Teaching procedural skills

Procedural skills workshops for primary care physicians in Israel: a comprehensive analysis

BACKGROUND

Some of the most common complaints addressed by primary care physicians (PCPs) require manual procedures, such as lacerations repair, abscesses drainage, ingrown toenails removal, dry needling for myofascial pain syndrome, and Epley maneuver for treating benign paroxysmal positional vertigo (BPPV). The aim of this study was to describe the procedural skills workshops program for PCPs implemented in Maccabi Healthcare Services and to investigate how many PCPs have participated and used the skills since the program's inception in 2017.

METHODS

In this observational study, we followed all participants in courses from 2017 to 2021. We extracted all procedures performed during these years by PCPs who learned the skill in MHS.

RESULTS

During the study period, 620 PCPs participated in workshops for dry needling, soft-tissue and joint injections, BPPV treatment, minor surgical procedures, and spirometry. Most procedures performed were dry needling (average annual number 3,537) and minor surgical procedures (average annual number 361). The average annual use per physician was highest for dry needling (annual average use per physician who used the learned skill was 50.9), followed by soft tissue and joint injections (16.8), minor surgical procedures (14.8), and BPPV treatment (7.5).

CONCLUSION

procedural skills workshops may expand PCPs' therapeutic arsenal, thus empowering PCPs and providing more comprehensive care for patients. Some manual skills, such as dry needling, soft tissue injections, and the Epley maneuver, were more likely to be used by participants than other skills, such as spirometry and soft tissue injections.

Utilizing a Referral-Based Procedure Clinic Rotation in Family Medicine Residency

INTRODUCTION

Performing clinical procedures is an essential component of family medicine (FM) residency training. A referral-based procedure clinic was established at our institution in 2014, and a yearly 2-week rotation was established for residents. The objective of this study was to determine the effect of a procedure clinic rotation on the numbers of procedures performed during residency training.

METHODS

We conducted a retrospective review on graduating FM residents from 2009 to 2019. Data collected include type and number of procedures performed each postgraduate year. We analyzed data as mean number of procedures per resident per year. We conducted statistical comparison with Wilcoxon-Mann-Whitney two-sample rank-sum tests.

RESULTS

Residents who participated in the procedure clinic rotation performed significantly more dermatologic procedures per year, joint and soft tissue injections and intrauterine device (IUD) insertions and removals, but did not perform significantly more circumcisions, endometrial biopsies, incision and drainages, subdermal contraceptive implant procedures, toenail removals, or vasectomies.

CONCLUSION

The establishment of a 2-week procedure clinic rotation for FM residents was associated with a significant increase in dermatologic procedures, joint and soft tissue injections, and IUD procedures. Further research can explore the impact of this rotation on procedural competency and confidence.

The assessment of procedural skills in physiotherapy education: a measurement study using the Rasch model

Background

Procedural skills are a key element in the training of future physiotherapists. Procedural skills relate to the acquisition of appropriate motor skills, which allow the safe application of clinical procedures to patients. In order to evaluate procedural skills in physiotherapy education validated assessment instruments are required. Recently the assessment of procedural skills in physiotherapy education (APSPT) tool was developed. The overall aim of this study was to establish the structural validity of the APSPT. In order to do this the following objectives were examined: i) the fit of the items of APSPT to the Rasch-model, ii) the fit of the overall score to the Rasch model, iii) the difficulty of each test item and iv) whether the difficulty levels of the individual test items cover the whole capacity spectrum of students in pre-registration physiotherapy education.

Methods

For this observational cross-sectional measurement properties study a convenience sample of 69 undergraduate pre-registration physiotherapy students of the HES-SO Valais-Wallis was recruited. Participants were instructed to perform a task procedure on a simulated patient. The performance was evaluated with the APSPT. A conditional maximum likelihood approach was used to estimate the parameters of a partial credit model for polytomous item responses. Item fit, ordering of thresholds, targeting and goodness of fit to the Rasch model was assessed.

Results

Item fit statistics showed that 25 items of the APSPT showed adequate fit to the Rasch model. Disordering of item thresholds did not occur and the targeting of the APSPT was adequate to measure the abilities of the included participants. Undimensionality and subgroup homogeneity were confirmed.

Conclusion

This study presented evidence for the structural validity of the APSPT. Undimensionality of the APSPT was confirmed and therefore presents evidence that the latent dimension of procedural skills in physiotherapy education consists of several subcategories. However, the results should be interpreted with caution given the small sample size.

