Title: Procedural Skills: Reality or Simulation
1Procedural Skills Reality or Simulation
- 7th Annual Jasper Medical Education Conference
- Dr Chris de Gara
2Medical History for the First Week in May
- May 2nd
- b.1903 Benjamin Spock American paediatrician
- May 4th
- 1892 Arthur Conan Doyle writes to Joseph Bell
(1837 1911) surgeon to the Royal Infirmary and
identifies him as his primary model for Sherlock
Holmes - May 5th
- 1881 Louis Pasteur public demonstration of
vaccination - May 6th
- b. 1856 Sigmund Freud
- 1954 Roger Bannister English medical student runs
the mile in 359.4 - May 7th
- 1889 Johns Hopkins Hospital opens
3Learning Objectives
- Upon completion of the presentation participants
will - Have been made aware of the AAMC recommended
procedure skills list and the inconsistency of
its adoption - Be provided with evidence of procedures performed
by students and family physicians and their
procedure related needs - Be introduced to an approach to learning
procedure skills being developed at the
University of Alberta
4The clinical skills contradiction
We teach these-
..but we rely on these-
5The Procedure Skill Contradiction
- see one .. do one .. teach one!
- The blind leading the blind??
- Matthew 1514
- Senior learners (with no specific training)
teaching junior learners - Delegated off to allied health professionals
- Who taught you how to insert a Foley catheter?
- Low priority on most medical school curricula
- cf. knowledge, communication, professionalism etc
etc - Yet major patient safety issue
- eg up to 30 complication rate from central line
insertion when performed by the inexperienced
6Undergraduate Procedures Research at the
University of Alberta
- What procedures are students doing during
undergraduate surgical clerkship? - Ladak A, Hanson J, de Gara C Can J Surg 49 (5)
329 334 2006 - A needs assessment study of surgical education
- Birch D Mavis B Can J Surg 49 (5) 335 340 2006
- Procedural skills whats taught, what ought to
be? - Turner S, Hanson J, de Gara C In press Education
for Health - A survey of procedures performed by Canadian
family physicians - Turner S Cave A Hanson J de Gara C Submitted
- Towards acquiring procedural competency
- Barkhurst J Begg D de Gara C Teaching Learning
and Education grant U of A
7What procedures are students doing during
undergraduate surgical clerkship?Ladak A, Hanson
J, de Gara C Can J Surg 49 (5) 329 334 2006
Adil Ladak PGY2 Plastic Surgery
8Undergraduate Surgery University of Alberta
- Pre curriculum change (2001)
- In 4th year
- 8 weeks in duration
- 24 lecture series in 2nd year
- Evaluations
- Pre- Post rotation MCQ
- 8 station OSCE
- clerkship evaluation by preceptors
- Post-curriculum change
- In 3rd year
- Only general surgery
- Specialty surgery for 6 weeks in 4th year
- 6 weeks
- No pre-rotation lecture series
- Evaluations
- Pre- Post rotation MCQ
- 8 station OSCE
- clerkship evaluation by preceptors
9The Study
- Logbooks
- Chatenay Warnock 96
- Paper experience log analysed
- Daily student recording
- clinical encounters
- surgical assists
- procedures performed
- Completed both pre- (1999-2001) and post- (2001
-2003) curriculum change
10 Central venous cannulation femoral, jugular or
subclavian
100
90
before
80
after
70
60
Percent of Students
50
40
30
20
10
0
0
1
2
3
4
5
Procedures Completed (p 0.392)
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12 Naso-gastric tube insertion and removal
before
after
100
90
80
70
60
Percent of Students
50
40
30
20
10
0
0
1
2
3
4
5
Procedures Completed (p 0.001)
13 Foley catheter insertion (male or female)
100
before
90
after
80
70
60
Percent of Students
50
40
30
20
10
0
0
1
2
3
4
5
Procedures Completed (p 0.222)
14Suture insertion and removal
100
before
90
after
80
70
60
Percent of Students
50
40
30
20
10
0
0
1
2
3
4
5
Procedures Completed (p 0.996)
15 16Results Summary
- In 8 of 15 procedures
- gt 50 of students did not do procedure at least
once - In 3 of 15 procedures
- gt 80 of students did not do procedure at least
once - In only 3 procedures did gt 50 of students do the
procedure 5 or more times.
