Procedural Skills: Reality or Simulation

1
Procedural Skills Reality or Simulation

• 7th Annual Jasper Medical Education Conference
• Dr Chris de Gara

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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

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

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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

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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
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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

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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

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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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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)
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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

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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.

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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
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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

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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?

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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
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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

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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
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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
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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

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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
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Histoquest - Dr David Begg
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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

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