Minor surgical procedures. Faculty development workshop

Minor surgical procedures Faculty development workshop L. Nasmith, MDCM, MED, CCFP E.D. Franco, MD, MPH

PROBLEM ADDRESSED Minor surgical procedures are an important part of general practice. Family medicine faculty members must feel competent in performing common office procedures in order to teach them to residents. OBJECTIVE OF PROGRAM To upgrade the skills of 25 family medicine faculty members in minor surgical procedures through a half-day workshop. MAIN COMPONENTS OF PROGRAM The workshop covered seven procedures: removal of lumps and bumps, basic suturing, intrauterine contraceptive device insertion, endometrial biopsy, casting and splinting, injection of joints, and office microscopy. Small groups of faculty members spent 30 minutes at each station where brief didactic sessions were followed by hands-on practice. The workshop was evaluated using an evaluation form immediately after the workshop and questionnaires before and 6 months after. CONCLUSION Teaching minor surgical procedures is an essential part of the curriculum in a family medicine residency program. A faculty development workshop in minor surgical procedures is one means of upgrading the skills of faculty members in order to ensure that they can teach adequately in this area.

PROBLEME Les interventions de chirurgie mineure sont une composante importante de l'exercice de l'omnipratique. II est essentiel que les professeurs de medecine familiale soient competents dans l'execution de ces techniques courantes en cabinet afin de bien les enseigner aux residents. OBJECTIF DU PROGRAMME Par un atelier d'une demi-journee, ameliorer les habiletes de 25 professeurs medecins de famille dans le domaine des techniques de chirurgie mineure. PRINCIPALES COMPOSANTES DU PROGRAMME L'atelier couvrait sept interventions: exerese de bosses et de tumefactions, sutures de base, insertion de sterilets contraceptifs, biopsie de l'endometre, attelles et platres, injections intra-articulaires et microscopie en cabinet. Chaque station offrait 'a un petit groupe de professeurs une session de 30 minutes incluant theorie et pratique. L'valuation de l'atelier comprenait un formulaire d'evaluation 'a completer immediatement au terme de l'atelier et des questionnaires 'a remplir avant la tenue de l'atelier et six mois plus tard. CONCLUSION L'enseignement des techniques de chirurgie mineure est une composante essentielle de tout programme de residence en medecine familiale. L'atelier de formation professorale dans le domaine des techniques de chirurgie mineure offre un moyen d'ameliorer les habiletes des professeurs et de s'assurer que leur enseignement est adequat.

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inor surgical procedures are an important part of general practice. In order to ensure that family physicians are skilled in this area, the College of Family Physicians of Canada requires as one of its criteria for accreditation that all residency training programs teach these skills.1 There appears to be general agreement in the literature on which procedures should be provided in outpatient primary care.` These include a variety of minor operations, such as excision of cysts and other skin lesions; suturing lacerations; intrauterine contraceptive device insertion; injection or incision of hemorrhoids; resection of ingrown toenails; and injection of joints, bursae, and tendons. Proponents of providing these services argue that performing minor surgery in general practice is more cost-effective and practical than sending patients to specialists.7 One British study estimated savings of £15000 ($30000) to a local health authority in 1 year if one general practitioner performed four procedures weekly.6 Patients expressed greater satisfaction because of the perceived personalized service provided by their own physicians8 and shorter delays in obtaining treatment.7 Specialists who perform minor procedures have raised concerns that family physicians and GPs are not competent to provide this type of care. These specialists claim that because GPs do not perform many operations,9 they are inexperienced, make faulty diagnoses, and inappropriately treat such conditions as malignant skin lesions.'0 To counter this criticism, a study in Great Britain demonstrated that since 1990, as the number of minor procedures performed by GPs increased, there was no erosion of the quality of care. No change was seen in the waiting time to see a GP, the accuracy of diagnosis, the use of histology, the adequacy of excisions, or the rate of complications." To acquire the skills for performing minor procedures competently, family physicians require adequate training either during residency'2" 3 or as continuing medical education.3 Such training could consist of oneon-one practical sessions, study days, or practice audits that would ensure that practitioners are both competent in minor surgical procedures and able to recognize their limits.'4 Family physicians should teach their own residents as well as their peers. Dr Nasmith, a Fellow of the College, is Associate Professor and Chair, and Dr Franco is a Research Associate, in the Department of Family Medicine at McGill University in Montreal.

