Cover: Biosorption for Wastewater Contaminants by Rangabhashiyam Selvasembian and Pardeep Singh

Veterinary Clinical Skills


Edited by


Emma K. Read, DVM, MVSc, DACVS

College of Veterinary Medicine, The Ohio State University

Columbus, OH, USA

Matt R. Read, DVM, MVSc, DACVAA

MedVet, Worthington, OH, USA

Sarah Baillie, BVSc, PhD, MRCVS

Bristol Veterinary School, University of Bristol

Bristol, UK






Logo: Wiley

Acknowledgments

This work would not have been possible without the contributions of many colleagues with whom we have worked over the years. We are grateful to the efforts of so many talented instructors and staff members in making our clinical skills training programs a reality. We are also delighted to have had the opportunity to watch our learners grow and mature into competent and caring practitioners. Thank you to them for taking care of the profession, animals, and their owners on a daily basis. Your work is difficult and vitally important.

We would also like to recognize the team at Wiley, specifically Erica Judisch and Merryl Le Roux. We have enjoyed working with you and appreciate your tremendous support on this project since from the beginning.

Emma

Thanks to my parents and family members who always supported me and helped me to achieve my career aspirations by encouraging me to work hard and seek out broad opportunities to learn. Thanks to my husband Matt for his unfailing support of all my projects and dreams, and for being my rock along the way.

To our co‐editor, Sarah, a special thanks for being such a wonderful collaborator and friend over the years. We feel very fortunate to have met you and have really enjoyed working with you ever since.

To Grace and Kate, thank you above all else. You are the light of our lives. Words can't express the love we have for you or our admiration for the people you are. Your patience with our many work hours, projects, and life changes are so appreciated. We love you with all our hearts. Chase your dreams with all your being – we are here for you!

Matt

For my incredible wife, Emma, for having the vision and passion to create this book despite everything else going on around us. I learn something new from you every single day. But enough with the summative assessments already!

For our two daughters, Grace and Kate. I am looking forward to again using evenings and weekends for the things you want to do! You are simply amazing and I am so thankful to be your dad.

And to my parents and friends who have supported and helped me through thick and thin. Life can be hard, but you make it easier.

Sarah

Thanks to Emma for inviting me to join this project, it is one of many we have collaborated on over the years. It has been a pleasure as always. Thanks to my husband John who is so supportive in so many ways in all my endeavors at work and at home. And finally this book, and my ongoing enthusiasm for “all things” clinical skills, wouldn't be such fun without all the help from my colleagues in the clinical skills lab team at Bristol.

List of Contributors

Stacy L. Anderson
College of Veterinary Medicine
Lincoln Memorial University
Harrogate, TN, USA

Elizabeth Armitage‐Chan
LIVE Centre, Department of Clinical Sciences and Services
Royal Veterinary College
Hatfield
UK

Sarah Baillie
Bristol Veterinary School
University of BristolBristol, UK

Teresa Burns
College of Veterinary Medicine
The Ohio State University
Columbus, OH
USA

Alison Catterall
Bristol Veterinary School
University of Bristol
Bristol
UK

Kate Cobb
School of Veterinary Medicine and Science
University of Nottingham
Sutton Bonington
UK

Sarah Cripps
School of Veterinary Medicine and Science
University of Nottingham
Sutton Bonington
UK

Marc Dilly
Faculty of Veterinary Medicine
Justus Liebig University Giessen
Giessen
Germany

Robin Farrell
UCD School of Veterinary Medicine
University College Dublin
Dublin
Ireland

Andrew Gardiner
Royal (Dick) School of Veterinary Studies
University of Edinburgh
Scotland
UK

Rachel Harris
Bristol Veterinary School
University of Bristol
Bristol
UK

Jennifer Hodgson
Virginia‐Maryland College of Veterinary Medicine
Virginia Tech
Blacksburg, VA
USA

Steven Horvath
College of Veterinary Medicine
The Ohio State University
Columbus, OH
USA

