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Gynecologic Procedural Workshops on a Shoestring Budget

Gynecologic Procedural Workshops on a Shoestring Budget. Sanford Lax, MD St. Joseph Mercy Livingston Family Medicine Program slax@ipcmd.com. Colposcopy and Endometrial Biopsy: Where did these Gynecologic procedures go?. Problem.

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Gynecologic Procedural Workshops on a Shoestring Budget

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  1. Gynecologic Procedural Workshops on a Shoestring Budget Sanford Lax, MD St. Joseph Mercy Livingston Family Medicine Program slax@ipcmd.com

  2. Colposcopy and Endometrial Biopsy:Where did these Gynecologic procedures go?

  3. 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

  4. 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..

  5. 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

  6. Changing Epidemiology • Change in Cytologic definitions • Consensus Guidelines ASCCP • Aging Population • HPV Vaccines • ACOG PAP/HPV Guidelines

  7. 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.

  8. 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

  9. Simulation Model Creation R&D Model and Hypothesis

  10. 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

  11. 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.

  12. 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

  13. Developing the Model • Requirement: simplicity and minimal cost • Ability to produce multiple units for large workshop • Ease of use • Adaptability for multiple procedures

  14. Inception

  15. 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

  16. The Workshop R&D

  17. 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

  18. 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

  19. Speculum

  20. Chicken Breast with TCA Markings

  21. Endometrial Biopsy Model

  22. Endometrial Pipelle Placement

  23. Cervical/Uterine Simulator for Endometrial Biopsy

  24. 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

  25. 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

  26. 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?

  27. 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.

  28. 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.

  29. 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

  30. 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

  31. Experimental Trials

  32. 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.

  33. 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.

  34. Acknowledgements

  35. Faculty and Residents St. Joseph MercyLivingston Family Medicine Residency

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