For many years clinical medicine and dentistry were taught by the principle of ‘See one, do one, teach one’. The inception and use of simulation within clinical teaching and learning has allowed students to confront their anxieties within a safe environment, while 434 ❘ Teaching in the disciplines
providing the teacher with a regulated, reproducible teaching arena. The simulated element will most commonly refer to materials, actors and role play.
A clinical skills centre or laboratory is incorporated into the infrastructure of most medical and dental schools in the Western world. Most now incorporate high-fidelity and virtual reality simulators, as well as SDL and CAL facilities. We found (at a medical school at which we both worked) that the employment of a dedicated skills teacher revolutionised the use and potential of the centre, as have others (e.g. at the University of Leeds Medical School (Stark et al., 1998)).
Peyton, a general surgeon, describes an excellent, and widely advocated, model for teaching skills, in simulated settings and otherwise, known as the ‘four-stage approach’.
Stage 1
Demonstration of the skill at normal speed, with little or no explanation.
Stage 2
Repetition of the skill with full explanation, encouraging the learner to ask questions.
Stage 3
The demonstrator performs the skill for a third time, with the learner providing the cue and explanation of each step and being questioned on key issues. The demonstrator provides necessary corrections. This step may need to be repeated several times until the demonstrator is satisfied that the learner fully understands the skill.
Medicine and dentistry ❘ 435
Interrogating practice
• How does the NHS of today influence the way students observe and learn clinical skills?
• How does the learning environment of the clinical skills centre differ from that of the clinical arena?
Interrogating practice
If you are not already using it, how could you adapt Peyton’s four-stage approach to your own (simulated or non-simulated) clinical teaching?
Stage 4
The learner now carries out the skill under close supervision, describing each step before it is taken (adapted from Peyton, 1998: 174–177).
This model may be expanded or reduced depending on the background skills of the learner. Digital/video recording may be used in stages 1 and 2. As in all teaching, the learner should be given constructive feedback and allowed time for self-appraisal, reflection and practice of the skills. Within the medical clinical skills centre, particularly in SDL, we have found the use of itemised checklists useful adjuncts to learning, particularly for the novice.
Simulation
Role play is an extremely useful teaching and learning tool. Students are able to inves- tigate, practise and explore all sides of a clinical interaction through their adopted roles;
these advantages may need to be pointed out to the student. Criticisms of this technique are usually a product of poorly prepared sessions. Clear roles, with demonstration by teachers, or using preprepared videos/DVDs, are useful ways of directing student learning. Providing a supportive but quite formal environment during the sessions also encourages students to maintain their role. Prewarned, with adequate debriefing and reflection, the students usually find this a useful technique.
Simulated patients (SPs)were first used in the 1960s; their use in dental and medical undergraduate and postgraduate education has expanded rapidly since the 1980s (Barrows, 1993). They may be used instead of real patients in difficult clinical scenarios (e.g. breaking bad news and in the reproduction of acute problems that would not be assessable in traditional clinical examinations). In North America, and more recently in the UK, trained real patients (patient as educator programmes) are increasingly used (e.g.
in the UK at the Sheffield University and King’s College London – see references), including in training and assessing intimate clinical procedures such as vaginal speculum or breast examination. In dentistry, SPs are principally used for communication skills training and in assessment (Davenport et al., 1998).
Simulation of clinical scenarios has become increasingly sophisticated. Within the safety of this setting, students can express themselves more freely while investigating the patient perspective through the eyes of the actors. The teacher must provide a clear brief for both actor and student, including detailed background scripts for the actors (see Case study 2 in Chapter 2). It is important that students feel reasonably comfortable in their given role and that the scenario is within their expected capabilities. Clear student learning objectives/outcomes are required at all stages, but excessive demands and expectations are often counterproductive. The simulation of clinical procedures and communications skills at the same time, in settings as near to the real as possible, is of increasing interest; this type of simulation also adds to realism/complexity in assessment 436 ❘ Teaching in the disciplines
(Kneebone et al., 2006a, 2006b). Even at undergraduate level, assessing simple clinical skills in isolation in simulated manners is unlikely to adequately prepare students for practice in the real world.