Procedural skills training during residency

Evidence

The literature on procedural skills training during residency is sparse. Incoming students begin residency with varying degrees of procedural exposure in medical school; in most cases, this previous exposure is marginal.⁷ It is not clear what proportion of family medicine residency programs offer dedicated procedural training, which is concerning as resident practices typically offer fewer opportunities to perform procedures compared with the practices of attending physicians.⁸ Fortunately, residents who receive direct hands-on procedural training report increased comfort and competency with those procedures.⁹ Not surprisingly, such training also makes residents more likely to offer these options to their patients.^10,11 Finally, it is worth considering the impact of potential expansion of the postgraduate program from 2 to 3 years in length. Although this will naturally provide residents with additional time to practise and solidify their procedural skills, to our knowledge, there are no data to suggest that similar levels of competence could not be achieved in the shorter time span with intentional exposure and education.

Our experience

As our family medicine residency program moved toward a competency-based model, we became increasingly concerned that our residents were not acquiring sufficient experience to achieve true competence in a number of core procedures. Residents themselves also expressed discomfort with some of these procedures, sharing that they felt underprepared to perform them independently upon graduation. In response, we established a procedure clinic at our family medicine training site (University Health Network–Toronto Western Family Health Team at the University of Toronto in Ontario). Our goal was to ensure that all of our residents had adequate exposure to the identified core procedural skills to achieve competency.

The clinic was first piloted in the 2013-2014 academic year. Four preceptors with procedural experience were recruited to supervise the clinic. None of these preceptors had specialized training; rather, they had accumulated experience through clinical practice, continuing medical education, and mentorship opportunities. The clinic was scheduled every 2 weeks during the first year of residents’ core family medicine rotation. Using a combination of educational priorities and clinical needs within our unit, we determined which procedures would be offered or performed: biopsies and excisions of skin lesions, joint injections, endometrial biopsies, and intrauterine device insertions.

Referrals were solicited from within our own clinic (ie, attending physicians were requested to book their patients into the procedure clinic rather than perform indicated procedures themselves). This allowed procedures to be concentrated within the dedicated resident clinics, permitting deliberate exposure and education.

In our first iteration, 10 first-year residents were divided into 2 groups. The intervention group was scheduled into the procedure clinic, while the control group continued to perform procedures in their regular clinics on an ad hoc basis. Preintervention and postintervention surveys were administered to both groups, examining the number of procedures completed during the 6-month pilot and residents’ subjective confidence in their skills on a scale from 1 to 10. Data from the residency program’s online patient tracker were also compared before and after the intervention for both groups. Procedural competence was evaluated and recorded using standardized field notes, but these were not formally compared across groups due to high variability in numbers and types of procedures performed.

The introduction of a dedicated procedure clinic to the family medicine residency program at our site appeared to successfully increase residents’ exposure to several standard office procedures (Figures 1 and 2); it also increased their level of confidence in executing these procedures, as well as their overall subjective preparedness for practice on a scale from 1 to 10 (Figures 3 and 4).

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Figure 1.

Procedures performed by the procedure clinic group vs the control group

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Figure 2.

Number of procedures performed during data collection period

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Figure 3.

Subjective confidence in various procedure types in the procedure clinic group vs the control group: Residents rated confidence on a scale from 1 to 10.

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Figure 4.

Readiness to practise in the procedure clinic group vs the control group: Residents rated readiness to practise on a scale from 1 to 10.

Given these findings, the procedure clinic was integrated into our core training program and has run highly successfully in the years since its introduction. In the intervening time, we used an iterative quality improvement approach to address some of the challenges we experienced in earlier years. For example, we were occasionally referred patients who were better suited to the scopes of dermatologists and plastic surgeons, so we fine-tuned our referral process (ie, developed a standardized referral form listing the provided services) to minimize these referrals. We also created information sheets for patients so that they would know what to expect following referral (including potential costs for services not covered by the Ontario Health Insurance Plan), and we have worked to maintain and expand our patient volumes and preceptor skill sets.

The procedure clinic continues to be highly active and well-rated by our residents. Since its inception, our residents have served a total of 801 patients and have biopsied or excised 450 skin lesions, treated 145 skin tags or warts, excised 116 cysts, performed 28 endometrial biopsies, placed 24 intrauterine devices, injected 32 joints, and performed 5 circumcisions.