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Procedural Skills: Reality or Simulation

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digital block anaesthesia. Sigmoidoscopy. Tracheotomy. Digital block anaesthesia. advocated by 75% of students. done by 83% of family physicians ... – PowerPoint PPT presentation

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Title: Procedural Skills: Reality or Simulation


1
Procedural Skills Reality or Simulation
  • 7th Annual Jasper Medical Education Conference
  • Dr Chris de Gara

2
Medical 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

3
Learning 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

4
The clinical skills contradiction
We teach these-
..but we rely on these-
5
The 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

6
Undergraduate 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

7
What 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
8
Undergraduate 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

9
The 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)
11
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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)
14
Suture 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

16
Results 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.

17
A needs assessment study of surgical
educationBirch D Mavis B Can J Surg 49 (5) 335
340 2006
18
Procedural 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
19
AAMC 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

20
Procedural 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?

21
Proportion 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.
22
Emphasis Placed on Skills by Schools, Family
Physicians and Students
High Agreement
Mid Agreement
Low Agreement
23
Summary
  • 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

24
Summary
  • 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

25
A survey of procedures performed by Canadian
family physicians Turner S Cave A Hanson J de
Gara C Submitted
N 423
26
Towards 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
27
Questions
  • 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

28
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29
The 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
?
30
Current Teaching Approaches
Ignore the issue!
Mannequins
or
LimbsandThings.com
Virtual reality
Simulators
31
Histoquest - Dr David Begg
32
The 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

33
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34
Interactive Web Based Virtual Reality for
Cricothyrotomy
35
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36
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37
Procedure Teaching in the Future
Using simulation
By practicing on patients
or leaving it to residency or maybe never!
38
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