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Transcript of Gynecologic Procedural Workshops on a Shoestring Budget Sanford Lax, MD St. Joseph Mercy Livingston...
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Gynecologic Procedural Workshops on a Shoestring Budget
Sanford Lax, MDSt. Joseph Mercy LivingstonFamily Medicine Program
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Colposcopy and Endometrial Biopsy:Where did these Gynecologic procedures go?
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Problem
• Rapidly decreasing gynecologic procedure volumes in FM training programs
• How do we train our residents on decreased procedure volumes
• How can we provide a realistic simulation to boost skill and confidence
• Procedural competency requires repetition
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Background
• Decreased volume of procedures in all FP and OB/GYN training programs
• 1994, Colposcopy training in 93% of programs• 2001, Colposcopy training in 81% of programs • 2001, Endometrial biopsy training in 76% of
programs• How do we compensate for this decrease in
procedure volume?• Tenore et. al., Sierpina, et. al..
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• Procedural competency requires repetition• 1989, old definitions of cytologic abnormalities
provided large quantities of abnormal PAPs and prior treatment guidelines provided a high case load.
• New Cytology/Pathology criteria and treatment algorithms - ASCCP
• By 2011, a full time family physician may only see a few abnormal PAP smears yearly
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Changing Epidemiology
• Change in Cytologic definitions • Consensus Guidelines ASCCP• Aging Population• HPV Vaccines• ACOG PAP/HPV Guidelines
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Survey of Training Techniques in FM Residencies
• FMC direct teaching and supervision 74%• Specialty clinics 62%• Workshops 46%• Procedure rotations 23%• Video 19%• Lectures 12%• Sierpina, et. al.
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Problem
• Rapidly decreasing gynecologic procedure volumes in FM training programs
• How do we train our residents on decrease procedure volumes
• How can we provide a realistic simulation to boost skill and confidence
• Procedural competency requires repetition
![Page 9: Gynecologic Procedural Workshops on a Shoestring Budget Sanford Lax, MD St. Joseph Mercy Livingston Family Medicine Program slax@ipcmd.com.](https://reader035.fdocuments.net/reader035/viewer/2022062620/551b475e550346d31b8b4acc/html5/thumbnails/9.jpg)
Simulation Model Creation
R&DModel and Hypothesis
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Goals for Model
• Simulate the anatomical/spacial relationships of the vagina, cervix and uterus for colposcopy and endometrial biopsy
• Simulate the mechanics of colposcopy and endometrial biopsy
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Hypothesis
• Procedure training with this simple model for coloposcopy and endometrial biopsy will improve resident confidence and proficiency.
• Procedure training with this model will increase the percentage of residents who will perform colposcopy and endometrial biopsy in their post-graduate practice.
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Hypothetical Solution and Research Model
• Procedural training through simulation• Development of training models• Development of training workshops• Testing the model for proficiency• Testing the Hypothesis and Outcomes
• Brotzman and Apgar 1998• Apgar et al, Colposcopy: Principals and Practice• George and Doto
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Developing the Model
• Requirement: simplicity and minimal cost• Ability to produce multiple units for large
workshop• Ease of use• Adaptability for multiple procedures
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Inception
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Supplies
• PVC plumbing supplies– 2” T with end cap and adaptor– Dr. Apgar created a similar model in 1996
• Welch-Allyn Speculum• Total cost < $15/unit• Media for Cervical simulation
– Potato– Chicken breast
• Media for Endometrial Bx simulation– Toilet float bulb and washers– Rubber ball with canal drilled out– Kiwi and Papaya have also been utilized
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The Workshop
R&D
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Principles of Procedural TrainingGeorge and Doto 2001
• Overview for learner so they may understand the procedure
• Demonstration of procedural skill• Instructor repeats the procedure with detailed
instruction• Learners talk through the procedure• Learner performs the skill
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Model and Workshop
• Didactic Lectures on procedures– Colposcopy and ASCCP Guidelines– Colposcopy Slides (Apgar)– Endometrial Biopsy
• Station hands on training with Faculty supervision• Pre- and post-test knowledge assessment• Pre- and post-workshop survey• Compare individual resident knowledge and survey
data longitudinally (coded for privacy)• George et. al.2001, Delzell et. al. 2001
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Speculum
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Chicken Breast with TCA Markings
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Endometrial Biopsy Model
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Endometrial Pipelle Placement
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Cervical/Uterine Simulator for Endometrial Biopsy
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Test Workshop
• Test workshops with this model were performed in 2009 and 2010 for all residents at our Family Medicine Residency.