Trainee perception of cognitive load during observed faculty staff teaching of procedural skills

OBJECTIVES

Although teachers impact learners' cognitive load, how specific teaching activities affect intrinsic, germane and extraneous load during procedural skills training is unknown. We sought to characterise teaching activities used in the exemplar procedural setting of colonoscopy, and to explore how they were enacted and how learners perceived them as affecting intrinsic, germane and extraneous cognitive load.

METHODS

We observed 10 colonoscopies performed by eight different gastroenterology fellows and supervised by 10 different attending physicians at two hospitals, and recorded the teaching activities observed, as well as details of when they were used and how they were enacted. After the colonoscopy, each fellow completed the Cognitive Load Inventory for Colonoscopy to quantify intrinsic, germane and extraneous load. We then interviewed each fellow to determine how he or she perceived teaching as affecting cognitive load. Qualitative data were subjected to content analysis. Instances of germane load-promoting activities were correlated with measured germane load.

RESULTS

We observed 515 instances of teaching activities. The intensity of teaching varied substantially, ranging from 0.7 to 3.3 activities per minute, as did the pattern of teaching activities used by different attending physicians. Little teaching occurred immediately before or after a procedure. Fellows usually perceived teaching as affecting cognitive load in ways that promoted learning, particularly by reducing intrinsic load and increasing germane load. Fellows strongly perceived that the provision of autonomy promoted germane load. Conversely, fellows perceived that excessive teaching increased extraneous load. Instances of germane load-promoting teaching activities correlated moderately with measured germane load.

CONCLUSIONS

Teaching in the exemplar procedural setting of colonoscopy affected learners' cognitive load in mostly beneficial ways, yet even 'good' teaching activities had detrimental effects when used excessively. Teachers of procedures should consider learner experience, task complexity and environmental factors to modulate the modality, content and intensity of teaching to promote balanced cognitive load and learning. Teaching more reservedly during the procedure and taking advantage of pre- and post-procedure opportunities may help.

The effect of an e-learning module on health sciences students' venipuncture skill development

Introduction

Venipuncture is a psychomotor skill required in many healthcare professions. E-learning could be used to overcome current barriers in face-to-face learning in healthcare education such as insufficient classroom space or qualified instructors. We sought to evaluate the effectiveness of an e-learning module on students' performance when used in addition to in-class training.

Methods

Overall, 224 health sciences students were approached to participate in this pilot study. Recruited students were divided into control and study groups. The control group received only in-class training, whereas the study group had access to the e-learning module in addition to in-class learning. Both groups were evaluated on their self-confidence using a Likert scale, academic competence using a multiple-choice questionnaire, and psychomotor competence from video skill recordings using an in-house rubric. Nonparametric, independent sample Mann-Whitney tests were performed to evaluate differences between groups.

Results

Overall, 114 students provided written informed consent; 84 students (control: n = 50, study: n = 34) participated in at least one component of the study. Significantly higher (p = 0.017) academic competence scores were observed in the study group. Significantly higher confidence levels were also observed postintervention for both the control (p = 0.0025) and study (p = 0.0011) groups; however, no significant differences were found between the study and control groups before (p = 0.441) or after (p = 0.883) intervention. Finally, no significant differences (p = 0.428) were observed for psychomotor skills between the study arms.

Conclusion

Our results suggest that there is potential for e-learning to increase the academic competence of students when used in conjunction with traditional learning; however, further research is needed to determine its efficacy on psychomotor skills.

Teaching Incision and Drainage: Perceived Educational Value of Abscess Models

OBJECTIVES

Incision and drainage (I&D) of skin abscesses is an important procedural skill for pediatric emergency medicine providers. Practical skills training using simulation provides an opportunity to learn and gain confidence with this invasive procedure. Our objective was to assess the perceived educational value of 2 versions of an abscess model as part of an educational workshop for teaching I&D.

METHODS

A combined didactic and practical skills workshop was developed for use at 2 national conferences. The didactic content was created through an iterative process. To facilitate hands-on training, 2 versions of an abscess model were created: 1 constructed from a negative mold and the other using a 3-dimensional printer. Participants were surveyed regarding prior experience with I&D, procedural confidence, and perceptions of the educational utility of the models.

RESULTS

Seventy physicians and 75 nurse practitioners participated in the study. Procedural confidence improved after training using each version of the model, with the greatest improvements noted among novice learners. Ninety-four percent of physicians, and 99% of nurse practitioners rated the respective models as either "educational" or "very educational," and 97% and 100%, respectively, would recommend the abscess models to others.

