VOL 52: MAY • MAI 2006 Canadian Family Physician•Le Médecin de famille canadien
561
Editorials
Evaluation of procedural skills in family medicine training
Christine Rivet,
MD CM, MCLSC, CCFP(EM), FCFPStephen Wetmore,
MD, MCLSC, CCFP, FCFPP
rocedures are regarded as an integral part of fam- ily medicine. There are many advantages to doing procedures in the offi ce: patients are more satisfi ed if procedures are done by their family physicians1,2; phy- sicians are able to provide continuity of care; procedures cost less than they would if performed by specialists; wait times are shorter; and physician satisfaction is greater.1 Studies show that family physicians are more likely to perform procedures in their practices if they received training for those procedures during residency.3,4Currently, the College of Family Physicians of Canada (CFPC) does not evaluate procedural skills on the Certifi cation Examination in Family Medicine. This does not indicate a lack of interest in promoting or evaluating procedures but, perhaps, a realization of the diffi culty of assessing procedures. Several experts have identifi ed the evaluation of procedural skills as the most challeng- ing aspect of developing procedural skills curricula.5-7
The curriculum for teaching procedural skills is not standardized, and, therefore, training varies widely among the 16 family medicine programs.8 This lack of standardization makes evaluation diffi cult. Yet the authors of an American national survey of procedural skill requirements in family practice residency have challenged educators: “If one accepts that procedural skills are a fundamental part of family practice training, then our specialty must assure core competency for a residency graduate.”9
Because evaluation drives the curriculum, the CFPC has an essential role and responsibility in the evalua- tion of procedural skills. There is a precedent with the patient-centred method: when this became the focus of the Certifi cation oral examinations (or simulated offi ce orals), training centres ensured that the patient- centred method was taught and learned in all the training programs.
Two important steps
There are 2 important initial steps the CFPC should take to ensure that all residents learn core procedures during their training. First, the CFPC should include standards for curricula on procedures in the Red Book of Standards for Accreditation of Residency Training Programs: Family Medicine; Emergency Medicine;
Enhanced Skills; Palliative Medicine. Second, the CFPC should include evaluation of procedures on the national Certifi cation examination.
The CFPC’s Working Group on Procedural Skills has developed a core group of procedural skills that all resi- dents should learn during their training; this is described in an article by Wetmore et al in the October 2005 issue of Canadian Family Physician.10 A core list accomplishes several goals: it allows residents to be aware of exactly which skills they need to master; it clarifi es the scope of family medicine for hospital medical advisory commit- tees; and it creates a guide for family medicine educators to develop explicit criteria for assessing competence.9
There are several ways to include procedures on the Certifi cation examination. Procedures can be evaluated using short-answer management problems, which could be created to review the steps of a procedure or the indi- cations, contraindications, and precautions. This would be particularly useful with such procedures as intrauter- ine device insertion or toenail removal that have many steps but few real-life opportunities for practice.
National Objective-Structured Clinical Examinations (OSCEs) would be expensive but could be considered, as OSCEs are currently being offered by the Medical Council of Canada for all residents after 18 months of training and by the Quebec College of Family Physicians for their combined Certifi cation examination and pro- vincial licensing examination. The administration fees for these examinations are more than $1000 per res- ident. Using OSCEs in family medicine departments might be less expensive and more feasible. Realistic models, such as the breast cyst aspiration model, could produce valid evaluation but are expensive. Realistic models for other procedures could be developed by curriculum-development groups to facilitate the trans- fer of skills and could be used for resident training and evaluation. Many simple, creative models are inexpen- sive and effective for training. One example of a breast cyst model is a balloon filled with flour and bath-oil beads, which readily simulates the technical aspects of the procedure.11 Practising suturing using pigs’ feet is a time-honoured method of training and could be used for evaluation. The use of checklists during OSCEs is impor- tant to ensure reliability of performance.
Evaluation of procedural skills in a national exami- nation would allow assessment of only specifi c skills for a few procedures, but it would also allow evaluation of such aspects as comfort with technical procedures and facility with instruments. This should provide some reas- surance for certifi cation bodies about skills training in
FOR PRESCRIBING INFORMATION SEE PAGE 654
➛
562
Canadian Family Physician•Le Médecin de famille canadien VOL 52: MAY • MAI 2006Editorials
general. Evaluation of procedural skills during examina- tions should supplement, but not replace, observation of procedural skills by a clinical preceptor. Such in-training evaluations of residents are useful for real-life assess- ments of performance for common procedures, such as cryotherapy, skin biopsies, and incision and drainage of abscesses. Real-life observation has many strengths.
