Clinical Skills Pearl Vol 2 (#4): What’s the best way to teach suturing and other procedural skills?

This "pearl" (previously known as a "muse") was contributed by Dr. K. Stobbe. It comes from Brydges, Carnahan, Safir and Dubrowski in Medical Education 2009, 43: 507-515. NOTE: this approach is meant for early learners – those with very little or no experience.
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We want our students to learn efficiently – i.e. the most learning in the least amount of time. We also want them to learn in a way that will stick – to retain their skills over time. The literature cites factors which can optimize the students’ learning, for both efficiency and retention. Self-guided learning and the setting of performance goals by students are more efficient and result in greater skill retention than traditional teaching.

What exactly is self-guided learning? Students first observe an expert performing the procedure, then are able to practice on their own, while being able to refer back to the expert performance when they wish (e.g. using a video). This is efficient – they learn the skill more quickly than traditional skills instruction.

Students who set their own goals retain their skills longer than those whose learning goals are set by the teacher. However they need guidance in setting goals, such as a list of what constitutes good performance. There are 2 general types of goals: outcome goals and process goals. It turns out that students who set process goals show greater skill retention than those who set outcome goals.

Here’s an example. When teaching suturing, outcome and process goals would look something like this:

• Outcome goals: Complete each interrupted suture and knot tie in a timely manner. Be sure to equally space the sutures, evert the skin edges, and ensure that every knot is square.

• Process goals: Needle is loaded on the driver 2/3 along the length and enters tissue perpendicular to the skin. Concentrate on hand pronation and supination when passing the needle through the tissue. Take the same size bite on each side of the wound. Ensure each throw is down square, either by having the sutures crossed, or by crossing your hands. Maintain appropriate tension on the tie.

How will this information affect my teaching of procedures for inexperienced students?

1. If a student has never seen the procedure performed, I’ll demonstrate it once, or tell them to view a video on-line.
2. Self-guided: I’ll ask the student what they want to focus on this time. I’ll restrict my feedback to the element the student’s interested in, unless they’re compromising patient care.
3. I’ll restrict my teaching comments to how they’re doing the procedure rather than the end result.

Dr. Karl Stobbe