CONCLUSIONS

A combined didactic and practical skills educational workshop using novel abscess models was effective at improving learners' confidence. Our novel models provide an effective strategy for teaching procedural skills such as I&D and demonstrate a novel use of 3-dimensional printers in medical education. Further study is needed to determine if these educational gains translate into improvement in clinical performance or patient outcomes.

Learner, Patient, and Supervisor Features Are Associated With Different Types of Cognitive Load During Procedural Skills Training: Implications for Teaching and Instructional Design

PURPOSE

Cognitive load theory, focusing on limits of the working memory, is relevant to medical education; however, factors associated with cognitive load during procedural skills training are not well characterized. The authors sought to determine how features of learners, patients/tasks, settings, and supervisors were associated with three types of cognitive load among learners performing a specific procedure, colonoscopy, to identify implications for procedural teaching.

METHOD

Data were collected through an electronically administered survey sent to 1,061 U.S. gastroenterology fellows during the 2014-2015 academic year; 477 (45.0%) participated. Participants completed the survey immediately following a colonoscopy. Using multivariable linear regression analyses, the authors identified sets of features associated with intrinsic, extraneous, and germane loads.

RESULTS

Features associated with intrinsic load included learners (prior experience and year in training negatively associated, fatigue positively associated) and patient/tasks (procedural complexity positively associated, better patient tolerance negatively associated). Features associated with extraneous load included learners (fatigue positively associated), setting (queue order positively associated), and supervisors (supervisor engagement and confidence negatively associated). Only one feature, supervisor engagement, was (positively) associated with germane load.

CONCLUSIONS

These data support practical recommendations for teaching procedural skills through the lens of cognitive load theory. To optimize intrinsic load, level of experience and competence of learners should be balanced with procedural complexity; part-task approaches and scaffolding may be beneficial. To reduce extraneous load, teachers should remain engaged, and factors within the procedural setting that may interfere with learning should be minimized. To optimize germane load, teachers should remain engaged.

Technical Skills Training for Veterinary Students: A Comparison of Simulators and Video for Teaching Standardized Cardiac Dissection

The goal of the study was to evaluate alternative student-centered approaches that could replace autopsy sessions and live demonstration and to explore refinements in assessment procedures for standardized cardiac dissection. Simulators and videos were identified as feasible, economical, student-centered teaching methods for technical skills training in medical contexts, and a direct comparison was undertaken. A low-fidelity anatomically correct simulator approximately the size of a horse's heart with embedded dissection pathways was constructed and used with a series of laminated photographs of standardized cardiac dissection. A video of a standardized cardiac dissection of a normal horse's heart was recorded and presented with audio commentary. Students were allowed to nominate a preference for learning method, and students who indicated no preference were randomly allocated to keep group numbers even. Objective performance data from an objective structure assessment criterion and student perception data on confidence and competency from surveys showed both innovations were similarly effective. Evaluator reflections as well as usage logs to track patterns of student use were both recorded. A strong selection preference was identified for kinesthetic learners choosing the simulator and visual learners choosing the video. Students in the video cohort were better at articulating the reasons for dissection procedures and sequence due to the audio commentary, and student satisfaction was higher with the video. The major conclusion of this study was that both methods are effective tools for technical skills training, but consideration should be given to the preferred learning style of adult learners to maximize educational outcomes.

An evidence-based approach to surgical teaching in ophthalmology

An apprenticeship model has traditionally been used in procedural and surgical teaching. As the pressures of work hours and patient outcome monitoring increase, surgical teachers need a more flexible plan for teaching procedural skills. We attempt to delineate a program of preprocedural, intraprocedural, and postprocedural teaching that can be used in the field of ophthalmology to maximize a resident's skill acquisition in a constructive learning environment. We review the literature on surgical teaching from within ophthalmology as well as other surgical fields and combine this with teaching experience in an ophthalmic surgical training program to produce a collection of procedural teaching guidelines. These guidelines are structured to serve in both individual teaching settings and in curriculum design.

Optimum number of procedures required to achieve procedural skills competency in internal medicine residents

BACKGROUND

Procedural skills training forms an essential, yet difficult to assess, component of an Internal Medicine Residency Program. We report the development of process of documentation and assessment of procedural skills training.

METHOD

An explanatory sequential mixed methods design was adopted where both quantitative and qualitative information was collected sequentially. A survey was conducted within the Department of Internal Medicine at The Aga Khan University Hospital, Karachi, Pakistan to determine the optimum number of procedures needed to be performed by residents at each year of residency. Respondents included both faculty and the residents in the Department. Thereafter, all responses were compiled and later scrutinized by a focus group comprising of a mix of faculty from various subspecialties and resident representatives.

