1. Robert Darios MD FAAFP Kenneth Thompson MD FAAFP STFM Procedures Group
Beyond Watch One Do One Teach One: A Comprehensive Procedures Curriculum for Family Medicine Residents
Robert Darios MD FAAFP
Kenneth Thompson MD FAAFP
STFM Procedures Group

2. Objectives Describe the need for a strong procedural curriculum
Participants will be able to implement a three part structured program with Classroom, Hands on and Evaluative components
Encourage residents to continue offering a wide range of procedures in their practices

3. Current State of Affairs Nationally
Fewer family Physician are doing procedures and they are doing fewer procedures
Medical students are coming into residency with less developed procedural skills
Supervision rules limit both student’s and resident’s ability to perform procedures independently

4. Our Situation Entering residents have less developed procedural skills
Fewer faculty are skilled in procedures
Supervision rules make it hard for residents to work independently
The types of procedures which are performed by Family Physicians in our community are changing. Out with Flex sigs, in with Botox

5. How We Responded Identified key faculty teachers
Established a Required Procedures list
Set up a more structured curriculum
Procedure clinics
Hands on work shops
Objective evaluation tools

6. Key Faculty Teachers Current faculty resources
Is more faculty development and training needed
Outside Preceptors

7. Required Procedures List
Based on STFM task force
Using the A0 A1 A2 terminology
AOA requirements
Local standard of care
Available teaching resources
What procedures are commonly done is changing

8. Sparrow / MSU Family Medicine Residency Core procedures
   
A0: All residents must be able to perform, but documentation not required
A1: All residents must be able to perform independently by graduation. Documented by level 4 or 5 Evaluation, or other equivalent certification.
A2: All residents must be exposed to and have the opportunity to train to independent performance
Skin
Remove corn/callous
Drain subungual hematoma
Skin staples
Fungal studies (KOH)
Laceration repair with tissue glues
Biopsies (AOA)
- Punch, excisional, incisional
Cryosurgery (AOA)
Remove warts, fingernail, toenail, foreign body (AOA)
Incision & drainage of abscess (AOA)
Including perirectal abcess
Simple laceration repair with sutures (AOA)
Electrosurgery
Layered Repair
Maternity care
Spontaneous vaginal delivery, including
Fetal monitoring
Fetal scalp electrode
IUPC & amnioinfusion
Amniotomy
Labor induction/augmentation
1st & 2nd degree laceration repair
3rd & 4th degree laceration repair
Instrumental delivery (Vacuum/Forceps)
Women’s health
Wet mount, KOH (AOA)
Pap smear
Endometrial biopsy
IUD insertion/removal (residents may opt out due to personal reasons)
Breast cyst Aspiration
Paracervical block
Vulvar biopsy
Cervical dilation
Colposcopy
Cervical cryotherapy
Uterine aspiration/ D&C
FNA breast
Bartholin’s cyst management
Remove cervical polyp
Life support courses
ACLS, NRP, ALSO
PALS, ATLS
Musculoskeletal
Initial management of simple fractures
Upper and lower extremity casts
Upper and lower extremity splints
Injection/aspiration (AOA)
- Large joint, bursa, ganglion cyst, trigger point
Reduction of shoulder dislocation
Closed reduction
Reduction of nursemaid’s elbow

9. Ultrasound
Basic OB ultrasound
- AFI, fetal presentation, placental location
U/S guidance for central vascular access, paracentesis, thoracentesis
Advanced OB ultrasound
- dating
- anatomic survey
Urgent Care & Hospital
Foreign body removal
- ear, nose
Ring removal
Fish hook removal
Phlebotomy
Peripheral venous access
Cerumen removal (AOA)
Eye procedures
- Fluorescein exam
- Foreign body removal
Endotracheal intubation (AOA)
Defibrilation (AOA)
EKG interpretation (AOA)
PFT interpretation(AOA)
Slit lamp exam
Ventilator management
Anterior nasal packing for epistaxis
Lumbar puncture
FNA of mass
Thoracentesis
Paracentesis
Arterial line
Central venous catheter
Venous cutdown
Pediatric vascular access
- peripheral, intraosseus, umbilical vein
Gastrointestinal
& Colorectal
Nasogastric tube
Fecal disimpaction
Digital rectal exam
Anoscopy
Flexible sigmoidoscopy
Excision of thrombosed hemorrhoid
Genitourinary
Bladder catheterization (AOA)
Urine Microscopy (AOA)
Newborn circumcision
Vasectomy
Nexplanon
Anesthesia
Topical anesthesia
Local anesthesia/Field block
Peripheral nerve block
Conscious sedation

10. Procedure Workshops Seven to nine a year 2 Hours each
Suturing and tissue handling 2 sessions
GYN procedures IUD EMB Nexplanon
OB procedures IUPC Vacuum perineal repair.
Cast/splint
Joint injections
Musculoskeletal Ultrasound

11. Procedure Clinics Procedures are done are during dedicated clinics
Half day long
Twice a week in our larger office
Once a week in the smaller office
4-6 procedures scheduled
Procedures can be done outside of procedure clinic. Not Rigid

12. Rational
By grouping procedures the resident’s learning curve is steeper
You learn a procedure better by doing 3 in a row the by doing 1 every 3 months
While it wasn’t intended to, it has increased the resident numbers slightly as some faculty will now refer to procedure clinic
Residents love it

13. Evaluation Every procedure is evaluated by the faculty preceptor.
Absolute 5 point scale
1 Assisted the preceptor
2 Hands on assist of the resident
3 Verbal assist ( hands off)
4 Done independently
5 Can teach the procedure

14. Residents are expected to achieve level 4 rating on all required procedures
No specific number is required, competence is
Outside, non residency, preceptors do not have to rank just verify the procedure

15. Challenges
What counts as a procedure? Anything with a CPT code? Wet prep has one
Logging with new innovations
Residents who don’t have enough procedures
Residents who don’t meet competency standards
What “Old” procedures to drop? What “new” ones to add?

16. Logging with New Innovations
New innovations tends to split out procedures by ICD 9 codes. What about ICD 10?
We prefer to lump them by type: skin excisions and biopsies, I&D’s
Residents may only log only one procedure in a category when there really is 10+ procedures in a larger more inclusive category

17. Residents Who Don’t Have Enough Procedures
It’s 4 months to graduation and a particular resident has not done a procedure or only Now what?
Making sure you know early
What can be done now to catch up

18. Residents Who Don’t Meet Competency Standards
A resident has done a reasonable amount but just can’t master the procedure.
Can they still graduate

19. What “Old” Procedures to Drop? What “New” Ones to Add?
In-patient procedures that used to be common place are now being done by a specialized team:
Lumbar puncture, Paracentesis, Thoracentesis, Central and Arterial Lines
Flex Sigs are being replaced by Colonoscopy as “Standard or Care”
Should we add cosmetic procedures, like Botox, Laser hair removal or Chemical peel?

20. What You Need To Do Now Identify key faculty
Develop your list of procedures
What is realistic
What is important
Do you need a dedicated clinic?
Plan workshops: who, when, where, what
Develop evaluation tools