Julie A. Hunt
College of Veterinary Medicine
Lincoln Memorial University
Harrogate, TN
USA

Keshia John
School of Veterinary Medicine
St. George's University
Grenada
West Indies

Jennifer T. Johnson
College of Veterinary Medicine
Lincoln Memorial University
Harrogate, TN
USA

Rikke Langebæk
Department of Veterinary Clinical Science
University of Copenhagen
Copenhagen
Denmark

Rachel Lumbis
Royal Veterinary College
Hatfield
UK

Susan M. Matthew
Department of Veterinary Clinical Sciences, College of Veterinary Medicine
Washington State University
Pullman, WA
USA

Missy Matusicky
College of Veterinary Medicine
The Ohio State University
Columbus, OH
USA

Catherine May
Faculty of Veterinary Science
University of Pretoria
Pretoria, South Africa

Tatiana Motta
College of Veterinary Medicine
The Ohio State University
Columbus, OH
USA

Máire O’Reilly
University College Dublin
Dublin
Ireland

Carolina Ricco Pereira
College of Veterinary Medicine
The Ohio State University
Columbus, OH
USA

Megan Preston
College of Veterinary Medicine
Lincoln Memorial University
Harrogate, TN
USA

Lindsey Ramirez
College of Veterinary Medicine
Lincoln Memorial University
Harrogate, TN
USA

Emma K. Read
College of Veterinary Medicine
The Ohio State University
Columbus, OH
USA

Matt R. Read
MedVet
Worthington, OH USA

Alfredo E. Romero
Faculty of Veterinary Medicine
University of Calgary
Calgary, Alberta
Canada

Elrien Scheepers
Faculty of Veterinary Science
University of Pretoria
Pretoria, RSA

Jennifer Schleining
College of Veterinary Medicine & Biomedical Sciences
Texas A&M University
College Station, TX
USA

Lucy Squire
Bristol Veterinary School,
University of Bristol
Bristol
UK

Jean‐Yin Tan
Faculty of Veterinary Medicine
University of Calgary
Calgary, Alberta
Canada

Abi Taylor
College of Veterinary Medicine
North Carolina State University
Raleigh, NC
USA

Sheena Warman
Bristol Veterinary School,
University of Bristol
Bristol
UK

Catherine Werners
School of Veterinary Medicine
St. George's University
Grenada
West Indies

Lissann Wolfe
School of Veterinary Medicine
College of Medical, Veterinary & Life Sciences
University of Glasgow
Glasgow
UK

Preface

Our original vision for this book was to try to collate the content of many years of conversations that we have had with colleagues and students about Clinical Skills teaching and learning into a single, useful resource. Many of those discussions centered around what is known about how to teach and learn better – in essence, where to spend one's precious time, effort, and resources in order to see the best returns. To this end, we wanted to create a book that would appeal to both instructors and students and provide a broad overview of what is already known about teaching and learning Clinical Skills for those starting out so they had a good base from which to take the leap.

We have been fortunate to help institute modern clinical skills training programs into our own institutions at a time when they were just beginning to be implemented across veterinary medicine. In the early days, we learned by trial and error by adapting “hard knocks” lessons we had learned in private practice to our academic learning environments. As programs evolved, so did the research that proves that there is value in learning how to use best teaching practices to inform Clinical Skills instruction. However, even though so much has been published, clinical skills instructors are a generous group and much of the sharing of information still tends to be open source or available by simply asking a colleague. Websites, conferences, and Zoom calls all serve as a means for sharing what we have learned, making sure that someone else does not have to reinvent the wheel.

The basis for this book is that, despite all of the sharing of ideas and best practices that has occurred to date (or maybe as a result of it!), it can still be challenging for instructors and students to review what has been documented about teaching and learning Clinical Skills in one concise place. New instructors often feel overwhelmed with all there is to know about teaching and assessment and, although many teachers may not be new to veterinary medicine or to teaching Clinical Skills, it is the evidence‐based teaching of others that is novel and challenging. Students tackling clinical skills training are often overwhelmed with where to begin and how best to practice the huge volume of skills and procedures that a veterinarian needs to be able to perform following graduation. Although handbooks have been published that list skills and explain “how to” perform a variety of procedures, a concise reference that summarizes all that is known about teaching, learning, and assessing clinical skills all in one place has still been missing.

