapesGoldberg, Gask & Tylee ; 2002

• Depression• Unexplained somatic symptoms• Chronic fatigue• Psychosis• Dementia

Five programmes:

The importance of role play

you are teaching a skill, not imparting knowledge. (The only knowledge is the vocabulary!)

you can only learn to ride a bicycle by getting on one, and trying: and some friendly advice at this stage helps a lot!

feedback afterwards, sometimes followed by another try, helps to perfect what is learned

can be individual, or in front of a class the way the feedback is given is of critical

importance

The doctor or nurse

- is told what they knew about this patient before today, as well as what has been said until this point in the session.

In developed countries, the first of these in important – but it may not be in developing countries.

The purpose of this is to SAVE TIME during the role play

The patient

Is usually asked to be their own gender, and their own age.

They are told exactly what symptoms they have, that have caused them to seek care; and if necessary, what has happened up till now in the consultation.

They are sometimes told what they expect from the consultation, and what they think the problem is due to

The ObserverThis is a key role!

The observer MUST give feedback to the others at the end, about what they have seen.

They must be told exactly what they are looking for

Teaching communication skills to medical students

• Brief lecture-demonstration to provide students with a vocabulary of component parts

• Discussion triggered by videotaped interviews

• Modelling of new skills by watching video• Role-play• Video or audio-feedback.

Teaching skills to groups of medical students

• If students are provided with a checklist of desirable behaviours, they can be taught by the junior doctor on the unit

• He or she checks off the behaviours, and gives advice

One to one feedback for psychiatrists and GPs in training

This works very well, as student does not have to expose own faults to peers

- but it is too expensive in terms of the teacher’s time; and similar results can be obtained in group teaching

special steps must be taken to avoid persecution!

groups have advantage that peers, rather than the omniscient teacher, provide alternative strategies. This is much more acceptable

Teaching clinical skills to young psychiatrists

At beginning of term, psychiatrists are given a list of relevant behaviours

Each psychiatrist makes a recording with a real patient: 10 minutes for a brief history [signal] 10 minutes for a relevant mental state

Do not interview your own patients! To be admitted to the teaching, you MUST

have made a recording Videotapes are viewed in a weekly

feedback session with a teacher

Teaching clinical skills to young psychiatrists - 2

At beginning of term, psychiatrists are given a list of relevant behaviours

Each psychiatrist makes a recording with a real patient: 10 minutes for a brief history [signal] 10 minutes for a relevant mental state

before viewing, psychiatrist says how s/he felt the interview went; mentions any problems

Anyone can ask for the tape to be stopped

Teaching clinical skills to young psychiatrists - 3

BUT: critical comments are not allowed. Questions can be asked, and alternative strategies can be suggested

The teacher should always start by finding something positive to say about the doctor

Teacher stops tape to draw attention to both positive and negative things – but with the latter, asks how others handle these problems. Someone usually suggests more positive behaviours. Only as last resort, says “another way you can handle this would be to….”

Teaching clinical skills to young psychiatrists - 4

Doctor who carried out interview can be asked to role play handling the situation a different way, with teacher providing the patient cue for the role play.

The whole experience must be seen as positive and interesting, not persecutory. Potential teachers should undergo the experience themselves first!

For the teachers, this is always found an interesting experience. Never the same twice!

Who are your teachers?

A variety of teachers is a plus point. Students say that they learn different

things from different teachers. Psychotherapists should be asked to help,

as well as eclectic psychiatrists: each contributes different things to the teaching

Teachers can alternate, providing they check off what they have taught about each week, so that students receive teaching on a wide range of skills

Problem detection skills

Beginning the interview picking up and responding to verbal and non-verbal

cues Establishing a time sequence Demonstrating empathy, being supportive Asking about early childhood Taking a sexual history Eliciting views about the self Eliciting hallucinations Exploring delusions and over-valued ideasAssessing early dementiaAppropriate control of the interview Summarising and reflecting back

Problem management skills

Testing out hypotheses during personal history Making links “Framework giving comments” Negotiation Exploring health beliefs Motivating change in behaviour Problem-solving skills Interviews with informants Conjoint interviewing Provision of information/education Arranging follow up or when they next will see

you

“my most difficult patient”

You can either ask the doctor to bring a recording made with a patient who causes them great difficulty; or if this is impossible, ask the doctor to role play this patient, and ask another doctor to interview him or her.

Before beginning, ask for BRIEF details of the problem posed

This teaching is fun. Really!

Can this be done without TV?

Yes – but it isn’t quite so good, as visual images are compelling

Use ordinary Walkman, trainee records entire interview with real patient

Trainee must choose [beforehand] which excerpt to play

Trainee starts by saying what problems were; what had happened before excerpt begins

Guidelines for group video-feedback:

• Set an agenda• Set ground rules• Provide opportunities for new skills• Be constructive, never critical• Make group do the work!• Conclude positively!

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Set an agenda:

Clarify purpose of the session

Fill in background

Engage group in asking questions

What does person being shown want from group?

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Set ground rules:

Check whether person has seen video themselves; obtain their permission to go on

Ensure group realises this may be difficult for the doctor being shown

Anyone can stop tape - and say what they would have done

Ensure group realises this is a real consultation - thus, confidentiality

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Provide opportunities for learning new skills:

Stop the tape at key points; encourage others to stop it as well

Ask group to comment on what they have seen

- how do they deal with situations like this?

Label key skills yourself throughout

Invite person suggesting new skill to demonstrate it, becoming patient yourself and giving them a cue to start

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Make group do the work:

Facilitate the group, don’t demonstrate to them

Summarise suggestions and keep session flowing

Ensure group sticks to the agenda

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Conclude positively:

Summarise

Ask feedback from person being shown

Facilitate development of action plan for future consultation with this patient

Assist formulation of new ,earning goals

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