(Welcome to Damian Roland our newest ICE blog author. – Jonathan (@sherbino)
By Damian Roland (@Damian_Roland)
A recent ICE Blog post tackled the theme of direct observation of clinical skills. I suspect we all empathized with the real world challenge of directly observing our trainees because of a perceived lack of time in the clinical workplace.
I use the term perceived deliberately, as I am unsure of any evidence suggesting that direct observation of learners is an impossible task. Of course, the intuitive argument is that if there are only two doctors providing direct clinical care, and one of them is observing the other, then you are cutting direct patient contact in half.
This is correct if we assume both clinicians are working with similar styles and efficacy. However, if the pairing involves a senior and junior clinician, the patient will have to be reviewed anyway. Perhaps seeing patients together may actually improve efficiency. (I suspect that this idea has not been tested (please let me know if it has!), but in my specialty of paediatric emergency medicine demonstrating the efficiency of direct observation would have a big impact on practice.)
Of course, direct observation is clearly not as simple (nor efficient) as I suggest. There are as many different clinical situations and confounders to observing clinical practice. It is why research and scholarship in this area is challenging (and why we like it so much!). I reflected on this recently when our program addressed a bulge in the number of trainee at times of the day when patient flow was lowest. This scheduling issue gives a great opportunity to observe practice, while allowing some freedom to explore different approaches.
One method I have been using is observing different clinical skills in different doctors during encounters with the same patient. This is especially useful in children presenting directly to our resuscitation room. One (or more doctors) are taken to the side and asked to observe. Another trainee is prepped as the ‘receiving’ clinician. The patient enters the room and I make a judgement on severity and need for any immediate intervention – obviously in some (rare) cases senior input is required immediately. If no life-threatening features are identified, I close the curtain around the patient, their family and the receiving clinician. I then ask the others doctors to describe what they have seen: approximate age, well or unwell, red flag features etc. It is amazing the first time you do this how little the observing doctors can describe about the patient. They don’t make that mistake again! Having highlighted salient points I direct my attention to see how the receiving doctor is getting on. In this way I have observed the clinical skills from a number of physicians, in a short space of time, while still keeping an overall handle on patient care.
Obviously, this is a very specific example and is not applicable to all specialties nor all clinical environments (e.g. ward, theatre, etc.). Although, there is a neat little open access article on other tips here.
I am finding I can use this approach when the department becomes busier, especially when medical students or interns are working. While not a panacea for all direct observation assessments, it is at least one small step in the right direction.
Medical education is not, and never has been, easy! I share my example in the hope others have personal practices they can discuss as well. Ultimately we need to find new ways to add value to the clinical observation of others. I suspect our available time is only going to get shorter.