1. Assessment and Intervention Enhances the Acquisition of Procedural Skills in Medicine David W. Musick PhD, Robert G. Carroll PhD, and Luan Lawson-Johnson MD Office of Medical Education, Division of Academic Affairs, Brody School of Medicine, East Carolina University Email: musickd@ecu.edumusickd@ecu.edu Abstract Procedural skills education for medical students is increasingly difficult to teach and assess. As education shifts to a competency-driven approach, the need to “re-establish the clinical skill development process” 1 is paramount. This project examined data from internal (M4 medical students) and external (residency program directors) surveys concerning proficiency in a designated set of clinical procedural skills. Skill acquisition by medical students is enhanced by a combination of internal and external assessment procedures. Introduction The education of future physicians involves the development of three distinct components well-described by Bloom et al 2 :  Cognitive, or the knowledge base required to practice medicine  Affective, or the attitudes & professionalism expected of physicians  Psychomotor, or the clinical and procedural skills required to practice medicine within a specific specialty (e.g., Surgery, Family Medicine, Pediatrics) The development of these three components occurs initially during the four years of medical school, wherein students learn what is expected and receive the MD degree. This training then continues within a 3-7 year residency training period in a specialty field, whereupon they complete their formal training and are then granted the opportunity to practice medicine independently. The teaching and assessment of required procedural skills for medical students has traditionally been unstructured, with students encouraged to seek out opportunities to practice procedures as they presented themselves within the inpatient or outpatient facilities of a teaching institution. This approach contributed to variability in the skill level of students graduating with the MD degree. More recently, the traditional approach of “see one, do one, teach one” has been supplemented by use of standardized patients, simulation technology and computer-based learning. These are now widely proposed as viable and safer methods of allowing students to practice their skills prior to the initial performance of a procedure with an actual patient. The clinical faculty of the Brody School of Medicine developed a formal curriculum pertaining to procedural skills in 2005-2006 and introduced it during the 2006-2007 academic year. The curriculum consisted of 35 specific procedures that were assigned across the first 3 years of the overall medical school curriculum. The majority of the skills were to be taught and assessed during year 3, which is the core clinical training year. Skills ranged from simple to complex, and were categorized broadly as those which could be performed using actual patients, or those that could be performed using a combination of actual patients and simulated experiences. The need to develop more explicitly measured and formal curricula for medical student procedural skills has been emphasized by the primary professional organization representing medical schools, the Association of American Medical Colleges 1,3. However, there have been very few published research studies about the effectiveness of such curricula, with only two publications located during the initial time period of this project 4,5. Results Materials and Methods We completed two surveys, one external and one internal. The external survey asked residency program directors of BSOM graduates to rate our graduates on their “basic procedural skills” along with 27 other aspects of clinical medicine. The internal survey asked six consecutive classes of senior medical students to report their experiences with the procedural skills curriculum during their four years of medical school. The external survey was launched first, and contributed important data to our decision to develop the formal skills curriculum. Internal data from 2007-2009 were used to design a new required 4 th year course in Emergency Medicine that emphasized procedural skills. Data from the 3 years after implementation of the course were used to assess impact. Conclusions References The AAMC Project on the Clinical Education of Medical Students. Washington, DC: Association of American Medical Colleges, 2004. Bloom, Benjamin S. & David R. Krathwohl. Taxonomy of educational objectives: The Classification of Educational Goals by a Committee of College and University Examiners. New York, Longmans Publishers, 1956. Recommendations for Clinical Skills Curricula for Undergraduate Medical Education. Washington, DC: Association of American Medical Colleges, 2005. Langdale LA; Schaad D; Wipf J; et al. Preparing Graduates for the First Year of Residency: Are Medical Schools Meeting the Need? Academic Medicine 2003; 78 (1): 39-44. Sanders CW; Edwards JC; Burdenski TK. A Survey of Basic Technical Skills of Medical Students. Academic Medicine 2004; 79 (9): 873-5. Engum, SA. Do You Know Your Students’ Basic Clinical Skills Exposure? The American Journal of Surgery 2002; 186: 175-81. Survey of Senior Medical Students, BSOM (2007-2012) Experiences with Brody Procedural Skills Curriculum YearRating Trend Compared to Baseline (06) 20063.70 n/a 2007 3.68- 20083.82+ 20093.63- 20103.81+ 20113.81+ External Rating of Basic Procedural Skills of BSOM Graduates (2006-2011) by their Residency Program Directors Skill Class of 2007200820093 Year Avg New EM Course 2010201120123 Year Avg TrendChange 1 Suction tracheostomy - sterile technique 6361455654383743--13 2 KOH/exam of skin 665155574644 45--12 3 Dressing change 88949392100629887--5 4 Oxygen tank: crack tank, assess flow 6171476043616456--4 5 Urinalysis/dipstick only (not microscopic exam) 8090768269788878--4 6 Biopsy, skin/excision or punch 7680727674786773--3 7 Thoracentesis (pleural tap) 14161816652813--3 8 Labor and delivery, normal vaginal 92989394969394 =0 9 Strep: rapid test/throat swab 96 979694989496=0 10 Hemoccult blood testing 94 889289959493+1 11 Suturing (removal of skin sutures) 9896 97100989698+1 12 KOH/vaginal smear/wet mount/pap smear/collect 94969495100969497+2 13 Suturing (removal of skin staples) 98 96971009810099+2 14 Suturing (simple) 98 9095969810098+3 15 Intubation/observe &perform 585758 48687062+4 16 Paracentesis (abdominal tap) 2226122022203024+4 17 Chest tube/observation 5669676467736869+5 18 Pulse oximetry: apply & validate sensing 7488727876859284+6 19 Catheterization, urethral/Foley 84 8986911009896+10 20 Fingerstick glucose measurement/obtain only 6880767574889686+11 21 Arterial blood gas/collect only (not interpret) 384532384851 50+12 22 Arthrocentesis 4235293533555347+12 23 Anesthesia, local infiltration 7884717889 9892+14 24 Metered dose inhaler (MDI)/instructions for use 5873516172738075+14 25 Lumbar puncture 4453434752627764+17 26 Injection: SCIMID 4947314244767164+20 27 Nasogastric/oralgastric intubation 2241263037675452+22 28 Venipuncture 3763424765 8070+23 29 Splinting only/not casting 4255474867698373+25 30 Nebulizer treatment 4759455065798777+27 31 Abscess incision/drain 6859606281959691+29 32 Blood culture/collection (adult) 20 282237657057+35 33 Catheter/IV, peripheral insertion 4953485072889485+35 34 Electrocardiogram/lead placement 514750497898 91+42 The new curriculum in required procedures increased the numbers of students who reported experience with procedural skills. Adding a mandatory Emergency Medicine rotation, which emphasized procedural skills, contributed to increased number of student opportunities to learn procedures. Certain procedures were likely less available during the study period, due to an increased regulatory burden and decreased frequency in the academic setting. As a result of this study, consideration of further changes to the formal procedural skills curriculum is indicated. Internal Survey of Graduating Physicians 2007-2012 Average improvement after introduction of required Emergency Medicine rotation: 9.7% Bars in same sequence as internal survey data table