Improving Internal Medicine Resident Comfort With Shoulder and Knee Joint Injections Using an Injection Workshop

Evaluation of Outpatient Procedures Simulation Curriculum for Internal Medicine Residents

BACKGROUND

Outpatient procedure training in internal medicine residency has not been shown to produce high-level outcomes such as improved volume and quality of procedures performed on real patients.

OBJECTIVE

The objective of this study was to improve the volume and quality of outpatient procedures performed by internal medicine residents by administering a simulation-based curricular intervention.

DESIGN

Validated teaching materials and local faculty input were used to design a simulation curriculum for teaching the knee joint injection/aspiration and skin abscess incision and drainage. A prospective curricular intervention was implemented for a single cohort of internal medicine interns.

PARTICIPANTS

All internal medicine interns at Beth Israel Deaconess Medical Center during the 2021-2022 academic year were allowed to participate in this educational intervention with no exclusion criteria.

INTERVENTIONS

Forty-seven interns received 30 min of simulation education for each procedure.

MAIN MEASURES

Primary outcomes included total number of procedures performed in clinic, volume of procedures performed by residents, percentage of total procedures performed by residents, and procedural success and complication rates before and after the curricular intervention.

KEY RESULTS

At 1-year post-curriculum, the total number of procedures in clinic increased by 25%. Procedures by residents increased by 110%, with joint injections/aspirations increasing by 317% and skin abscess incision and drainage increasing by 200%. Complication rates reduced from 25 to 0%, and 100% of resident-performed procedures post-curriculum were completed successfully.

CONCLUSION

These findings demonstrate that a novel outpatient procedures simulation curriculum can positively impact higher-level clinical practice outcomes for internal medicine residents.

Workshop, Assessment, and Validity Evidence for Tools Measuring Performance of Knee and Shoulder Arthrocentesis

INTRODUCTION

Musculoskeletal concerns are common, yet residents at our institution lacked arthrocentesis training. We created a workshop to teach residents knee and shoulder arthrocentesis, developed simulated assessment scenarios (SASs) with tools to measure procedural proficiency, and collected validity evidence.

METHODS

A multidisciplinary group conducted a modified Delphi to define content for the workshop, SASs, and assessment tools. We defined minimum thresholds for competence in knee and shoulder arthrocentesis using the modified borderline-group method. We implemented the workshop and SASs in 2020 and 2021 and analyzed assessment tool scoring for statistical reliability and validity. Our program evaluation included SAS performance, participants' survey responses, and change in the number of arthrocenteses performed in the internal medicine (IM) resident primary care clinic.

RESULTS

Sixty-one residents (53 IM, eight physical medicine and rehabilitation [PM&R]) participated. Fifty-two (85%; 46 IM, six PM&R) completed the evaluation survey. We procured data from 48 knee and 65 shoulder SASs for validity evidence. All arthrocentesis SAS performances met the proficiency standard except one resident's shoulder SAS. Validity evidence revealed strong interrater reliability (α = .82 and .77 for knee and shoulder, respectively) and strong relational validity (p < .001 for both procedures). All participants rated workshop quality and usefulness as good or very good. The number of arthrocenteses performed at our institution's primary care clinic increased.

DISCUSSION

We created a workshop to teach residents arthrocentesis and assessment tools with strong validity and reliability evidence. The workshop was well regarded by residents, who applied their arthrocentesis skills during patient care.

Improving Self-Confidence of Military Medical Providers With Joint Procedure Simulation: A Pilot Study

INTRODUCTION

Military medical providers are a unique population that encounter different environments across the world. From hospital clinics to war zones, these providers must perform procedures and rely on their training and skill to help their patients. This pilot study aimed to assess the self-confidence of military medical providers performing joint aspiration and injection before and after a simulation workshop in both clinical and austere settings.

METHODS

In 2016, 25 military physicians from various military facilities participated in a 1-hour knee arthrocentesis and injection and shoulder injection workshop. Education was provided on the knee and shoulder anatomy and various approaches to performing the procedures before the hands-on portion of the workshop. Surveys assessing self-reported confidence levels by performing the procedures in the clinic and austere settings were completed before and after simulation training.

RESULTS

The results were analyzed and grouped based on the provider experience level, simulation environment, and specific procedure performed. There was a statistical significance seen in the shoulder arthrocentesis group, which included all participating providers, with a P-value of <.01 in the clinic setting and a P-value of <.001 in the austere setting. In the knee aspiration simulation, there were also improvements in the provider confidence, but it was not statistically significant with P-values of .36 and .14 in the clinical and austere settings, respectively.

CONCLUSION

Simulation training can lead to increased medical provider self-confidence in performing musculoskeletal joint aspirations and injections in both clinic and austere settings. The military medicine demographics have had little research in joint injections and provider confidence to date. This pilot study was one of the first to evaluate this unique population. The methods used in this study, and the positive data collected on provider confidence, can be used in larger studies, encompassing other medical providers to increase the confidence of providers throughout various fields of medicine.

Training and assessment of musculoskeletal ultrasound and injection skills-a systematic review

OBJECTIVES

To examine how residents are trained and assessed in musculoskeletal ultrasound (MSUS), MSUS-guided and landmark-guided joint aspiration and injection. Additionally, to present the available assessment tools and examine their supporting validity evidence.

METHODS

A systematic search of PubMed, Cochrane Library, and Embase was conducted in accordance with the PRISMA guidelines and studies published from January 1, 2000 to May 31, 2021 were included. Two independent reviewers performed the search and data extraction. The studies were evaluated using the Medical Education Research Quality Instrument (MERSQI).

RESULTS

9,884 articles were screened, and 43 were included; 3 were randomized studies, 21 pre- and post-test studies, 16 descriptive studies, and 3 studies developing assessment tools. The studies used various theoretical training modalities e.g. lectures, anatomical quizzes and e-learning. The practical training models varied from mannequins and cadavers to healthy volunteers and patients. The majority of studies used subjective "comfort level" as assessment, others used practical examination and/or theoretical examination. All training programs increased trainees' self-confidence, theoretical knowledge, and/or practical performance, however few used validated assessment tools to measure the effect. Only one study met the MERSQI high methodical quality cut-off score of 14.

CONCLUSION

The included studies were heterogeneous, and most were of poor methodological quality and not based on contemporary educational theories. This review highlights the need for educational studies using validated theoretical and practical assessment tools to ensure optimal MSUS training and assessment in rheumatology.