RESULTS

A total of 64 responses were obtained. A significant difference was found in eight procedural skills' status between residents and faculty, though none of these were significant after accounting for multiple consecutive testing. However, the results were reviewed and a consensus for the procedures needed was developed through a focus group. A finalized procedural list was generated to determine: (a) the minimum number of times each procedure needed to be performed by the resident before deemed competent; (b) the level of competency for each procedure for respective year of residency.

CONCLUSION

We conclude that the opinion of both the residents and the faculty as key stakeholders is vital to determine the number of procedures to be performed during an Internal Medicine Residency. Documentation of procedural competency development during the training would make the system more objective and hence reproducible. A log book was designed consisting of minimum number of procedures to be performed before attaining competency.

Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine

Acquisition of competency in procedural skills is a fundamental goal of medical training. In this Perspective, the authors propose an evidence-based pedagogical framework for procedural skill training. The framework was developed based on a review of the literature using a critical synthesis approach and builds on earlier models of procedural skill training in medicine. The authors begin by describing the fundamentals of procedural skill development. Then, a six-step pedagogical framework for procedural skills training is presented: Learn, See, Practice, Prove, Do, and Maintain. In this framework, procedural skill training begins with the learner acquiring requisite cognitive knowledge through didactic education (Learn) and observation of the procedure (See). The learner then progresses to the stage of psychomotor skill acquisition and is allowed to deliberately practice the procedure on a simulator (Practice). Simulation-based mastery learning is employed to allow the trainee to prove competency prior to performing the procedure on a patient (Prove). Once competency is demonstrated on a simulator, the trainee is allowed to perform the procedure on patients with direct supervision, until he or she can be entrusted to perform the procedure independently (Do). Maintenance of the skill is ensured through continued clinical practice, supplemented by simulation-based training as needed (Maintain). Evidence in support of each component of the framework is presented. Implementation of the proposed framework presents a paradigm shift in procedural skill training. However, the authors believe that adoption of the framework will improve procedural skill training and patient safety.

A review on considerations needed educating new physicians

The long process of medical education is important crucial parts related to public health. This research was led to study the educational alternatives in teaching new physicians. The necessity for a revolution in the medical education is due to the increased number of medical students, constant number of constant number of cases, and their prospects enhanced professors workload and enhanced supervisory agency mistake less clinical events happening for medical students, interns and residents. Newer techniques have become available in improving education. Stimulation has been utilized before as an educational technique in military training, space programs, aviation industry, sports stimulation, nuclear power industry, teaching anatomy, anesthesiology, and resuscitation training. Physical models (in a skills lab or workshop), computer programs including (over the internet), standard patients, etc., can be utilized for this technique. By reviewing the literature, we can conclude that several subjects are needed to be explained earlier education. Thus, to conduct an accurate program, these questions must be answered, appropriately.

Low-fidelity simulation improves mastery of the aseptic technique for labour epidurals: an observational study

PURPOSE

The objective of this study was to determine the impact of a low-fidelity simulation model on mastering the sterile technique during placement of epidural catheters.

METHODS

Trainees, including residents and fellows, were given conventional teaching consisting of a lecture and a video demonstration on the appropriate sterile technique to apply during the placement of epidural catheters. The trainees were then provided with a one-on-one demonstration session using a low-fidelity Styrofoam™ epidural model, followed by a series of simulation sessions. After conventional teaching and following each simulation session, the trainees were assessed on their performance until competence was achieved based on a 15-point checklist. The retention of competence was subsequently evaluated bi-weekly in clinical practice for four assessments.

RESULTS

Twenty-one trainees participated in the study. The average score for the residents following conventional teaching was 6.0 out of 15 points on the checklist. Following the initial one-on-one hands-on demonstration, the average score increased to 10.8 (difference = 4.8, 95% confidence interval (CI): 3.3 to 6.2; P < 0.001). The average score for the fellows following conventional teaching was 7.9 out of 15 points on the checklist. Following the initial one-on-one hands-on demonstration the average score increased to 11.2 (difference = 3.3, 95% CI: 0.05 to 6.6; P = 0.047). During the retention of competence phase, scores ranged from 13-15 for both residents and fellows.

CONCLUSION

This study describes a comprehensive teaching model for mastering the sterile technique during epidural catheter placement. It suggests that low-fidelity simulation improves the learning process when used in addition to conventional teaching.

Video-assisted structured teaching to improve aseptic technique during neuraxial block

BACKGROUND

Teaching epidural catheter insertion tends to focus on developing manual dexterity rather than improving aseptic technique which usually remains poor despite increasing experience. The aim of this study was to compare epidural aseptic technique performance, by novice operators after a targeted teaching intervention, with operators taught aseptic technique before the intervention was initiated.