17A needs assessment study of surgical
educationBirch D Mavis B Can J Surg 49 (5) 335
340 2006
18Procedural skills whats taught, what ought to
be?Turner S, Hanson J, de Gara C In press
Education for Health
Simon Turner 4th year PGY1 General Surgery
19AAMC Procedure Skill Guidelines
- 1999 AAMC recommends teaching of procedural
skills in medical school - 8 skills
- the medical school must ensure that before
graduating a student will have demonstrated
competency in - Foley insertion
- IV starts
- Venepuncture
- NG tube insertion
- Lumbar puncture
- Arterial puncture
- Suturing
- Thoracentesis
20Procedural skills Whats Taught, What Ought to
Be?
- Literature review
- 13 papers
- 152 procedures
- 24 skills sited gt 4 times
- Survey monkey
- 79 US Canadian Associate Deans
- What do they teach?
- 423 Family Canadian Physicians
- What do they do?
- 243 U of A medical students
- What would they like to learn?
21Proportion of Schools Teaching Skills ()
Figure 1. Proportion of schools teaching skills
(). No skills were recommended or required by
all responding schools, including the 8 AAMC
recommended skills. 3 skills were taught by
less than half of the schools.
22Emphasis Placed on Skills by Schools, Family
Physicians and Students
High Agreement
Mid Agreement
Low Agreement
23Summary
- No skill identified in the study taught by all
medical schools - 8 AAMC recommended skills taught by majority of
schools - Thoracentesis taught by only 59 of schools
- 3 skills not taught by majority of schools
- digital block anaesthesia
- Sigmoidoscopy
- Tracheotomy
- Digital block anaesthesia
- advocated by 75 of students
- done by 83 of family physicians
- only taught by 45 of schools
24Summary
- Sigmoidoscopy and tracheotomy
- done by few family physicians
- advocated by over 70 of students
- 43 taught sigmoidoscopy (rigid
proctosigmoidoscopy) - 27 taught tracheotomy
- Only
- Foley catheterization
- Pap smear
- Venepuncture
- taught at a higher rate than requested by
students done by GPs
25A survey of procedures performed by Canadian
family physicians Turner S Cave A Hanson J de
Gara C Submitted
N 423
26Towards acquiring procedural competencyBarkhurst
J, Ahn J, Caldwell C, Brisbourne M, Palmer T,
Walji, A Begg D, de Gara C Teaching Learning
Education grant U of A
Judson Barkhurst 4th year AHFMR studentship
Justin Ahn 3rd year CIHR studentship
27Questions
- How can students (and other allied health
professionals) acquire a level of competency in
clinical procedures that will, if ever be seen,
but have the potential to be life saving without
endangering patients? - Who are we teaching procedure skills for?
- To better equip students for residency?
- Students ultimate career?
- If certain procedures are now delegated acts
(Foley, NG tube, venepuncture) or best performed
by specialists (thoracentesis, lumbar puncture)
should precious time be better spent teaching
such procedures or more on a needs basis
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29The Procedure Skills Matrix
common
rare
- Cricothyrotomy
- Needle thoracoscopy
- Arrest of hemorrhage
- Lumbar puncture
- Venepuncture
- Foley catheterisation
- IV start
- Pap smear
vital
- NG tube insertion
- Thoracentesis
- Central line insertion
- Anoscopy
less vital
?
30Current Teaching Approaches
Ignore the issue!
Mannequins
or
LimbsandThings.com
Virtual reality
Simulators
31Histoquest - Dr David Begg
32The Study
- Goal to provide students (3rd year surgical
clerks) with a measure of competency in rare but
potentially life saving procedures - Cricothyrotomy
- (Needle thoracoscopy)
- (Arrest of arterial hemorrhage)
- Multifaceted approach
- Pre- post evaluation MCQ
- Didactic teaching session web based
- Virtual reality knowledge acquisition and
performance of procedure self directed - Mannequin based procedure performance
- Faculty evaluation of video using validated
assessment tool
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34Interactive Web Based Virtual Reality for
Cricothyrotomy
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37Procedure Teaching in the Future
Using simulation
By practicing on patients
or leaving it to residency or maybe never!
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