Because it focuses on actual problems in clinical prac- tice, residents are motivated by its relevance. It permits more than the evaluation of procedural skills: it is the only setting that allows evaluation of the integration of history taking, doctor-patient relationship, decision making, and empathy.12 Clinical settings, however, do have drawbacks. The procedure experience provided varies from setting to setting and depends on clinical opportunities, preceptor interest, and availability. The training experience can be maximized by improving on validity and reliability with the use of checklists. Without structured criteria, 2 evaluators often disagree with each other when assessing a learner.13
The Working Group on Procedural Skills and other groups under the guidance of the CFPC’s Committee on Examinations could create step-by-step checklists of each procedure for family medicine training programs.
Individual family medicine programs could train resi- dents to assess their colleagues. This would improve the knowledge and skills of those being assessed and those performing assessments.
Earlier introduction
The more common procedures, such as incision and drainage of abscesses, could be taught to medical stu- dents during family medicine rotations and electives by family medicine faculty and residents. Students entering family medicine residency would then have these skills, and it would increase the presence and contribution of family medicine at the undergradu- ate level. Harper and colleagues found a positive cor- relation between the number of procedures taught in family medicine programs and successful residency recruiting.14 This might offer a needed boost to the recruitment of medical students to family medicine residency programs.
Training programs
The CFPC should increase the number of continuing medical education events on procedural skills and link them to Mainpro® credits to increase the ability of aca- demic family physicians to teach procedural skills.
Similarly, training programs need to give higher prior- ity to procedural skills training. This should be reflected in faculty recruitment and curriculum development.
Such strategies as procedural skills clinics and referrals from family physicians to family medicine training sites could also be used to increase the opportunities for resi- dents to learn procedures.
We need a combination of methods to evaluate resi- dent performance of procedures effectively. To increase performance of procedures in practice, we need to high- light office procedures at all levels of medical education:
medical school, residency programs, and continuing medical education.
It is time for action in teaching and evaluating proce- dural skills. The CFPC can provide leadership by focus- ing on the following steps:
• promote adoption of a core list of procedures by fam- ily medicine training programs;
• encourage curriculum development for procedural skills training, including development of practical models to facilitate skills transfer, especially for less common clinical procedures;
• encourage in-training evaluation involving procedural skills assessment; and
• evaluate core skills training on the national Certification examination.
Dr Rivet is an Associate Professor in the Department of Family Medicine at the University of Ottawa in Ontario, and Dr Wetmore is an Associate Professor in the Department of Family Medicine at the University of Western Ontario in London.
Correspondence to: Dr Christine C. Rivet, Family Medicine Centre, 210 Melrose Ave, Ottawa, ON K1Y 4K7;
telephone 613 761-4334; fax 613 761-4200;
e-mail rivet@uottawa.ca
The opinions expressed in editorials are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
References
1. Sharman J. Patient’s response to a general practice minor surgery service.
Practitioner 1986;230:27-9.
2. DeWitt DE. Skills training in primary care residency. Problems and solutions from the family practice perspective. Postgrad Med 1987;81(2):155-62.
3. Al-Turk M, Susman J. Perceived core procedure skills for Nebraska family physicians. Fam Pract Res J 1992;12:297-303.
4. Pringle M, Hasler J, DeMarco P. Training for minor surgery in general practice during preregistration surgical posts. BMJ 1991;302:830-2.
5. Sierpina VS, Volk RJ. Teaching outpatient procedures: most common settings, evaluation methods, and training barriers in family practice residencies. Fam Med 1998;30(6):421-3.
6. Wigton RS. Measuring procedural skills. Ann Intern Med 1996;125(12):1003-4.
7. Lancaster CJ, Johnson AH, Hamadeh GN. Survey of family medicine residents evaluation methods. Fam Med 1993;25(10):646-9.
8. Van der Goes T, Grzybowski SC, Thommasen H. Procedural skills training. Canadian family practice residency programs. Can Fam Physician 1999;45:78-85.
9. Tenore JL, Sharp LK, Lipsky MS. A national survey of procedural skill require- ments in family practice residency programs. Fam Med 2001;33(1):28-38.
10. Wetmore SJ, Rivet C, Tepper J, Tatemichi S, Donoff M, Rainsberry P. Defining core procedure skills for Canadian family medicine training. Can Fam Physician 2005;51:1364-5.
11. Delva D, Tomalty L, Payne P. Fine needle aspiration of breast lumps [Practice Tips]. Can Fam Physician 2002;48:1055-6.
12. Spencer J. Learning and teaching in the clinical environment. BMJ 2003;326:591-4.
13. Reznick RK. Teaching and testing technical skills. Am J Surg 1993;165(3):358-61.
14. Harper MB, Mayeaux EJ Jr, Pope JB, Goel R. Procedural training in family practice residencies: current status and impact on resident recruitment. J Am Board Fam Pract 1995;8(3):189-94.