• Residents were satisfied with the model and it ease of use.
• A current research protocol is being developed to test the hypothesis.– Will require repetition of workshop 2-4x a year or
individual retesting and practice
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Survey Tools
• Pre and Post Colposcopy confidence scale• Pre and post Endometrial Bx confidence scale• Program evaluation/satisfaction/Usefulness
scales• Pre and post Likelihood of procedural practice
after graduation• Pre and post-test knowledge assessment
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Pre and Post Workshop Survey
• How many colposcopies have you performed?• What is your skill level with Colposcopy? ( 1= novice,
5= expert )• Do you expect to perform colposcopy in your future
practice?• How may endometrial biopsies have you performed?• What is your skill level with endometrial biopsy? ( 1=
novice, 5= expert )• Do you expect to perform endometrial biopsy in your
future practice?
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Colposcopy Survey
• Rank this colposcopy workshop’s usefulness. • This workshop boosted my confidence
performing colposcopy.• I will perform colposcopy in my future
practice.• I would recommend this colposcopy workshop
to a fellow resident.
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Endometrial Biopsy Survey
• Rank this endometrial biopsy workshop’s usefulness.
• This workshop boosted my confidence performing endometrial biopsy.
• I will perform endometrial biopsy in my future practice.
• I would recommend this endometrial biopsy work shop to a fellow resident.
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Trial of Experimental Model
• FM residents were satisfied with this model for simulation of colposcopy and endometrial biopsy
• Potato was preferred over chicken breast for simulating the feel of a colposcopic biopsy
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Current Research
• IRB submission of research project• Refinement of measurement survey tool• Search for participating programs in our region
– Each program would require its own IRB review• Optimizing training sessions per year
– Workshop vs individual self study and testing• Individual resident data compared longitudinally for
increased power of smaller numbers– Coded for individual privacy
• Future research and use of Model– Cervical Dysplasia Treatment - LEEP /Cryotherapy
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Experimental Trials
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References
• 1. Tenore Josie L., SM, Sharp Lisa K., Lipsky Martin S. A National Survey of Procedural Skill Requirements in Family Practice Residency Programs. Family Medicine 2001 Jan, 33(1), 28-38.
• 2. Sierpina Victor S., Volk Robert J. Teaching Outpatient Procedures: Most Common Settings, Evaluation Methods, and Training Barriers in Family Practice Residencies. Family Medicine 1998 June, 30(6), 421-423.
• 3. Nothnagle Melissa, Sicilia Julie M., Forman Stuart , Fish Jeremy , Ellert William, Gebhard Roberta, Kelly Barbara F., Pfenninger John L., Tuggy Michael, MacMillan Rodney Wm., STFM Group on Hospital Medicine and Procedural Training. Required Procedural Training in Family Medicine Residency: A Consensus Statement. Family Medicine 2008 April, 40(4), 248-252.
• 4. Kelly Barbara F., Sicilia Julia M., Forman Stuart, Ellert William, Nothnagle Melissa. Advanced Procedural Training in Family Medicine: A Group Consensus Statement. Family Medicine 2009 June, 41(6), 398-404.
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• 5. Brotzman Gregory L., Apgar Barbara S. Assessing Colposcopic Skills: The Instructors Handbook. Family Medicine 1998 May, 30(5), 350-355.
• 6. Delzell John E. Jr., Pereira Susan L., Ruplinger Jacqueline. Colposcopy 101: A Didactic Curriculum to Compliment the Clinical Experience. Family Medicine 2001 October, 33(9), 658-660.
• 7. George John H., Doto Frank X. A Simple Five-step Method for Teaching Clinical Skills. Family Medicine 2001 September 33(8), 577-578.
• 8. Sparks Rhonda A., Bessley Andrea D., Jones Andrew D.. The “Sponge Perineum:” An Innovative Method of Teaching Fourth-degree Obstetrical Perineal Laceration Repair to Family Medicine Residents. Family Medicine 2006 September 38(8), 542-544.
• Paul Maureen, Nobel Kristin. Papaya: A Simulation Model for Training in Uterine Aspiration. Family Medicine 2005 April 37(4), 242-244.
• 9. Apgar, B Brotzman, G Spitzer, M. Colposcopy: Principles and Practice, 2nd Edition, Philadelphia, Elseiver in press.
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Acknowledgements
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Faculty and Residents St. Joseph Mercy
Livingston Family Medicine Residency