Let’s Talk About Hand Skills

A few years ago, my daughter sustained an injury while playing soccer and required a below-knee cast. The technician who applied the cast was an expert, and his performance was poetry in motion. He had our full attention throughout the encounter as he maintained a steady banter that included providing use and care instruction, answering questions, and sprinkling in humorous anecdotes. (“Don’t shove anything down your cast, including chocolate chip cookies. And yes, I’ve seen that!”) It would have been obvious to any casual observer that he was highly skilled in every aspect of the procedure, but his performance even held up to my more rigorous scrutiny. There was no wasted motion as he prepared the plaster bandage, applied padding, and molded splints and plaster rolls in place. To all appearances his focus was exclusively on the interaction with my daughter, and the physical tasks required little or no conscious thought or effort. O&P is a procedural discipline. Almost every patient encounter in O&P requires psychomotor skills, which we commonly refer to as hand skills. These skills require the coordination of “sensory information and muscular response when doing a given action,” and involve force, speed, and precision while completing fine motor and gross physical tasks. 1 Cognitive and affective domains of expertise, those involving thinking and feeling, respectively, are an essential part of providing O&P care, but almost all encounters also involve tasks in the psychomotor domain. As education standards have changed in response to the changing role of the O&P practitioner as a member of the healthcare team, increasing emphasis has been placed on the cognitive and affective domains of learning during initial education. To accommodate the realities of limited time, less educational focus is devoted to clinical and technical procedures that are performed less commonly. But those procedures may still be encountered in clinical practice. Some procedures and projects have been removed from accreditation requirements as clinical practice changes. Compared to prior generations, relatively less time is spent on tasks in the psychomotor domain to add those related to other aspects of clinical practice. Kids These Days A common criticism of recent O&P graduates and the schools that train them is that novice clinicians lack hand skills, and curricular changes are often cited as the cause. While occasionally these criticisms relate to interventions that are rarely provided, such as wood sockets (Yes, I’ve heard that!), others relate to skills that remain an integral part of O&P practice. In these cases, concerns about hand skills may be warranted, and ongoing, spirited discussion among experienced clinicians and educators is an important part of ensuring that educational practice is adequately preparing students for the real world. Some criticisms are based on interactions with a limited number of novice clinicians, and experienced clinicians may find that in some cases educators agree with their assessment. (Not every O&P student excels in every aspect of their education.) However, generalization about the hand skills of a generation without a mutual understanding of how to teach and assess them, or what characterizes expertise, provides little meaningful or actionable insight and is not likely be an accurate appraisal of the state of education in the profession. Improving our understanding of the role of psychomotor skills and how proficiency develops will contribute positively to the training of residents and junior clinicians and improve our effectiveness as educators and supervising clinicians. Candidate Ability and Skill Psychomotor ability refers to the capacity to learn psychomotor skills and is assumed by some teaching and learning experts to be relatively unchangeable. If this is true, the acquisition of psychomotor skills early in training will be more difficult for students with less innate ability, and lower performance can be expected to persist well past school and residency. Most applicants to O&P programs have stronger academic backgrounds and less practical experience than those in prior generations. It is possible that applicants to O&P schools possess above-average innate psychomotor ability that attracts them to a profession that requires it. However, less experience prior to school may leave applicants unaware of the rigorous psychomotor demands of the profession, without opportunity for their lower innate ability to be recognized, and with less opportunity to develop skills prior to beginning their education. For whatever reason, lack of innate ability or a lack of hands-on experience, educators and clinical supervisors will continue to work with graduates with less skill than they have in these areas. Some attempts have been made to screen candidates for psychomotor ability prior to admission into educational programs that involve procedural skills (e.g., dentistry and surgery). 1 Optimally, this type of assessment closely matches the specific demands of each profession. Even if we had such a test for O&P, the lack of validated qualitative and quantitative standards for proficiency in O&P complicates the prediction of future performance prior to beginning formal training. For the foreseeable future, we will be left with the challenges inherent in training students and residents who have had less experience in the field, some of whom have a lower level of natural aptitude. Understanding Skill Acquisition An accurate understanding of how skills are acquired can give helpful perspective. According to the conscious competence model of learning, individuals progress through stages defined by their competence and their awareness of it: unconscious incompetence, conscious incompetence, conscious competence, and unconscious competence. 2 The source of this model is uncertain, but the progression it describes appeals to our common sense. For example, most of us can recall different times in our experience of driving a car that appear to match each of these stages. A model proposed by Dreyfus and Dreyfus in 1980 describes learning as a progression through five levels: novice, advanced beginner, competent, proficient, and mastery (or expertise). 3 The initial levels of performance involve following rules with little thought for context, and proficiency and mastery involve intuitive decision-making and independent development of rules. In this model, “Expertise is characterized by a fluid performance that happens unconsciously, automatically, and no longer depends on explicit knowledge. Thus, the progression is envisaged as a gradual transition from a rigid adherence to taught rules and procedures through to a largely intuitive mode of operation….” 