Practical Observation Techniques

How can you expect me to spend 30 minutes watching a clerk assess a patient?

Direct observation is a key teaching tool. It allows assessment of communication skills and physical examination expertise and also provides insight into the learner’s clinical reasoning capabilities. Unfortunately, residents and even medical students report that being observed during clinical rotations is an infrequent event.

Importance of direct observation

• Provides insight into communication skills
• Reviews physical examination techniques
• Allows assessment of competence
• Reinforces desired behaviours
• Provides an opportunity to remedy errors or undesirable habits (such as pen twirling or tapping!)

Surprisingly, clinical skills plateau during residency and increasing experience tends to ingrain bad habits rather than lead to improvement. Clerkship and residency are the vital times to modify behaviours. Because direct observation is so important and yet so often omitted, weekly documented observation sessions are now mandatory for all family medicine residents.

What makes observation difficult to perform in clinical practice? Clearly, time pressures are the most problematic, but there are other issues.

Barriers to direct observation

• Time
  The learner takes too long to observe and the clinic gets further and further behind schedule so there’s no time to give feedback.
• Equipment
  Most rural clinics don’t have one way mirrors or video equipment
  Getting consent is a concern
• Effect of an observer
  When the preceptor enters the room the dynamic changes. How can you keep the patient’s attention focused on the learner?
• The reluctant learner
  Being watched is intimidating and learners often discourage the preceptor from observing. Sometimes we’re only too happy to defer the observation session until another day.

Overcoming these barriers will depend on local circumstances but here are some possible solutions.

Time

• Observe 5 – 10 minute fragments of the clinical encounter. For example:
  • Watch how the student discovers the history of the presenting complaint.
  • Have the student bring you in to review the physical examination.
  • Observe the resident negotiate the treatment plan with the patient.
• Some physicians enter times for direct observation into their office schedule. Booking a direct observation session at the beginning of the day once a week helps with the reluctant learner as well!
• Direct observation outside the office may work well. Paradoxically, often the emergency department is less frenetic than the office.
• Save the feedback for the end of the day. Making field notes will help record key observations and meets the documentation needs for the universities
  
  Sample: Field note form

Equipment

• It’s not essential to invest in expensive video tools, although the departments of family medicine will usually provide some financial support. If you choose to use video, remember to schedule some time to review the tapes.
• Consider using a webcam. This low cost solution works well and removes the need for tapes and monitors.
• Avoid recording dressing / undressing or intimate examinations.
• Audio recording is well worth considering. It is easy to use and less intimidating for both the learner and the patient.

Patient consent is important for any type of recording. Feel free to modify the sample form below

Sample: Videotape sample consent form

Observation

• Warn the patient in advance that you may be coming in for part of the session and that you will be a “Fly on the Wall.”
• Sit out of sight of the patient and try to avoid the temptation to jump in when the learner seems to be on the wrong track.
• The process may be easier if you don’t know the patient well. Try it with the walk-in patient or in the emergency department.

Learner reluctance 

• Normalize the process by discussing the expectation for regular observation at orientation and make it a joint responsibility to arrange.
• Have the learner observe you and give you feedback on performance
• Ask the learner what part of the encounter you should observe and comment on.

Practical Observation Techniques Observe 5 - 10 minute fragments Make a field note to help with feedback Try scheduling a weekly observation session Experiment with a webcam or audiorecorder