We hope that this book helps point newbies of all types in the right direction while also serving as a go‐to reference for experienced teachers. The enthusiasm and dedication to clinical skills training is as evident now as it was when it started over 10 years ago and we are immensely grateful to all of the authors who participated in this project and shared their expertise and experiences so openly. Together, we look forward to further innovations that will make even more confident and competent day‐one graduates who will be better prepared to treat the animals in their care.

About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/read/veterinary image

There you will find valuable material designed to enhance your learning, including:

  • Appendices 1 and 2 from the book as downloadable PDF

1
What Is a Clinical Skill?

Emma K. Read1 and Sarah Baillie2

1 College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA

2 Bristol Veterinary School, University of Bristol, Bristol, UK

Historically in veterinary medicine, degree programs have been based upon the Flexner model described in medical education, with two basic blocks: two to three years of preclinical training and one to two years of clinical training (Flexner, 1910). Approximately 10–15 years ago, a trend developed in veterinary education to include more hands‐on training during veterinary programs, often beginning in the start of the first year, with an emphasis on teaching day‐one skills necessary for success in practice (Hubbell et al., 2008; Doucet and Vrins, 2009; Welsh et al., 2009; Smeak et al., 2012; Dilly et al., 2017 RCVS, 2020;). The idea of moving clinical training earlier in the program and further emphasizing integration of knowledge and other skills into the clinical workplace led to current veterinary programs being more like two inverse wedges rather than two blocks placed one on top of the other as separate units of the same program (Figure 1.1).

Formal veterinary clinical skills training programs, which emphasized the use of models and simulators and constructed dedicated clinical skills centers for teaching, began in the early to mid‐2000s as a way to accommodate this need for earlier training (Baillie et al., 2005; Scalese and Issenberg, 2005; Pirkelbauer et al., 2008; Read and Hecker, 2013; Dilly et al., 2017). Reports of objective structured clinical examinations (OSCEs) that are used to assess learners' hands‐on skills, and descriptions of best practices for implementing skills curricula, began to follow (Smeak, 2007; Rhind et al., 2008; May and Head, 2010; Hecker et al., 2010; Read and Hecker, 2013; Dilly et al., 2017).

Concurrently, over the last 10 years, there has been a recognition of the need to incorporate more professional skills training (NAVMEC, 2011; Cake et al., 2016). Today's employers are not only searching for confidence and technical competence in new graduates but good communication abilities as well (Perrin, 2019). Rather than simply being competent in one's hands‐on skills alone, effective integration of professional communication and technical skills performance is crucial for successful practice (NAVMEC, 2011; Rhind et al., 2011). Other “marketable skills” described in a recent report of the characteristics most often sought by employers posting job advertisements in the United Kingdom included enthusiasm, special interest, communication, all‐rounder, client care, team player, autonomous, caring, ambitious, and high clinical standards (Perrin, 2019). These “skills” are important to employers and are key to minimizing dissonance and dissatisfaction for the graduates as well (May, 2015; Perrin, 2019).

Schematic illustration of Flexner model versus the more recent curricular models that are more like inverse wedges introducing clinical content earlier into the start of the curriculum.

Figure 1.1 Flexner model (with separation between preclinical and clinical blocks) versus the more recent curricular models that are more like inverse wedges introducing clinical content earlier into the start of the curriculum.

