Procedure World & Competency: The Next Generation How many of you teach procedural skills to residents? I would like to share with you how we have set up our procedural teaching. Teaching and Evaluating Procedural Skills

John Sheffield, MD Ellen Johnson, MD Penn State/Good Samaritan Family Practice Residency Program Lebanon, PA

Overview Introduction Nuts & Bolts - How we do it Sessions Models Faculty Evidence that it works Resident satisfaction Looking towards the future…Competency Evaluations

Introduction Everyone agrees, “Family Medicine should include procedural training”, but… But, that being said, there are many questions that need to be answered…

Standards for teaching? There are none. What is the best way to teach procedures? Is there a best way? See one, do one, teach one? Does that work?

Number needed for competency? There are no numbers. AAFP doesn't not recommend a specific number of any procedures. For the Big Procedures (EGD and Colonoscopy) they recommend attending a training course and then finding someone to proctor you. You are then deemed competent when your proctor feels you are competent. And how does one define competency? Does it have to do with SPEED? Cosmetic outcome? Infection rate? Patient satisfaction?

Consistency from one residency to another? There is none. In a survey of 326 Family Medicine Programs in 1999, the number of required procedures ranged from a low of 3 to a high of 117. Only 21% of those mandated competency in those procedures and only 8% defined what competency meant.

What does the ACGME say? “The primary responsibility for the determination of procedural competency rests with the program director and faculty.” “At the time of program review, the program will need to demonstrate how It assesses competency of residents.”

Penn State/GSH FP Residency Two week procedural workshop rotation Occurs in second half of September of second year Each half-day session includes didactics plus hands-on practice Most taught by our FP faculty Two patient care sessions per week

Procedures We Teach Endometrial Sampling ALSO Course Episiotomy Repair IUD Insertion Joint Injection/Aspiration Neonatal Resuscitation Review Suturing Workshop Umbilical Vein Cath. ALSO Course Billing/Coding for Procedures Breast Cyst Aspiration Casting/Splinting Colonoscopy Colpo with Biopsy Dermatologic Procedures What I’d like to do now is describe each workshop individually.

Billing & Coding for Procedures 60-90 minute session Objectives Use of -25 modifier Billing for materials Cosmetic procedures not typically covered by payers Pre- and Post tests Testing involves actually patient scenarios where residents are asked to fill out the billing form. This past September, the pretest scores averaged 33% overall. The post-test scores improved to an average of 94%.

Breast Cyst Aspiration Combine with Endometrial Sampling Didactic session covers evaluation of breast mass Model uses: Ziploc sandwich bags Wrapping tissue Scented Bath beads

Casting/Splinting Half-day session Concentrates on splinting Residents practice on each other

Colonoscopy Half-day session Didactics covers colon CA and screening AccuTouch Endoscopy Trainer We decided this year to begin teaching colonoscopy instead of flexible sigmoidoscopy. Mostly because we weren’t doing flex sigs and will be trying to get into the area of colonoscopy screening.

Colposcopy w/ Biopsy Taught in 2 half-day sessions Half-day of didactics Half day of practice Also covers cervical cryo

Colposcopy Model Model uses: Plastic cup Hot Glue Gun Piece of chuck steak White-out Freezer

Dermatologic Procedures One half-day Multiple procedures Toenail removal Electrocautery Biopsy Shave Excision Punch Cryo Anesthesia techniques Other topics include: Use of dermabond I & D of abscesses Epidermal inclusion cyst removal Treatment of warts Use pig’s feet as models.

Endometrial Sampling Half-day session with Breast cyst Aspiration Didactic session covers: Endometrial CA Evaluation of Postmenopausal bleeding Our model for this workshop is to use a calf’s liver. The ‘skin’ on the surface of the liver gives a bit of a “POP” when the Pipelle enters it, sort of like the sensation you sometimes get as you pass through the cervix. The residents are actually able to aspirate the liver tissue which is very realistic. They then practice threading the plunger back into the Pipelle to put the sample in the formalin container.

Episiotomy Repair Half-day session Model borrowed from Family Centered Maternity Care During this session we review repair of episiotomies and perineal lacerations using the model from the AAFP’s conference. We review 3rd and 4th degree tears as well as 2nd degree.

IUD Insertion Mirena Had 2-hour session with all residents (new procedure for us) Used company’s models.

Joint Injection/Aspiration Half-day session Didactics covers multiple joint anatomy Use Sawbones Models Beeps when joint entered Residents often practice on each other

Sawbones Models Costs: Wrist – Trigger Finger $335 Carpal tunnel First carpal metacarpal joint DeQuervain’s disease Radioulnar and carpal joint Knee – Patella Pouch $335 Tibio-femoral joint space Ilio-tibial bursa Pes Anserine bursa Shoulder – subacromial bursa $345 AC joint Glenohumeral joint space Bicipital Groove Sternoclavicular joint Also have elbow, trunk, hip, and foot/ankle www.sawbones.com

Neonatal Resuscitation Review Taught by our IM/Peds Faculty member Reviews Umbilical Vein Catheterization

Why (wait until) 2nd year? More time in the office. Basic rotations completed. Still have 2 years to “practice” doing procedures. Able to pay more attention to subtle nuances of the office (i.e., billing and coding).

Why the ALSO Course? Resident take the course for the first time during Orientation (July of first year). Much more learned after 2 months of OB rotation.

Why not send them out to a conference? Residents learn to do procedure in your setting with your equipment. Residents learn how to bill and code on your encounter forms. Residents learn from the faculty who will be supervising them.

Other benefits… Only 6 residents More one-on-one teaching Residents get to spend time together as a class Good for morale and bonding Half-day sessions allow thorough review of each procedure. There is evidence from the surgery literature that combining cognitive skills training enhances the ability of residents to correctly execute a surgical skill. We try to do that with our didactic sessions.

Do they really learn? RESIDENT PRETEST (%) POST-TEST (%) 1 68 85 2 57 83 3 78 95 4 70 92 5 63 93 6 We give a pretest and posttest consisting of 34 true-false questions and 14 multiple choice questions. These are the results of our latest group of residents.

One year later… RESIDENT 2004 2005 1 87 % 85 % 2 95 % 3 80 % 77 % 4 93 % 70 % 5 6 88 % 83 % This table shows out last year’s resident group as they scored on the test last year, right after procedure weeks and then a year later on the same quiz.

Resident Satisfaction Study from 2003 (Sharp, et al) “…significant numbers of residents are not being taught certain procedures in a manner that results in residents feeling competent to perform them”. From a survey of 265 Family Practice chief residents done in 2001.

Comfort Level We ask our residents to rate this statement: I now feel comfortable doing this procedure under supervision Average rating is 1.27 (Likert scale with 1 = Strongly agree to 5 = strongly disagree) Lowest rating is for Flexible sigmoidoscopy Score of 2 Procedure that definitely requires practice

Comments from Residents My level of confidence was really elevated with this 2-week procedure learning. Excellent workshop; learned a lot of things that are very important for FP. Cleared up a lot of confusion with billing and the 25 modifier. I am better prepared to do procedures.

Practical Skills Assessment Incorporate practical section of testing Would include evaluation of “critical steps” needed to do each procedure correctly. Done with the same models used in workshop Set up in “stations”.

Competency Checklists Detailed list of critical steps necessary to competently perform each procedure. Each step rated as: Not competent – little/no knowledge Partially competent – able to perform with prompting Fully competent – needs little/no prompting