1. Development of a Competency-based Family Medicine Residency Ambulatory Procedural Skill Training Program Tricia C. Elliott, M.D., F.A.A.F.P. Program Director, Baylor College of Medicine/Kelsey-Seybold Clinic Family Medicine Residency Program Clinical Assistant Professor, Baylor College of Medicine Department of Family & Community Medicine

2. Workshop Goals Present a systematic approach of one residency program’s development of a competency-based ambulatory procedure skill training curriculum Present the list of “core” ambulatory procedures in which residents are trained along the six core competencies Discuss the online competency-based evaluation tool and log for procedures

3. Workshop Objectives Understand logistical steps and structural components of developing a procedure curriculum. Obtain examples of a competency-based procedure evaluation tool and log. Develop specific “core” set of required office- based procedures for individual family medicine residency training program

4. Project Objectives Develop a “core” set of required office-based procedures for a Family Medicine residency training program Develop an ambulatory procedural skill training curriculum based on these specific “core” procedures along a patient-centered model that trains residents along the six core competencies Develop a web-based competency-based evaluation tool for residents and faculty

5. Methods Location Baylor College of Medicine/Kelsey-Seybold Family Medicine Residency program, Houston, Texas The program is a community-based, university- sponsored program in a multispecialty group practice setting

6. Methods 1.Survey of faculty and residents to establish core procedures and initial self-reported competency for each procedure 2.Reorganization of Family Medicine Center (FMC) procedure room and supplies to create a supportive systems-based practice 3.FMC staff orientation for all established procedures

7. Methods 4.Quarterly 3 to 4 hour procedure workshops for residents annually 5.Faculty-developed “core” procedure manuals 6.Web-based/PDA core competency-based evaluation tool and log

8. Methods 7.Establish a FMC procedure clinic staffed by second and third year residents 8.Procedure coding classes 9.Post residency survey to evaluate continued competency and relevance of residency procedure training for the first year of practice

9. Resident Survey The survey listed the most common ambulatory procedures, categorized by systems, taught in at least 50% of family medicine residency programs 2,4 and those taught by some nationally recognized procedural training institutions.

10. Resident Survey List of Procedures Dermatology –Incision & Drainage –Sebaceous Cyst Excision –Suturing –Skin biopsy –Cryosurgery –Ingrown Toenail Removal Musculoskeletal –Casting & Splinting –Joint Injection –Joint Aspiration

11. Resident Survey List of Procedures Gynecology –Pap smear –Wet mount/KOH –Colposcopy –Cervical biopsy –Endocervical curettage –LEEP/Cervical conization –Endometrial sampling Gynecology (cont.) –Endocervical polypectomy –Bartholin’s cyst/abscess –IUD insertion –IUD removal

12. Resident Survey List of Procedures Cardiology –EKG interpretation –Cardiology Stress Testing Gastrointestinal –Flexible sigmoidoscopy Other –Circumcision of the Newborn –Vasectomy –Botox injections –Microdermabrasion/ Chemical peels –Laser hair/vein removal

13. Resident Survey 1.Importance for performing as a physician in future practice after residency 2.Opportunities for adequate training in residency 3.Self-assessed competency for performing each procedure.

14. Procedure Room Reorganization FMC has one main procedure room, along with another main supply room A procedure room and supply room inventory was performed, with the help of the FMC Nurse Coordinator.

15. Procedure Room Reorganization The faculty were surveyed in regards to the types of procedures they perform and the supplies and equipment they commonly utilize for each procedure. This data was compiled to create a new standard FMC supply list and order adequate number and types of tools and equipment. Information collected to create faculty- personalized procedure profiles

16. Nurse and Staff Orientation A procedure nurse was identified and assigned to facilitate the maintenance of the procedure room and to be assigned to the procedure clinic. Mandatory procedure nursing orientation sessions for all FMC nurses were conducted. Instructions for all procedures, which included equipment, supplies, and methods, were posted in the procedure room, along with pictures of the different tools to aid nurses in identifying the proper equipment

17. Procedure Workshops Creation and implementation of focused quarterly 3 to 4 hour procedure training workshops for the residents Didactic presentations with breakout practical sessions with hands-on training for the residents supervised by faculty Speakers include family medicine faculty and specialty faculty

18. Procedure Workshops Each resident is given a bound “core” procedure manual at each workshop that is specifically created by the procedure faculty to include the goals, objectives, schedule, detailed instructions and equipment list for each procedure, key articles, nursing instructions, consent forms, coding, and patient education handouts. Each resident completes a workshop evaluation at the end of each workshop.

19. Procedure Workshops Dermatology Dermatology & Cosmetic Procedures Joint Injection I (Knees & Shoulders) Joint Injection II (Hands, Wrists, Elbows, Feet & Ankle) Casting and Splinting Cardiac Stress Testing Gynecologic Procedures (upcoming)

20. “Core” Procedure Manuals

21. Web-based Core Competency-Based Evaluation Tool and Log Key component in meeting the competency evaluation standards required by the ACGME. E*Value ™ residency management software system –user-friendly and enables the residents to log the procedures they perform, along with providing the flexibility to create program- generated procedure evaluations that can define and list the core procedures and establish the criteria for competency for these procedures

22. Web-based Core Competency-Based Evaluation Tool and Log Created an evaluation tool for E*Value ™ that clearly defines criteria under each of the six core competencies At the end of each procedure evaluation, the evaluator must answer whether the resident is able to perform the procedure competently and independently Each procedure has a set minimum required to achieve competency