The Royal College of Veterinary Surgeons (RCVS) Day One Competences and the American Association of Veterinary Medical Colleges’ (AAVMC) North American Veterinary Medical Education Consortium (NAVMEC) report are both recognized as early frameworks that defined competencies across a number of areas that lead to graduate success (NAVMEC, 2011 RCVS, 2020;). More recently, there have been other developments toward employability of new graduates and improved teaching of professional skills. The VetSet2Go project represents an international collaboration of educators (https://www.vetset2go.edu.au), who surveyed employers, clients, new graduates, and other stakeholders before combining this information with what was already published in the literature. The resulting white paper and framework have been used to guide development of resources, as well as tools for educators and learners (Cake et al., 2016; Hughes et al., 2018). This framework highlights professional identity formation, skills needed for practice career longevity, and development of resilience. More recently, outcomes‐based frameworks have been described (Bok et al., 2011; Molgaard et al., 2019; Matthew et al., 2020). The AAVMC's competency‐based veterinary education (CBVE) framework is currently being considered and implemented across multiple international veterinary schools simultaneously, which brings exciting opportunities for conducting comparative analysis of students and graduates across schools. Having a shared framework of competencies, entrustable professional activities, milestones, and terminology is critical for training educators, comparing learners, and generalizing results across programs (Molgaard et al., 2018a; Molgaard et al., 2018b; Salisbury et al., 2019). With schools historically only focusing on their own programs, this opportunity has not existed in veterinary medicine to date.

In the strictest sense, veterinary clinical skills are psychomotor tasks that can be assessed in a simulated environment (satisfying “shows how” on Miller's pyramid of clinical competence) or within the actual clinical workplace (satisfying “does” on Miller's pyramid of clinical competence, see Figure 5.1) (Miller, 1990). Obvious examples might include donning and doffing a surgical gown, suturing skin, performing venipuncture, safely restraining a patient, or performing a complete physical examination. But what about interpreting herd records, observing animal behavior, or designing an isolation facility? Recently, authors have argued that the pinnacle of Miller's pyramid of clinical competence is not just related to technical skill competence as Miller originally described but is actually “is trusted” (to perform on one's own) (ten Cate et al., 2020) or “is” (to incorporate the development of professional identity) (Cruess et al., 2016).

During curriculum development or program revision to incorporate further clinical skills training, there can be heated debate among educators and practitioners about what skills are the most necessary to teach, or even about what constitutes a “clinical skill.” Before the more recent rise of competency‐based education, some educators and practitioners used Delphi‐like processes and developed lists of skills to be taught in veterinary programs such as Day 1 Skills, first published in 2002 (RCVS, 2020). These practitioners tended to focus on what they believed was important for their own daily practice and based the skills list on what might be needed for their particular geographical location. Practitioners also focused on what they wished to be taught to students who were soon to become their employees and colleagues. Educators tended to focus more on their own areas of specialty and what they believed new graduates should be able to perform based on past teaching experience.

The more recently described competency‐based approaches to education have tried to focus more on “outputs,” rather than only on “inputs” for determining what should be taught in the curriculum. The majority of veterinary graduates today will enter private small animal, first‐opinion practice, and it has been suggested that educators focus on asking practitioners working in that environment what skills the graduate will need (Bain and Salois, 2019). It should be noted that a broad range of practices must be consulted because there are differences in equipment and personnel available from practice to practice. Surveys of practicing veterinarians engaged in performing authentic veterinary tasks in general practice have also proven critical to determining the frequency, importance, and perceived difficulty for performance of these skills (Hubbell et al., 2008; Doucet and Vrins, 2009; Smeak et al., 2012; Luby et al., 2013; Kreisler et al., 2019). Not being limited in licensure at present, veterinary graduates ultimately require a broad range of skills for commonly seen conditions and diseases of all the major domestic species, and they require different skills than a specialist working in a tertiary referral environment (May, 2015). It is critically important that information be gathered across all types of practice, and published surveys exist in the literature for skills in surgery, equine practice, bovine practice, and small animal practice (Hubbell et al., 2008; Doucet and Vrins, 2009; Smeak et al., 2012; Luby et al., 2013; Kreisler et al., 2019). These resources are very useful and essential to consult when considering what to incorporate into an educational program.