3 These models may accurately describe some aspects of learning, but they do not fully explain expertise in general and clinical mastery specifically. What truly distinguishes clinical and other types of experts from novices is their ability to integrate a variety of types of knowledge and skill to assess and treat complex problems. Experts can perform this much more easily, quickly, and effectively than novices, but their actions are not completely intuitive. Skills and Clinical Decision-making Adolfo Peña, MD, authored an insightful critique of applying the Dreyfus model in medical education. The model views expertise as an “immediate intuitive situational response” that “is ongoing and non-reflective,” and a fluid performance that “happens unconsciously, automatically, naturally.” 3 Peña counters that “medical educators have proposed a hybrid model where masters are highly intuitive as well as reflective: ‘the master is the practitioner who self-assesses and self-regulates and reflects in, on and for action.’” 3 In other words, clinical practice requires both implicit and explicit knowledge and skill. According to Peña, while the Dreyfus model defines expertise “almost exclusively in terms of implicit knowledge…a model that does not respect the complex and rich interaction between both domains of knowledge will have difficulty explaining skills that are not just routines but instead very complex tasks, i.e., finding solutions to problems.” 3 Burgess et al. echo this perspective and point out that “those that attain high skill levels do so because they continually reflect on their own performance.” 2 The challenge in O&P education is to help trainees develop a complex set of skills that involve these different types of knowledge. Providing a prosthesis requires a wide variety of skills while performing patient assessment, taking an impression, fitting, and alignment, each of which involves making clinical decisions as well as using our eyes and hands. The discussion between educators and clinical supervisors about educational priorities must include thoughtful perspectives about key questions such as: Which skills are most important to learn? How much emphasis should be placed on which aspects of clinical practice? Which important learning activities should be sacrificed for those that have more impact on early clinical performance? By the time they complete their education, many current O&P graduates have completed as many or more prostheses than graduates 30 years ago. Requiring them to fabricate and fit an exoskeletal transtibial prosthesis and multiple patellar-tendon-bearing variants would not match contemporary practice. Given the fact that providing multiple total-surface-bearing designs better prepares students for what they will encounter in residency, the lack of experience in exoskeletal designs appears to be a reasonable tradeoff. The same applies to the current focus on ischial containment socket designs at the expense of quadrilateral. Activities designed to teach clinical reasoning, rather than those that focus on hand skills, help students develop competency in this more demanding aspect of clinical practice. If students have the most exposure to common procedures and designs, they can develop proficiencies that are less common as they encounter the relatively small number of patients who require them. Teaching Clinical Skills In their 2020 article, Burgess et al. describe several frameworks for teaching procedural skills. According to the authors, “Common to most skills teaching literature is that skills are best learned by following a sequenced and stepped approach to teaching—whether a simple or complex task. However, most skills required in healthcare are complex, requiring more than seven skill elements, and are difficult to teach, learn, and retain.” 2 Most educator and clinical supervisors would concur. An educational approach that combines instruction in psychomotor tasks along with clinical reasoning and decision-making is a more effective way to teach clinical procedures, because it matches the way they will be performed in real life. However, this leaves less time for the multiple iterations required to develop proficiency in a wide range of psychomotor skills. According to Burgess et al., “Clinical skills, such as taking a patient history, performing a physical examination, [and] synthesizing and presenting data, require multiple cognitive and psychomotor skills. As such, clinical skills are more readily demonstrated than described.” 2 The multiple iterations and demonstration of skills that are necessary to achieve proficiency are only possible in the context of clinical practice. Students are likely to see more patients and provide more interventions of any particular type in one month of a busy residency than they did throughout their entire education program. The educational program establishes a foundation of understanding and skill, with residency being a more effective time for developing proficiency. Residency is a continuation of education that builds on the foundation established during school. By offering more supervision early, and increasing independence as residents demonstrate proficiency, clinical supervisors have the unique opportunity to blend educational and real-world objectives. The training during this period should be expected to have more impact on skill development and clinical proficiency than an educational program. Conclusion Skilled clinicians may not recall their own struggles and low performance during the learning process, a reality captured by the adage “The older I get the better I was.” Additionally, what appears to be unconscious competence in experts may actually be the ability to very efficiently process information, make decisions, and perform a task. If at any point during the application of my daughter’s cast I had asked the cast technician to describe what he was doing, it is likely that he could have clearly described both the task and the rationale for it. This level of performance is only possible after many years of experience and many iterations. O&P educators expect to encounter daily the challenges that come with teaching and learning clinical tasks. Clinical supervisors are faced with those same challenges while managing a full patient load, productivity demands, their own professional development, and reimbursement headaches. Discussions between these groups of dedicated professionals is essential to our progress as a profession. Together we have the opportunity to add education and real-world experience to innate ability and help novice clinicians become experts. Let’s keep the discussion going. John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center (NUPOC). He has over 30 years of experience in patient care and education. References Changiz, T., Z. Amouzeshi, A. Najimi, and P. Adibi. 2021. A narrative review of psychomotor abilities in medical sciences: Definition, categorization, tests, and training. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences 26. Burgess, A., C. van Diggele, C. Roberts, and C. Mellis. 2020. Tips for teaching procedural skills. BMC Medical Education 20(2):1-6. Peña, A. 2010. The Dreyfus model of clinical problem-solving skills acquisition: A critical perspective. Medical Education Online 15(1):4846.

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