Old Dog, New trick… teaching procedural skills

The news this week for me – I learned a new procedure!  Yes, after many years of doing things that I had learned and practiced I found myself in the situation where I could have a crack at something new.   This was an interesting experience for me because :-

  1. It has been a while since I tried to do something unfamiliar.
  2. It was an interesting exercise as a teacher to go back to being the novice, to feel the pressure of that moment.
  3. There is something deeply satisfying about acquiring a new arrow in one’s skills quiver
  4. I learned [from the inside] about how to better teach practical procedures.
  5. I was on the awkward side of the tension between letting the novice “have a go” and yet keeping the patient safe.

So what was this new skill?  I learned how to perform a subtenon eye block.  This is a relatively simple anaesthetic technique that appears to be quite dangerous and painful, but is actually not so bad.  If you want to see it in action… check out this clip from [edit: no ultrasound required!].  Simple enough to do, but requires the use of unfamiliar instruments, in a very sensitive part of the body with a patient whom is wide awake.

The big difference between my learning this skill and the previous learning in procedures such as epidurals etc [aside from about 15 years] was that I had a mental structure as to how I was going to make the most of my mentor’s availability to teach.  Having been exposed to the SETT UP technique, and trying to use it with my students it was great to be able to apply it to myself.

I basically used the 5-step technique described by George and Doto in 2001, with a bit of a FOAMed twist.  Here is the five-stage approach:

  • Conceptualisationthe learner must understand why it’s done, when it’s done, when it’s not done, and the precautions involved.

This can be pulled from any anaesthesia or ophthalmology textbook.  There is a list of indications, contraindications and the stuff you need to tell the patient before performing the procedure.  Review the basic sciences.  Anatomy is important to review as this is not an area most ED docs have to contemplate often.

  • Visualisationthe learner must see the skill demonstrated in its entirety from the beginning to end so as to have a model of the performance expected.

This is where FOAM comes in  – one can watch dozens of videos.  I watched it done by multiple practitioners, using a variety of techniques on a range of mammals (dogs, horses… all get cataracts).  The key is to see it done in multiple ways in order to get a feeling for the varied and acceptable techniques.  This is great for building confidence.

  • Narrationthe learner must hear a narration of the steps of the skill along with a second demonstration.

Once again – pop onto Google / Youtube or any of the great FOAMed resources.  There are plenty of narrated videos showing it stage by stage. However, the best narration occurs when your teacher performs it live with you watching.  Connecting the audio with the visual in the flesh seems to lay down the memory more effectively.

  • Verbalisationif the learner is able to narrate correctly the steps of the skill before demonstrating there is a greater likelihood that the learner will correctly perform the skill.

This step is important to do immediately prior to performing the skill.  Better than simple verbalisation is what Cliff Reid calls “cognitive simulation” – mentally rehearsing the steps in one’s head.  For this procedure I was holding imaginary scissors in my hand and rolling along an imaginary eyeball to rehearse the motor action involved.

  • Practicethe learner having seen the skill, heard a narration, and repeated the narration, now performs the skill.

Practice, practice and more practice.  I was lucky enough to be able to repeat the procedure six times in one day.  Importantly, I insisted that my teacher continue to observe my technique and provide feedback.  The old “see one, do one…” is a myth. Usually it is the little things – the tips that experts do automatically, and only recall when they watch a novice perform them.  One patient’s block was technically challenging and I was required to troubleshoot with my teacher.  This is probably one of the most crucial steps – learning what to do when the plan goes awry.

So after a day of being the novice I have developed a few insights.  In order to teach a procedure – we should be walking our student through the above stages in order to make the most of the opportunity and maximise the chances of the skill ‘sticking’.  Unfortunately,  in most places I have worked there is usually little deliberate practice or any of the steps above.  Certainly this is how I learned most of my skills – trial, error and quite bit of patient harm I imagine.

To teach a skill the ideal mentor should:

  • have mastery of the skill.
  • be able to perform the skill with confidence and clarity.
  • be able to articulate the subtleties of the technique
  • be able to deal with the complications and fix errors
  • have the patience to allow the learner to “faff”.  Faffing is how one develops the feel / touch required.
  • keep the patient calm and reassured.  Anxiety can be a real block to effective learning
  • be prepared to give practical, realistic feedback immediately after the task

So if you are a trainee – please be proactive when learning skills.  Simply waiting for somebody to teach you on an opportunistic basis is not ideal.  You need to have done steps 1, 2 and maybe 3 in your own time.  You need to be prepared to complete the steps when the opportunity arises on your shift.  Most importantly – become an active “cognitive simulator” – mentally rehearse your technique and steps to lay down the motor memory.

If you are a teacher of procedural skills – thank you!  I was very lucky to have a patient and confident mentor this week.  He allowed me to faff a little and feel safe.  Probably the thing that helped me the most during my supervised subtenon blocks was the kind voice beside me saying: ” great…  keep going… that’s it!” – simple words but they really help to build confidence.  Much more helpful than the silence we often observe in these tense moments.

Let me know if you have any pearls for teaching procedures.  What did your favourite teacher do that made the skills easy to learn?



  1. I like the encouragement and “good, good” comments from the mentor. I do this with students/registrars with the hopes that it 1. supports learner 2. Reassures the pt that I am happy with the care by the student

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