Integration of clinical skills in the curriculum requires consideration of when to present the material and whether to integrate it with other competencies. It is not enough for learners to learn the technical performance alone because without the knowledge of when to use the skill, when not to use the skill and how to modify the performance of the skill when needed, then the learner performs as a trained technician (Michels et al., 2012). The development of a veterinary professional requires that the learner has declarative or background knowledge, procedural knowledge about how to perform the skill, and can also apply diagnostic reasoning and clinical decision‐making. In effect, developing a clinical skills program means achieving a comprehensive consensus on all of these aspects and not simply generating a list of skills (Michels et al., 2012).

Initially, the emphasis of outcomes‐based education in the health professions was on the postgraduate learner, but more recently there has been a shift to incorporate undergraduate training as well (Ferguson et al., 2017). The competency‐based educational approach supports the continual documented improvement of learner performance from novice to proficient and emphasizes training in the clinical workplace (Dreyfus, 2004). Assessment is becoming increasingly focused on a programmatic approach that includes multiple direct observations of student performance that are then integrated to provide a complete picture of learner competence (Bok et al., 2018; Norcini et al., 2018; van Melle et al., 2019).

The development of entrustable professional activities (EPAs) is ushering in a new era for skills training where students are ultimately encouraged to bring individual skills and competencies together in a comprehensive authentic workplace procedural performance (ten Cate, 2005). EPAs are activities that are performed in the workplace and offer a chance for observation and assessment. Assessors have a chance to observe “in the moment” and comment on the learner's ability to perform tasks required in practice. The repetitious completion of such activities in the clinical veterinary teaching environment allows the trainee to grow and learn from the formative feedback provided to them. The AAVMC's CBVE working group recently defined nine different domains and 32 competencies in a framework, which represents consensus across a number of veterinary programs (Molgaard et al., 2018a; Molgaard et al., 2018b). The group then described eight EPAs that can be used for assessing and documenting learner development during the clinical years of the training program. Clinical skills training is now evaluated across programs through the use of OSCEs to assess introductory individual skills and short procedures in the years prior to clinical rotations, and EPAs and workplace‐based assessments that evaluate more complex procedures or activities where multiple competencies need to be performed simultaneously in the clinical environment (Petersa et al., 2017; ten Cate et al., 2018; Molgaard et al., 2018b).

Programmatic assessment has recently been validated in veterinary medicine and shows that a change in performance is not simply due to variability between raters but is due to variance in learners’ growth (Bok et al., 2018). This is important because we can now demonstrate learner change over time and predict the rate at which mastery will occur (Pusic et al., 2015). Limitations of accreditation (e.g. American Veterianry Medical Association’s Council on Education mandating the maintenance of a four‐year program) and reduced financial support (e.g. in the United States, many colleges have poor public support and rely heavily on tuition dollars) may mean that true time‐independent advancement may prove challenging for veterinary programs.

In summary, veterinarians used to talk about “see one, do one, teach one,” but today this is no longer considered a valid approach to teaching and learning skills (Michels et al., 2012). Clinical skills teaching, learning, and assessment have evolved. There is a growing body of evidence regarding learning theories, teaching and assessment principles, and learner development that can be used to the advantage of learner, teacher, and other stakeholders. An abundance of research and scholarship has changed the way that educators teach and the way programs are designed. This book is intended to focus on teaching, learning, and assessment of clinical skills in the modern veterinary curriculum and is a resource guide for students, as well as their instructors. This book is written for both veterinary and veterinary nursing students and includes chapters regarding development of skills curriculum (Chapter 2), how skills are best taught and learned (Chapter 3), and how skills are best practiced prior to assessment (Chapter 4). Also included are chapters on how learners know if they are learning what they need to (Chapter 5), how learners know they are being assessed fairly (Chapter 6), how learners can best learn in a simulated environment (Chapter 7), how to make use of peer teachers (Chapter 8), and what other skills are vital to a successful practice career (Chapter 9). The appendices include examples of OSCE assessments and recipes for simple models that instructors and learners can use and make.

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