METHODS

Starting July 2008, two groups of second-year anaesthesia residents (pre- and post-teaching intervention) performing their 4-month obstetric anaesthesia rotation in a university affiliated centre were videotaped three to four times while performing epidural procedures. Trained blinded independent examiners reviewed the procedures. The primary outcome was a comparison of aseptic technique performance scores (0-30 points) graded on a scale task-specific checklist.

RESULTS

A total of 86 sessions by 29 residents were included in the study analysis. The intraclass correlation coefficient for inter-rater reliability for the aseptic technique was 0.90. The median aseptic technique scores for the rotation period were significantly higher in the post-intervention group [27.58, inter-quartile range (IQR) 22.33-29.50 vs 16.56, IQR 13.33-22.00]. Similar results were demonstrated when scores were analysed for low, moderate, and high levels of experience throughout the rotation.

CONCLUSIONS

Procedure-specific aseptic technique teaching, aided by video assessment and video demonstration, helped significantly improve aseptic practice by novice trainees. Future studies should consider looking at retention over longer periods of time in more senior residents.

Evidence-based consensus on the insertion of central venous access devices: definition of minimal requirements for training

There is a lack of standard minimal requirements for the training of insertion techniques and maintenance of central venous access devices (CVADs). An international evidence-based consensus task force was established through the World Congress of Vascular Access (WoCoVA) to provide definitions and recommendations for training and insertion of CVADs. Medical literature published from February 1971 to April 2012 regarding 'central vascular access', 'training', 'competency', 'simulation', and 'ultrasound' was reviewed on Pubmed, BioMed Central, ScienceDirect, and Scopus databases. The GRADE and the GRADE-RAND methods were utilized to develop recommendations. Out of 156 papers initially identified, 83 papers described training for central vascular access placement. Sixteen recommendations are proposed by this task force, each with an evidence level, degree of consensus, and recommendation grade. These recommendations suggest central venous access education include didactic or web-based teaching with insertion procedure, infection prevention, complications, care, and maintenance of devices, along with laboratory models and tools for simulation practice incorporating ultrasound. Clinical competence should be determined by observation during clinical practice using a global rating scale rather than by the number of procedures performed. Ensuring safe insertion and management of central venous devices requires standardized education, simulation practice, and supervised insertions.

Clinical skills assessment of procedural and advanced communication skills: performance expectations of residency program directors

BACKGROUND

High stakes medical licensing programs are planning to augment and adapt current examinations to be relevant for a two-decision point model for licensure: entry into supervised practice and entry into unsupervised practice. Therefore, identifying which skills should be assessed at each decision point is critical for informing examination development, and gathering input from residency program directors is important.

METHODS

Using data from previously developed surveys and expert panels, a web-delivered survey was distributed to 3,443 residency program directors. For each of the 28 procedural and 18 advanced communication skills, program directors were asked which clinical skills should be assessed, by whom, when, and how. Descriptive statistics were collected, and Intraclass Correlations (ICC) were conducted to determine consistency across different specialties.

RESULTS

Among 347 respondents, program directors reported that all advanced communication and some procedural tasks are important to assess. The following procedures were considered 'important' or 'extremely important' to assess: sterile technique (93.8%), advanced cardiovascular life support (ACLS) (91.1%), basic life support (BLS) (90.0%), interpretation of electrocardiogram (89.4%) and blood gas (88.7%). Program directors reported that most clinical skills should be assessed at the end of the first year of residency (or later) and not before graduation from medical school. A minority were considered important to assess prior to the start of residency training: demonstration of respectfulness (64%), sterile technique (67.2%), BLS (68.9%), ACLS (65.9%) and phlebotomy (63.5%).

DISCUSSION

Results from this study support that assessing procedural skills such as cardiac resuscitation, sterile technique, and phlebotomy would be amenable to assessment at the end of medical school, but most procedural and advanced communications skills would be amenable to assessment at the end of the first year of residency training or later.

CONCLUSIONS

Gathering data from residency program directors provides support for developing new assessment tools in high-stakes licensing examinations.

Defining competency-based evaluation objectives in family medicine: procedure skills

OBJECTIVE

To develop evaluation objectives for assessing competence in procedure skills using a key-features approach. This was part of a multiyear project to develop competency-based evaluation objectives for Certification in Family Medicine.

DESIGN

Nominal group technique.

SETTING

The College of Family Physicians of Canada in Mississauga, Ont.

