Overview:
The procedures curriculum is intended to be a longitudinal experience comprised of lectures, focused experiences (rotations) and office-based experiences.
Goals:
- Define the expectations and requirements for procedural training during residency.
- Provide a structured educational experience in procedural medicine.
- Provide a structured system to ensure that residents are adequately trained to perform desired procedures within the scope of Family Medicine.
- Document the experience of residents in performing procedures to assist in supervision and credentialing.
Objectives:
At the completion of the three-year curriculum residents will:
- Demonstrate technical competence to perform the required procedures at a proficient level to a supervising physician. (PC)
- Explain the indications, contraindications, risks and benefits of the procedures they are trained to perform to a supervising physician. (MK)
- Be able to discuss the details of relevant procedures with patients and be able to obtain appropriate informed consent for a procedure. (ICS)
- Discuss the limitations of their training and the need to refer appropriate patients for further care with a supervising physician. (SBP)
Implementation:
Educational Methods
Procedural education is intended to be a three-year longitudinal experience. While it is anticipated that the bulk of in-office procedural experience will occur in the second and third years of residency, this curriculum aims to educate residents during all three years of their training. Some experiences, particularly hospital-based procedures, will be most accessible during the first year of training.
The curriculum will consist of scheduled lectures on various procedures appropriate to family medicine as indicated in attachment A. Procedural workshops will be held for specific procedures as documented in attachment B. Residents will also be expected to gain additional knowledge through independent study in preparation to perform procedures. Relevant reference materials will be available and provided by the program for each of the required procedures.
Focused procedural experiences will occur under the direction of family medicine and specialty faculty on specific rotations. Residents are encouraged to gain procedural experience during their required and elective rotations.
Office procedures and education will be supervised by the family medicine faculty and other appropriate physicians.
Resident Responsibilities
Residents are expected to perform procedures on their continuity patients as medically necessary.
Procedures will be performed under direct supervision of a physician qualified to perform the procedure until a resident has been approved to perform a particular procedure independently. The process for gaining this approval is documented below. It is expected that a resident will gain approval for all required procedures prior to graduation. For those procedures not required for graduation, the recommendation of the residency program for gaining privileges for a desired procedure will be based on meeting the criteria for independent performance during residency. A complete list of required and partial list of elective procedures can be found in attachment C.
Approval for Independent Performance of Procedures (“Sign Off”):
- Every procedure will be supervised until a resident is “signed off” for that procedure
- A resident may perform a procedure unsupervised if they have been “signed off” for that procedure. (Certain advanced procedures may require supervision until graduation despite being “signed off.” All procedures performed in the clinic must be discussed with a supervising physician prior to starting the procedure.)
- A positive recommendation for granting of privileges will be made for those procedures for which a resident has been “signed off.”
Resources
Pfenninger, JL, Fowler, GC, Pfenninger and Fowler’s Procedures for Primary Care, Second Edition, Mosby, St. Louis , 2003.
Methods of Evaluation
Residents will receive multiple evaluations throughout their procedural training. Immediate instruction and feedback will be given for each supervised procedure performed. Each procedure performed will be documented in the residency procedure documentation system, which allows for faculty evaluation of each procedure. Finally, when seeking approval for independent performance of a procedure, a formal evaluation tool and oral exam will be completed with an attending for that procedure. See details of this process below.
Procedure for “Sign Off” Approval:
- A designated minimum number of procedures will be performed.
- The resident must then inform a supervising physician (attending or fellow) who performs the particular procedure that they wish to be approved.
- That physician observes the resident perform the procedure without assistance from the faculty.
- That physician also quizzes the resident on detailed aspects of the procedure, possible complications, and variations.
- An evaluation sheet is completed by the observer.
- If the resident performs the procedure adequately, discusses indications contraindications and follow up appropriately, and adequately addresses the observer’s questions including possible complications and management of them adequately, they may be signed off.
- This approval must be supported by the program director and the resident’s team leader.
- The resident will be informed and a record will be kept of which procedures can be performed independently.
- Residents are encouraged to learn to perform additional procedures within the scope of Family Medicine that are not specifically addressed in this curriculum. An individual plan for these experiences will be designed by the resident and approved by the program director.
Required procedures to complete prior to graduation:
Excisional skin biopsy (1)
Punch/shave skin biopsy (3)
Skin laceration repair (5)
Incision and drainage (3)
Anoscopy (2)
Joint/bursa aspiration/injection (5)
Casting/splinting application (5)
Endotracheal intubation (5)
Lumbar puncture (5)
Vaginal delivery (40)
Delivery of continuity OB patient (c-section or vaginal) (10)
Pediatric Circumcision (5)
Interpretation of Fetal Monitoring Test (1)
Management of ICU/Critical Care patient (15)