23. Web-based Core Competency-Based Evaluation Tool and Log Parameters to evaluate each competency: 1.Patient Care –Performing a history –Performing appropriate physical examination –Appropriate gathering and interpretation of information –Patient counseling –Discusses with patient the prior therapies and alternatives to the procedure –Informed consent discussed and obtained

24. Web-based Core Competency-Based Evaluation Tool and Log 2.Medical Knowledge –Understands and verbalizes indications and contraindications for procedure, along with the risks and benefits –Outlines steps of the procedure –Appropriate equipment selection –Appropriate patient preparation –Appropriate anesthesia selection –Proper execution /technique –Recognition of pathology –Understands how to manage complications –Appropriate outcome –Aftercare and Follow up

25. Web-based Core Competency-Based Evaluation Tool and Log 3.Practice-Based Learning & Improvement –Evaluates performance and follows through with needed improvements –Develops a team approach with nurses/medical assistants

26. Web-based Core Competency-Based Evaluation Tool and Log 4.Interpersonal & Communication Skills –Demonstrates therapeutic relationship with patient and family –Provides thorough explanations to patient throughout procedure –Considers patient comfort throughout procedure –Positions patient appropriately and respectfully –Answers patient’s questions effectively –Communicates with team/assistant effectively

27. Web-based Core Competency-Based Evaluation Tool and Log 5.Professionalism –Accepts responsibility –Demonstrates sensitivity to cultural issues, age, and disability –Acts in best interest of the patient 6.Systems-based Practice –Demonstrates understanding of practice –Advocates for best quality care and most cost- effective approach

28. Procedure Clinic FMC Procedure clinic staffed by a second or third year resident and the procedure nurse Supervised by faculty Occurs one session biweekly All FMC faculty and residents can refer patients in need of procedures provided by the procedure clinic Second and third year residents additionally staff Family Planning/Women’s Health procedure clinic two to three times yearly

29. Procedure Clinic FMC Procedures Performed –incision & drainage –sebaceous cyst excision –skin biopsy –cryosurgery –ingrown toenail removal –joint/cyst/bursa injection and/or aspiration –endometrial biopsy –IUD insertion –IUD removal

30. Coding Compliance Classes Conducted by our Kelsey-Seybold Coding Compliance department These classes are incorporated in the regular didactic sessions, such as in weekly noon conferences or biweekly core curriculum classes CPT and ICD-9 codes included in procedure manuals

31. Post Procedure Curriculum Survey Plan to conduct post-residency surveys of our graduates to evaluate continued competency, performance of procedures in practice, and relevance of residency procedure training for the first year of practice Re-survey the third year residents who have completed three years of the curriculum

32. Conclusions The Procedure Curriculum had an overall positive impact on residents’ opportunities in training and self-assessed competency for dermatology, musculoskeletal, and certain gynecology and cardiology procedures Procedures are an integral component of residency training and in practicing family medicine Residents desire to have broad-based procedural training during the residency training period

33. Conclusions Resident opinion varies with regards to the importance of performing various ambulatory procedures in future practice Self-assessed competency often reflect the limitations in opportunities for these procedures in training and vary from not proficient in areas such as flexible sigmoidoscopy, circumcision, vasectomy, and cosmetic procedures to adequately proficient or highly proficient in dermatology, gynecology and musculoskeletal procedures

34. Conclusions We developed an initial “core” list of office-based procedures for family medicine residency training. – (a) dermatology: incision & drainage, sebaceous cyst excision, suturing, skin biopsy, skin cryosurgery, ingrown toenail removal –(b) gynecology: pap smear, wet mount/KOH, endometrial biopsy, IUD insertion, IUD removal –(c) musculoskeletal: casting & splinting, joint/bursa/cyst injection, joint/bursa/cyst aspiration

35. Conclusions Highlights need for consensus and a “core” set of required ambulatory procedures for family medicine residency programs, along with standardized competency-based evaluations for these procedures These proposed steps are useful components to create a comprehensive ambulatory procedural skill family medicine residency training curriculum that incorporates and measures all six core competency requirements and graduates residents who are competent and highly proficient in procedures relevant to practice

36. Acknowledgements Brenda Brehm, MS, Kelsey Research Foundation Oscar Wehmanen, Kelsey Research Foundation Troy Tucker, Program Administrator All residents from 2006-2007 to current Nicholas Solomos, MD, Associate Program Director, BCM/Kelsey-Seybold Clinic FMRP

37. Bibliography/References 1.American Academy of Family Physicians (www.aafp.org)www.aafp.org 2.Norris TE, Felmar E, Tolleson G. Which procedures should be taught in family practice residency programs? Family Medicine, 1997 Feb; 29(2):99-104. 3.Phelps KA, Taylor CA. The role of office-based procedures in family practice residency training. Family Medicine, 1996 Sep; 28(8):565-9. 4.Tenore JL, Sharp LK, Lipsky MS. A national survey of procedural skill requirements in family practice residency programs. Family Medicine, 2001 Jan; 33(1):28-38. 5.Wickstrom GC, Kelley DK, Keyserling TC, et al. Confidence of academic general internists and family physicians to teach ambulatory procedures. J Gen Intern Med 2000 Jun; 15(6):353- 60. 6.Accreditation Council for Graduate Medical Education (www.acgme.org)www.acgme.org 7.Norris TE, Cullinson S, Stephan D. Teaching procedural skills. J Gen Intern Med 1997; 12 Suppl 2 (April): 64-70. 8.Wetmore SJ, Rivet C, Tepper J, et al. Defining core procedure skills for Canadian family medicine training. Can Fam Physician 2005; 51:1364-65 9.Rivet C, Wetmore SJ. Evaluation of procedural skills in family medicine training. Can Fam Physician 2006; 52:561-62.