PARTICIPANTS

An expert group of 7 family physicians and 1 educational consultant, all of whom had experience in assessing competence in family medicine. Group members represented the Canadian context with respect to region, sex, language, community type, and experience.

METHODS

Using a nominal group technique, the expert group developed the general key features for procedure skills. The expert group also linked the key features to already established skill dimensions in the domain of competence, to the 4 principles of family medicine, and to the CanMEDS roles.

MAIN FINDINGS

The general key features were developed after 5 iterations. Ten key features were outlined and were shown to reflect all the essential skill dimensions in the domain of competence for family medicine. The key features were linked to 2 of the 4 principles of family medicine and to 4 of the CanMEDS roles.

CONCLUSION

The general key features for procedure skills were developed to assess competence in procedure skills in family medicine.

Efficacy of peer-assisted learning across residencies for procedural training in dermatology

BACKGROUND

With new care models such as the medical home, there is an expanding need for primary care providers to be trained in dermatologic procedures. Yet, many internal medicine residency program graduates feel unprepared to perform these procedures. The aim of this study was to evaluate the effect of a structured peer-assisted learning approach to improve residents' knowledge and skills related to common dermatologic assessment techniques.

METHODS

Eight medicine-dermatology resident educators, with a faculty member, facilitated dermatologic procedure workshops for 28 internal medicine and medicine-pediatrics resident learners. Learners completed preworkshop and postworkshop surveys, assessing their knowledge and skill levels as well as the efficacy of the resident educators and the educational value of the workshop as a whole.

RESULTS

All learners were able to properly demonstrate the techniques at the workshop's conclusion. The median sum score of self-reported knowledge increased from 3 to 9.5 (scale, 0-10; P < .001). The median sum score of self-reported skills increased from 10 to 16 (scale, 4-20; P < .001). Resident educators were favorably evaluated by their peers, and 96% of participants rated the experience as being of high educational value.

CONCLUSION

Peer-assisted learning is effective in teaching dermatologic procedures in graduate medical education. Resident learners found peer-assisted learning to be beneficial and rated their peer teachers highly. Further studies should focus on outcomes in practice, looking at the number of dermatologic procedures performed by learners, as well as the effects on resident educators.

Who is teaching and supervising our junior residents' central venous catheterizations?

BACKGROUND

The extent to which medical residents are involved in the teaching and supervision of medical procedures is unknown. This study aims to evaluate the teaching and supervision of junior residents in central venous catheterization (CVC) by resident-teachers.

METHODS

All PGY-1 internal medicine residents at two Canadian academic institutions were invited to complete a survey on their CVC experience, teaching, and supervision prior to their enrolment in a simulator CVC training curriculum.

RESULTS

Of the 69 eligible PGY-1 residents, 32 (46%) consenting participants were included in the study. There were no significant baseline differences between participants from the two institutions in terms of sex, number of ICU months completed, previous CVC training received, number of CVCs observed and performed. Only 16 participants (50%) received any CVC training at baseline. Of those who received any training, 63% were taught only by senior resident-teachers. A total of 81 CVCs were placed by 17 participants. Thirty-two CVCs (45%) were supervised by resident-teachers.

CONCLUSIONS

Resident-teachers play a significant role both in the teaching and supervision of CVCs placed by junior residents. Educational efforts should focus on preparing residents for their role in teaching and supervision of procedures.

Do procedural skills workshops during family practice residency work?

OBJECTIVE

To determine if participation in a procedural skills workshop during family practice residency affects future use of these skills in postgraduate clinical practice.

DESIGN

Survey involving self-assessment of procedural skills experience and competence.

SETTING

British Columbia.

PARTICIPANTS

Former University of British Columbia family practice residents who trained in Vancouver, BC, including residents who participated in a procedural skills workshop in 2001 or 2003 and residents graduating in 2000 and 2002 who did not participate in the procedural skills workshop.

MAIN OUTCOME MEASURES

Self-assessed experience and competence in the 6 office-based procedural skills that were taught during the procedural skills workshops in 2001 and 2003.

RESULTS

Participation in a procedural skills workshop had no positive effect on future use of these skills in clinical practice. Participation in the workshop was associated with less reported experience (P = .091) in injection of lateral epicondylitis. As with previous Canadian studies, more women than men reported experience and competence in gynecologic procedures. More women than men reported experience (P = .001) and competence (P = .004) in intrauterine device insertion and experience (P = .091) in endometrial aspiration biopsy. More men than women reported competence (P = .052) in injection of trochanteric bursae. A third year of emergency training was correlated with an increase in reported experience (P = .021) in shoulder injection.

