1. Patient Discomfort and Resident Confidence after Intra-Articular Injection Simulation Training: A Randomized Controlled Trial
ADAE O. AMOAKO MD, NEHA KAUSHIK MD, TIMOTHY D. RILEY MD1;
AND GEORGE G.A. PUJALTE MD2
1Department of Family and Community Medicine,
Penn State Hershey Medical Center, Hershey, PA
2Sports Medicine, Divisions of Primary Care, and Orthopedics,
Mayo Clinic Health System, Waycross, GA

2. Disclosures
Dr. Pujalte is part-owner of Ridonk, LLC®, a company that develops medical applications (“apps”).
Dr. Riley has no disclosures

3. Background Arthritis and other MSK diseases
Over 40 million adults
60 million by 2020
May need intraarticular injections
Family physicians expected to know how to perform knee intraarticular injections

4. Background
“The goal of family practice training is to produce fully competent physicians capable of producing high quality care…of which should include procedure skills which are within the scope of family practice.” – ACGME

5. Background
“Family medicine residencies should strive to teach... procedures done by a substantial number of practicing family physicians, both in the ambulatory and inpatient settings” – AAFP

6. Background Injection workshops and trainings
Increased confidence and preparedness in Internal Medicine residents
Limited studies in Family Medicine

7. Purpose of study
Does extra simulation training have an effect on the comfort level of Family Medicine residents being trained to do knee injections, and the pain level felt by their patients as they perform the injections?

8. Study Design Randomized controlled trial
Family medicine residents at Penn State Milton S. Hershey Medical Center randomized into two groups
Penn State Hershey IRB-approved

9. Methods The intervention group The control group
2 simulations sessions
1 patient encounter
The control group
Typical training
No model simulation
Patients who needed steroid injections anyways
Patients consented to take part in study at time of injection
Reminders hung in resident and attending work areas with details of study protocol to facilitate obtaining injections
Results ed to investigators

10. Methods Measured Outcomes
Pain level of procedure as described by patient
Scale of 1-10
Comfort level of resident
Very comfortable
Somewhat comfortable
Not comfortable
Not very comfortable
Attending asked patient level of pain after procedure
Asked resident level of comfort in doing the procedure

11. Methods
Data Analysis
A Wilcoxon Rank Sum test was used in calculating all p-values
P < 0.05 was defined as the level of statistical significance
Statistical Analysis System (SAS), version 9.3 (SAS Institute Inc.)

12. Results 29 Residents 3 Didn’t Participate 26 Participated Intervention
Control
Investigators
Opted Out 12 14 2 1

13. Preliminary Results Intervention group Control group
6 out of 12 patient encounters
Control group
7 out of 14 patient encounters

14. Preliminary results Comfort Level Comparison
Comparison of Intervention and Control Group by Residents’ Comfort Level
Study group
Total
(n = 26)
Encounters
Mean
Min
Max
P-value
Intervention 12 6
1.20
1.00
2.00
0.057
Control 14 7
2.13
4.00

15. Comparison of Intervention and Control Group by Patients’ Pain Level
Preliminary results
Pain Level Comparison
Comparison of Intervention and Control Group by Patients’ Pain Level
Study group
Total
(n = 26)
Encounters
Mean
Min
Max
P-value
Intervention 12 6
1.80
0.00
4.00
0.156
Control 14 7
3.63
1.00
9.00

16. Limitations of study Small sample size Technique
Supervising faculty influence
Pilot study, not expecting statistical significance
One technique taught on model; attendings may use other techniques during patient care
Relationship with faculty, skill of faculty, extent and quality of pre-procedure prep

17. Preliminary conclusion
Residents in the intervention group were more comfortable with the procedure with a difference that approached significance
We found a nonsignificant trend toward decreased pain during the procedure for the intervention group

18. Implication of study
Model simulation training may boost residents’ comfort level and reduce patient discomfort during corticosteroid knee injections.
Further study with larger sample size is needed to characterize extent of effect
Similar research could be considered for steroid injection involving other joints
Another avenue for future study could be whether residents with higher level of comfort are more likely to perform the

19. Acknowledgement Erik Lehman MS
Penn State Hershey Department of Public Health Sciences

20. References
Okkes IM, Polderman GO, Fryer GE, et al. The role of family practice in different health care systems: a comparison of reasons for encounter,diagnoses, and interventions in primary care populations in the Netherlands,Japan, Poland, and the United States. J FamPract ; 51:72–73.
The American Academy of Family Practice. Procedural Skills. ( Accessed July, 29, Hershey, PA: ACGME 2013.
Lisa K. Sharp, Ralph Wang, and Martin S. Lipsky. Perception of Competency to Perform Procedures and Future Practice Intent: A National Survey of Family Practice Residents. Acad Med. 2003;78:926 –932.
Wigton, RS., Alguire, P. The declining number and variety of procedures done by general internisist: A resurvey of members of the American College of Physicians. Ann Intern Med. 2007; 146:
Jolly, M, Curran JJ. Underuse of intra-articular and peri-articular corticosteroid injections by primary care physicians. J Clin Rheum Vol 9;3.
Gormley GJ, Corrigan M, et. Al. Joint and soft tissue injections in the community: questionnaire survey of general practitioners’ experiences and attitudes. Ann Rheum Dis 2003;62:61-64.