Welcome to Part 3 of 4 of our resident education series. Part 1 described some philosophical issues about general residency education structure, while Part 2 delved more specifically into best practices for journal clubs. Today, let’s continue this series by reviewing some ideas for clinical and surgical training. What methods can help us optimize training for our residents?

Clinical Training: Downplayed in Resident Education

It’s not a sexy statement, but it’s true that the majority of podiatric practice occurs in the clinic rather than the operating room. Most podiatrists spend somewhere between 50% and 80% of their time in the clinic. As such, this is a highly important aspect of residency training that receives somewhat less emphasis than the surgical side. Consider that the current requirement of 75 biomechanical encounters is rather small compared with the 400 total surgical case minimum, especially since biomechanics should play a very important role in most aspects of lower extremity care. With that in mind, let’s focus on the nonsurgical side of training.

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“The majority of podiatric practice occurs in the clinic rather than the operating room”

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A Pyramid of Training

The typical clinical training experience is reasonably consistent across the country. The residents see some number of patients, present information to an attending, answer various questions - sometimes in a Socratic manner - and then treat the patients. This is repeated until the clinic ends. How much education the resident obtains will depend on how good a teacher the attending is and how much reading the resident does after clinic is over. A variation on this theme is the hospital-based bedside rounds, during which residents present their patients to an attending, and a discussion occurs about the patients - in some cases involving the patients themselves, but mostly speaking about rather than to the patients.

To make clinical teaching more effective, it is helpful to think of our trainees in terms of a continuum of learning. Miller’s triangle of clinical competence provides a clear and concise way to think about this. Starting from the base toward the peak this runs as follows:

Clearly, we have knowledge at the bottom of the pyramid and action at the top of the triangle. “Knows” relates to a novice’s basic understanding of a concept, while “knows how” involves the interpretation of knowledge (ie the trainee knows how to do something but can’t actually do it yet). The more advanced “shows how” is seen through a demonstration of learning in a simulated or objective structured clinical examination (OSCE) standpoint, and “does,” relates expertise integrated into actual practice. It is highly useful to understand where a trainee lays in this continuum so the educator can help move the trainee along.

In some ways, this is the easiest aspect of resident training because it lends itself to some easy assessment steps:

During my own teaching encounters, I commonly come across a problem we might call the “Heisenberg Teaching Uncertainty Principle.” You might recall the Heisenberg Uncertainty Principle is a quantum physics concept that states that the act of observing a process changes that process. The Heisenberg Teaching Uncertainty Principle says that an attending physician’s presence in the room will affect how the trainee will perform. You’re watching so they try to impress you (or at least not their natural selves). Have you ever tried to listen first hand to one of your residents obtaining a history from a patient? I can bet it would be different without you in the room!

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“The Heisenberg Teaching Uncertainty Principle says that an attending physician’s presence in the room will affect how the trainee will perform”

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Another problem is that we cannot be there to witness every skill performed by all of our trainees. There must be a certain level of trust, except it must be “verified trust.” This was brought home to me recently when I watched a video of one of my trainees applying a compression bandage for a venous leg ulcer (my residents are making videos to help teach the Western University students). The trainee made a lot of errors, and at first I was frustrated (mostly because my patient actually left with a poorly applied bandage). Then I realized the educational potential of these videos: I could “observe” a trainee in action without actually being there.

Here’s the plan for my new assessment and feedback method, which I will institute at the start of the upcoming academic year. If any of you think this might be a good idea, please feel free to use it. Write in to the PRESENT Podiatry eTalk and give us your feedback.

My New Assessment and Feedback Method of Teaching Residents

Each resident will be given a checklist of clinical skills that they will be required to have recorded by someone else. The resident will demonstrate the particular skill and then forward the video to me. We will then watch the video, while I provide feedback at my leisure. The resident then practices that skill in future clinics and later again records their performance of that same skill. This begins to move the assessment into the competency realm rather than simply believing they can do something because they’ve done it X number of times. Essentially, it is an ongoing OSCE skills examination. I have attached a document containing both the skills checklist and accompanying grading rubrics for some of the skills here so you get the gist. You’ll note the rubrics are mostly surgical, which can also be added to this method. Change the checklist at will to make yours better!

It’s important to note that these videos must remain HIPAA complaint, so be sure to consider that if you attempt this method. You should also consider the medicolegal ramifications. I suggest having the patient sign a consent to images and video form, and let them know they may receive call backs if something viewed was of potential harm to the patient.

For those of you who use database or cloud storage for your residencies, you might also consider setting up shared files to have the residents submit their videos so you don’t receive 100 extra emails.

To round off this topic, here are some other suggestions for clinical training from the medical education literature.

Despite how you like to teach, a common theme from the educational literature is the importance of understanding the knowledge and skill level of your trainees. In that way, you can tailor your teaching to that person in the most efficient way and provide the most effective and constructive feedback. Next week, we’ll wrap up this series on resident education with thoughts about teaching surgery.