CONCLUSION

Participation in a procedural skills workshop during family practice residency did not produce a significant increase in the performance of these skills on the part of participants once they were in clinical practice. The benefit of a skills workshop might be lost when there is no opportunity to practise and perfect these skills. Sex bias in the case of some procedures might represent a needs-based acquisition of skills on the part of practising physicians. Short procedural skills workshops might be better suited to graduated physicians with more clinical experience.

Are Canadian General Internal Medicine training program graduates well prepared for their future careers?

BACKGROUND

At a time of increased need and demand for general internists in Canada, the attractiveness of generalist careers (including general internal medicine, GIM) has been falling as evidenced by the low number of residents choosing this specialty. One hypothesis for the lack of interest in a generalist career is lack of comfort with the skills needed to practice after training, and the mismatch between the tertiary care, inpatient training environment and "real life". This project was designed to determine perceived effectiveness of training for 10 years of graduates of Canadian GIM programs to assist in the development of curriculum and objectives for general internists that will meet the needs of graduates and ultimately society.

METHODS

Mailed survey designed to explore perceived importance of training for and preparation for various aspects of Canadian GIM practice. After extensive piloting of the survey, including a pilot survey of two universities to improve the questionnaire, all graduates of the 16 universities over the previous ten years were surveyed.

RESULTS

Gaps (difference between importance and preparation) were demonstrated in many of the CanMEDS 2000/2005 competencies. Medical problems of pregnancy, perioperative care, pain management, chronic care, ambulatory care and community GIM rotations were the medical expert areas with the largest gaps. Exposure to procedural skills was perceived to be lacking. Some procedural skills valued as important for current GIM trainees and performed frequently (example ambulatory ECG interpretation) had low preparation ratings by trainees. Other areas of perceived discrepancy between training and practice included: manager role (set up of an office), health advocate (counseling for prevention, for example smoking cessation), and professional (end of life issues, ethics).

CONCLUSION

Graduates of Canadian GIM training programs over the last ten years have identified perceived gaps between training and important areas for practice. They have identified competencies that should be emphasized in Canadian GIM programs. Ongoing review of graduate's perceptions of training programs as it applies to their current practice is important to ensure ongoing appropriateness of training programs. This information will be used to strengthen GIM training programs in Canada.

Einführung eines kompetenzbasierten Facharztweiterbildungsprogramms in einer neurologischen Abteilung

BACKGROUND

Competency-based programs have long been the basis of graduate medical education in British and North America. Such formally defined program structures are lacking in German graduate medical education.

METHODS

The methods and assessment tools used in a curriculum-based program of graduate education in medical specialties are presented. The feasibility of the program was tested in day-to-day use in a pilot study conducted within a neurology department. Experience of it during a 1-year period after implementation has also been collected.

RESULTS

It was found that implementation of the program is feasible providing that both the trainers and the students are well motivated, that adequate resources are provided, and that a formal training system is provided for the trainers. This is confirmed by the 1-year experience of the program in routine clinical practice.

CONCLUSIONS

The competency-based program presented, which is compatible with many quality management systems, offers management and assessment tools that will make for more satisfactory postgraduate medical education.

Defining core procedure skills for Canadian family medicine training

OBJECTIVE

To create a list of core and enhanced procedures suitable for family medicine training.

DESIGN

Mailed or e-mailed survey using a Delphi technique.

SETTING

Randomly selected family physician practices across Canada.

PARTICIPANTS

Family physicians from urban, small-town, and rural practice locations and academic family physicians. All were experienced family physicians with from 3 to 36 years in practice.

INTERVENTIONS

Participant physicians were asked to rate each of 158 procedures as to whether they would expect a graduate from a Canadian family practice training program to have learned and be capable of performing that procedure in their own community. In a second survey, participants were asked to verify the core and enhanced procedures lists produced from the first survey.

MAIN OUTCOME MEASURES

Physicians' opinions about a comprehensive list of skills.

RESULTS

Twenty-two physicians responded to the first survey (92% response rate) and 14 to the second (58% response rate). Sixty-five core procedures and 15 enhanced procedures were identified in the surveys. More procedures were ranked on the core list and were performed by rural and small-town physicians than by urban physicians. Physicians' agreement with placement of procedures on the core list ranged from 55% to 100% and of procedures on the enhanced list from 50% to 64%. Fifty-five of the procedures on the core list had agreement from more than 70% of participants.

