Beyond Watch One Do One Teach One A

Beyond Watch One Do One Teach One: A Comprehensive Procedures Curriculum for Family Medicine Residents Robert Darios MD FAAFP Kenneth Thompson MD FAAFP STFM Procedures Group

Objectives Describe the need for a strong procedural curriculum Participants will be able to implement a three part structured program with Classroom, Hands on and Evaluative components Encourage residents to continue offering a wide range of procedures in their practices

Current State of Affairs Nationally Fewer family Physician are doing procedures and they are doing fewer procedures Medical students are coming into residency with less developed procedural skills Supervision rules limit both student’s and resident’s ability to perform procedures independently

Our Situation Entering residents have less developed procedural skills Fewer faculty are skilled in procedures Supervision rules make it hard for residents to work independently The types of procedures which are performed by Family Physicians in our community are changing. Out with Flex sigs, in with Botox

How We Responded Identified key faculty teachers Established a Required Procedures list Set up a more structured curriculum Procedure clinics Hands on work shops Objective evaluation tools

Key Faculty Teachers Current faculty resources Is more faculty development and training needed Outside Preceptors

Required Procedures List Based on STFM task force Using the A 0 A 1 A 2 terminology AOA requirements Local standard of care Available teaching resources What procedures are commonly done is changing

Sparrow / MSU Family Medicine Residency Core procedures Skin A 0: All residents must be able to perform, but documentation not required A 1: All residents must be able to perform independently by graduation. Documented by level 4 or 5 Evaluation, or other equivalent certification. A 2: All residents must be exposed to and have the opportunity to train to independent performance Remove corn/callous Drain subungual hematoma Skin staples Fungal studies (KOH) Laceration repair with tissue glues Biopsies (AOA) - Punch, excisional, incisional Cryosurgery (AOA) Remove warts, fingernail, toenail, foreign body (AOA) Incision & drainage of abscess (AOA) Including perirectal abcess Simple laceration repair with sutures (AOA) Spontaneous vaginal delivery, including - Fetal monitoring - Fetal scalp electrode - IUPC & amnioinfusion - Amniotomy - Labor induction/augmentation - 1 st & 2 nd degree laceration repair Electrosurgery Layered Repair Endometrial biopsy IUD insertion/removal (residents may opt out due to personal reasons) Breast cyst Aspiration Paracervical block Vulvar biopsy Cervical dilation Colposcopy Cervical cryotherapy Uterine aspiration/ D&C FNA breast Bartholin’s cyst management Remove cervical polyp PALS, ATLS Maternity care Women’s health Wet mount, KOH (AOA) Pap smear Life support courses Musculoskeletal ACLS, NRP, ALSO Initial management of simple fractures Upper and lower extremity casts - Upper and lower extremity splints Injection/aspiration (AOA) - Large joint, bursa, ganglion cyst, trigger point 3 rd & 4 th degree laceration repair Instrumental delivery (Vacuum/Forceps) Reduction of shoulder dislocation Closed reduction Reduction of nursemaid’s elbow

Ultrasound Urgent Care & Hospital Foreign body removal - ear, nose Ring removal Fish hook removal Phlebotomy Peripheral venous access Cerumen removal (AOA) Eye procedures - Fluorescein exam - Foreign body removal Endotracheal intubation (AOA) Defibrilation (AOA) EKG interpretation (AOA) PFT interpretation(AOA) Gastrointestinal Nasogastric tube & Colorectal Fecal disimpaction Digital rectal exam Anoscopy Genitourinary Anesthesia Bladder catheterization (AOA) Urine Microscopy (AOA) Basic OB ultrasound - AFI, fetal presentation, placental location U/S guidance for central vascular access, paracentesis, thoracentesis Advanced OB ultrasound - dating - anatomic survey Slit lamp exam Ventilator management Anterior nasal packing for epistaxis Lumbar puncture FNA of mass Thoracentesis Paracentesis Arterial line Central venous catheter Venous cutdown Pediatric vascular access - peripheral, intraosseus, umbilical vein Flexible sigmoidoscopy Excision of thrombosed hemorrhoid Newborn circumcision Topical anesthesia Local anesthesia/Field block Vasectomy Nexplanon Peripheral nerve block Conscious sedation

Procedure Workshops • • Seven to nine a year 2 Hours each Suturing and tissue handling 2 sessions GYN procedures IUD EMB Nexplanon OB procedures IUPC Vacuum perineal repair. Cast/splint Joint injections Musculoskeletal Ultrasound

Procedure Clinics Procedures are done are during dedicated clinics Half day long Twice a week in our larger office Once a week in the smaller office 4 -6 procedures scheduled Procedures can be done outside of procedure clinic. Not Rigid

Rational By grouping procedures the resident’s learning curve is steeper You learn a procedure better by doing 3 in a row the by doing 1 every 3 months While it wasn’t intended to, it has increased the resident numbers slightly as some faculty will now refer to procedure clinic Residents love it

Evaluation Every procedure is evaluated by the faculty preceptor. Absolute 5 point scale 1 Assisted the preceptor 2 Hands on assist of the resident 3 Verbal assist ( hands off) 4 Done independently 5 Can teach the procedure

Residents are expected to achieve level 4 rating on all required procedures No specific number is required, competence is Outside, non residency, preceptors do not have to rank just verify the procedure

Challenges What counts as a procedure? Anything with a CPT code? Wet prep has one Logging with new innovations Residents who don’t have enough procedures Residents who don’t meet competency standards What “Old” procedures to drop? What “new” ones to add?

Logging with New Innovations New innovations tends to split out procedures by ICD 9 codes. What about ICD 10? We prefer to lump them by type: skin excisions and biopsies, I&D’s Residents may only log only one procedure in a category when there really is 10+ procedures in a larger more inclusive category

Residents Who Don’t Have Enough Procedures It’s 4 months to graduation and a particular resident has not done a procedure or only 1 -2. Now what? Making sure you know early What can be done now to catch up

Residents Who Don’t Meet Competency Standards A resident has done a reasonable amount but just can’t master the procedure. Can they still graduate

What “Old” Procedures to Drop? What “New” Ones to Add? In-patient procedures that used to be common place are now being done by a specialized team: Lumbar puncture, Paracentesis, Thoracentesis, Central and Arterial Lines Flex Sigs are being replaced by Colonoscopy as “Standard or Care” Should we add cosmetic procedures, like Botox, Laser hair removal or Chemical peel?

What You Need To Do Now Identify key faculty Develop your list of procedures What is realistic What is important Do you need a dedicated clinic? Plan workshops: who, when, where, what Develop evaluation tools