1. ©2015 MFMER | slide-1 Procedure Clinic Training Confidence and Competence Jason O’Grady MD Eva Fried MD, MHP

2. ©2015 MFMER | slide-2 Outline The relevance of formal Procedure Training in Family Medicine Residency The Impact of procedure training What is known? What is unknown Overview of the Mayo FM Procedure Clinic Our Study design and scope

3. ©2015 MFMER | slide-3 Relevance of FM resident procedure training ACGME: The performance of “specialty-appropriate procedures to meet the health care needs of individual patients, families, and communities” was named as a key component of the Family Medicine Milestones project. 1 STFM: The STFM Group on Hospital and Procedural Training have issued consensus statements on required and advanced procedures to be included in all Family Medicine training programs. 2,3 Residents and Physicians: Harper Et al identified a significant positive correlation has been between program emphasis on procedural raining and successful recruitment. 4 Tucker et al showed a lack of training and experience during residency is a common reason for limiting the scope of procedural practice. 5

4. ©2015 MFMER | slide-4 Core Procedures Core procedures which a resident must be able to perform upon graduation per the STFM consensus statement. 2 Biopsies Cryosurgery Nail, Wart, Foreign Body removal Incision and Drainage Simple laceration repair Spontaneous Vaginal Delivery Vacuum-Assisted Delivery Pap Smear Vulvar Biopsy Bartholin’s Cyst Management Cervical Polyp removal Endometrial Biopsy IUD insertion/removal FNA Breast ACLS, PALS, ATLS, ALSO Closed reduction and Splinting of fractures Injection/Aspiration of joints, bursa, cysts, trigger points Reduction of Nursemaid’s elbow Basic Prenatal US Ultrasound Guidance for Central Venous Access, paracentesis, thoracentesis Fluorescein Exam Eye Foreign Body removal Anterior nasal packing Lumbar Puncture FNA of Mass Anoscopy Excision of thrombosed hemorrhoid I&D of perirectal abscess Perianal skin tag removal Newborn circumcision Topical and local anesthesia

5. ©2015 MFMER | slide-5 Impact of resident procedure training What is known? Increased number of procedures during training associated with increased self-assessed confidence and competence. 6,7 Association between experience and confidence also shown in medical school graduates. 9 Rural trainees tend to do more procedures, have more confidence. 8 Males: more experience, higher self-assessed competence. 7,10 Confidence and Competence vary by training structure but not modality. 11 Strongest effect seen with: Workplace based training Close proximity to clinical practice Opportunity for practice spaced over weeks to months.

6. ©2015 MFMER | slide-6 Impact of resident procedure training What is unknown? Confidence vs. competence Most studies published to date report self-assessed competence reported on a likert scale Barnsley et al found no correlation between self- assessed competence and observed competence in procedural and cognitive skill. 12 Clanton et al found increased correlation between self-assessed and observed competence only after training. 13 Best method of non-experience-based teaching Byrne et al found no superiority of one training method when comparing lecture, computer based, simulation, and video assisted feedback. 11

7. ©2015 MFMER | slide-7 Mayo Clinic FM Procedure Clinic Dedicated clinic, staffed by FM consultants, PAs, and NPs (3 providers per half day) Average 7.1 procedures per half day per provider 12 half days of training, usually in 2 week blocks, required in each year of residency Common procedures include: –Scalpel-free vasectomy –Joint/Bursa injections –Peripheral nerve blocks –Skin biopsies –IUD placement/removal –Nexplanon placement –Cryosurgery –Endometrial Biopsy –Nail removal –Frenulotomy –Neonatal circumcision –Skin tag removal

8. ©2015 MFMER | slide-8 Our Study Design and Scope Question: What is the impact of Procedure Clinic Training on… Self Assessed Confidence Competence as assessed by a consultant supervisor Future practice plans Resident Pre and Post Training surveys: Number of each procedure performed Confidence in performing the procedure Intent to perform the procedure in future practice Interest in including procedure in future practice if further training were available Before and After Surveys – Consultant Resident competence at performing each procedure 24 residents participating in procedure clinic in a given year.

9. ©2015 MFMER | slide-9 Results to date Five residents have completed the survey 100% reported that they would include the listed procedures in future practice if adequate training were available. Several were unsure if they would include frenulotomy, vasectomy, cryosurgery in future practice.

10. ©2015 MFMER | slide-10 Citations 1.ACGME Program Requirements for Graduate Medical Education in Family Medicine. 2014. Available at: https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf. https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf 2.Nothnagle M, Sicilia JM, Forman S, et al. Required procedural training in family medicine residency: a consensus statement. Fam Med. 2008;40(4):248–52. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18481404.http://www.ncbi.nlm.nih.gov/pubmed/18481404 3.Kelly BF, Sicilia JM, Forman S, Ellert W, Nothnagle M. Advanced procedural training in family medicine: a group consensus statement. Fam Med. 2009;41(6):398–404. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19492186.http://www.ncbi.nlm.nih.gov/pubmed/19492186 4.Harper MB, Mayeaux EJ, Pope JB, Goel R. Procedural training in family practice residencies: current status and impact on resident recruitment. J Am Board Fam Pract. 1994;8(3):189–94. Available at: http://www.ncbi.nlm.nih.gov/pubmed/7618497.http://www.ncbi.nlm.nih.gov/pubmed/7618497 5.Tucker W, Diaz V, Carek PJ, Geesey ME. Influence of residency training on procedures performed by South Carolina family medicine graduates. Fam Med. 2007;39(10):724–9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17987415.http://www.ncbi.nlm.nih.gov/pubmed/17987415 6.Boots RJ, Egerton W, McKeering H, Winter H. They just don’t get enough! Variable intern experience in bedside procedural skills. Intern Med J. 2009;39(4):222–7. doi:10.1111/j.1445-5994.2009.01699.x. 7.Connick RM, Connick P, Klotsas AE, Tsagkaraki P a, Gkrania-Klotsas E. Procedural confidence in hospital based practitioners: implications for the training and practice of doctors at all grades. BMC Med Educ. 2009;9:2. doi:10.1186/1472- 6920-9-2. 8.Goertzen J. Learning procedural skills in family medicine residency Comparison of rural and urban programs. Can Fam Physician. 2006;52. Available at: http://www.cfp.ca/content/52/5/622.short. Accessed September 2, 2014. 9.Promes SB, Chudgar SM, Grochowski CO, et al. Gaps in procedural experience and competency in medical school graduates. Acad Emerg Med. 2009;16 Suppl 2:S58–62. doi:10.1111/j.1553-2712.2009.00600.x. 10.Sharp LK, Wang R, Lipsky MS. Perception of competency to perform procedures and future practice intent: a national survey of family practice residents. Acad Med. 2003;78(9):926–32. Available at: http://www.ncbi.nlm.nih.gov/pubmed/14507626. 11.Byrne AJ, Pugsley L, Hashem M a. Review of comparative studies of clinical skills training. Med Teach. 2008;30(8):764–7. doi:10.1080/01421590802279587. 12.Barnsley L, Lyon PM, Ralston SJ, et al. Clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence. Med Educ. 2004;38(4):358–67. doi:10.1046/j.1365-2923.2004.01773.x. 13.Clanton J, Gardner A, Cheung M, Mellert L, Evancho-Chapman M, George RL. The relationship between confidence and competence in the development of surgical skills. J Surg Educ. 2014;71(3):405–12. doi:10.1016/j.jsurg.2013.08.009.