CONCLUSION

Procedure lists represent the opinions of Canadian family physicians about the importance of specific procedure skills for new family physicians in their communities. Procedure lists will be helpful for family medicine training programs to evaluate and refine their teaching of procedure skills.

Teaching Physicians Procedural Skills at a National Professional Meeting

BACKGROUND

Practicing physicians often wish to improve their procedural skills but have limited educational opportunities to do so.

DESCRIPTION

To summarize the effects of two procedural workshops on participants' confidence, proficiency, and practice patterns.

EVALUATION

Following completion of a skin biopsy or arthrocentesis workshop, participants completed a post-course and an 8-month follow up evaluation. Recipients of this training rated it highly and reported that following training they performed more procedures, referred less, and noted an increase in their confidence that was still evident eight months after the workshop.

CONCLUSION

Skin biopsy and arthrocentesis/joint injection skills can be taught to practicing physicians in a workshop setting at national professional meetings.

U.S. and Canadian internal medicine clerkship directors' opinions about teaching procedural and interpretive skills to medical students

PURPOSE

Although medical students gain experience in performing procedures during their clinical clerkships, which skills they should acquire remains unclear. The authors sought opinions from internal medicine clerkship directors regarding procedural and interpretive skills students should and do learn during clerkships.

METHOD

In 2002, the 123 members of the Clerkship Directors in Internal Medicine (CDIM) were confidentially surveyed using a 79-item questionnaire about the appropriateness of 20 procedural skills, demographics, clerkship characteristics, and curricula in procedural skills. Participants had the choice of completing a mailed paper questionnaire or an electronic version on the CDIM's Web site. After univariate analysis, adjusted comparisons among participants were made using linear regression.

RESULTS

Surveys were completed by 89 clerkship directors (72%). Most thought that students should be taught 17 of 20 procedural skills. However, the majority thought students do not learn five of these skills. Over 80% of respondents thought students should learn: chest x-ray interpretation, electrocardiogram interpretation, phlebotomy, throat culture, blood culture, urinalysis, Pap smear, central line placement, peripheral blood smear. However, the majority thought students do not learn five of these skills. The mean of skills that should be taught and are learned were 15 (standard deviation [SD] = 3) and 12 (SD = 4), respectively. About half used formal teaching in procedures (44%), used logs (51%) and tested competency (45%).

CONCLUSIONS

CDIM members thought medical students should be taught a variety of procedural skills but thought students fail to learn many. These findings may help prioritize which procedures to teach. It may be helpful to develop standardized curricular materials on teaching procedures.

Cusum analysis is a useful tool to assess resident proficiency at insertion of labour epidurals

PURPOSE

Cumulative sum (cusum) analysis is a statistical and graphical tool that examines trends for sequential events over time. It has been used to determine proficiency in technical procedures. We used cusum to determine the number of labour epidural attempts necessary for proficiency in our training program.

METHODS

Residents unfamiliar with epidural anesthesia kept a log of their labour epidural successes and failures during a six-month hospital rotation. Failure was defined as a dural puncture or relinquishing the procedure to staff. Cusum analysis was performed using an acceptable failure rate of 10%. Residents were deemed competent when their graph remained below the calculated cusum boundary.

RESULTS

Eleven anesthesia residents were recruited. The number of epidural attempts over six months ranged from 75 to 128. Ten residents attained competency by cusum between one and 85 attempts. One resident failed to achieve competency by cusum after 75 attempts.

CONCLUSION

After a period of training, residents are expected to perform the skill of labour epidural insertion independently. This study illustrates that some residents may need as many as 75 attempts to ensure proficiency. Training programs could use cusum to track the progress of their residents' technical skills in order to guarantee an adequate experience.

Procedure skill competence and certification in internal medicine residency training

BACKGROUND

Procedure skill training and competency certification are an important part of internal medicine residency training. Expert guidelines exist on the minimum number of procedures recommended to attain competence, but these have not been validated.

PURPOSE

To study the validity of the American Board of Internal Medicine (ABIM) recommended procedure guidelines.

METHODS

We performed a retrospective review of all monthly procedure log sheets collected during residency training for the graduates of our internal medicine residency program. The number of procedure attempts and the length of time needed to be certified as competent in 13 different procedures were recorded and compared with ABIM guidelines.

RESULTS

There were 69 graduates with an average of 32.7 monthly procedure log sheets per resident. There was a wide variation in the number of attempts and time needed to attain competence in the measured procedures. Overall, our residents received their competency certification for each required procedure within 1 SD of the corresponding ABIM recommendation.

CONCLUSIONS

Our study suggests that the ABIM recommended guidelines on procedure skill competence may be valid on the program level