Table 1. Results of immediate evaluation of workshop sessions (n = 25) SESSION

NOT USEFUL

SOMEWHAT USEFUL

VERY USEFUL

Removal of lumps and bumps

0

9 (36%)

16 (64%)

Suturing techniques Joint injections IUD insertion

1 (4%)

9 (36%)

15 (60%)

4 (16%)

17 (68%)

4 (16%)

0

10 (40%)

15 (60%)

Endometrial biopsy

0

1 (4%)

24 (96%)

Casting and splinting Office microscopy

0 5 (20%)

15 (60%) 16 (64%)

10 (40%) 4 (16%)

Workshop In the Department of Family Medicine at McGill University, faculty supervisors had taught residents minor surgical procedures during their clinic time. No structured program ensured that all residents were taught common office procedures. Residents often complained that their exposure to techniques was minimal. Faculty members also expressed concern that their skills in office procedures were inadequate for teaching effectively. As a result of these concerns, the department set up a half-day workshop on minor surgical procedures. The department's Surgery Subcommittee was given responsibility for organizing the workshop. Subcommittee members had personal interest and expertise in this area because of their experience in both urban and rural settings. Procedures covered in the workshop were removal of lumps and bumps, basic suturing, IUD insertion, endometrial biopsy, casting and splinting, injection of joints, and office microscopy. These were chosen over other common procedures because of the time limit on the workshop and the skills of the faculty who would act as facilitators for each session. The workshop consisted of seven stations that were repeated every 30 minutes. Stations were set up to allow for brief didactic presentations and demonstrations followed by hands-on practice. Twenty-five faculty members from the five teaching units in the department rotated through these stations in groups of three or four. In the sessions on removal of lumps and bumps and suturing, workshop leaders first demonstrated basic techniques for removing common lesions or of suturing and then allowed participants to practise on pigs' feet and receive feedback on technique. A similar

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Table 2. Number of participants reporting an increase in number of procedures performed and taught and feelings of competence in performing and teaching procedures (n = 24) PROCEDURE

MORE PERFORMED N (%)

MORE TAUGHT N (%)

MORE COMPETENCE PERFORMING N (%)

MORE COMPETENCE TEACHING N (%)

Removal of lumps and bumps

4 (17)

2 (8)

9 (38)

10 (42)

Suturing

4 (17)

7 (29)

6 (25)

9 (38)

............................................................................................................................................................................................................................

Joint injections IUD insertion

4 (17)

4 (17)

5 (21)

2 (8)

8 (33)

6 (25)

Endometrial biopsy

4 (17)

4 (17)

13 (54)

10 (42)

Casting and splinting

4 (17)

2 (8)

3 (13)

7 (29)

Office microscopy

6 (25)

3 (13)

5 (21)

6 (25)

9 (38)

10 (42)

............................................................................................................................................................................................................................

process was used at the stations on injection of joints, IUD insertion, and endometrial biopsy. Models of a shoulder and a knee were used for the injection session. The department purchased a model of the pelvis, on which participants could practise gynecologic procedures. Due to limited time, two facilitators led the casting and splinting session and divided the group according to interest. Participants used plaster to apply casts on their colleagues' forearms and to make slabs for splints. Four microscopes were set up to permit viewing of vaginal smears and urine specimens that had been prepared beforehand. Charts and handouts were used to explain how to obtain specimens and apply them adequately to slides. Detailed but practical handouts were distributed at the end of each session. (Copies are available from the authors.)

Evaluation At the end of the workshop, all participants completed an evaluation form. Each session was rated on a scale of "not useful," "somewhat useful," and "very useful." Space for comments was provided. Questions on the form asked which sessions were the most and least useful and called for suggestions for changes to the workshop. Participants were asked to state what they were planning to do differently in their practice and in their teaching as a result of the workshop. Ratings for each session of the workshop are summarized in Table 1. Overall, participants found the sessions somewhat to very useful. Their comments indicated they were satisfied with the quality of the teaching and they appreciated the hands-on opportunities. The sessions on endometrial biopsy, suturing,

removal of lumps and bumps, and IUD insertion were found to be the most useful, while those on office microscopy and joint injections were found to be least useful. Participants suggested that more time be spent at each station. Thirteen (52%) faculty members expressed intent to perform endometrial biopsies as a result of the workshop, six (24%) claimed they would insert more IUDs and remove more lumps and bumps, and five (20%) said they would inject more joints. In response to how the workshop would affect their teaching, eight (32%) said they would teach more and six (24%) claimed to have greater self-assurance. We also evaluated the workshop with self-report assessments 1 week before and 6 months after the activity. A questionnaire was developed to determine the number of times over the past 6 months that participants had performed each of the procedures to be covered in the workshop, the number of times they had taught each of these procedures, and their perceived level of competence in performing and teaching these procedures on a scale of "not competent," "somewhat competent," and "very competent." A question was added to the follow-up questionnaire asking which aspects of the workshop had been the most useful. Twenty-four participants completed both questionnaires; one person completed only the first one. All participants indicated that they performed and taught more procedures after the workshop and that they felt more competent in performing and teaching these techniques (Table 2). Responses to the follow-up questionnaire indicated that the sessions thought to be most useful were endometrial biopsy (six respondents), suturing (four), lumps and bumps (one), and IUD insertion (one). Five (20%) thought the practical nature of the workshop was useful, and three (12%)

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stated that their confidence had increased. Three suggested that more time be allotted at each station.

Discussion To provide adequate training in procedural skills to family medicine residents, faculty members must receive the training necessary to upgrade their own skills.'5'16 Few articles in the literature demonstrate an increase in the quantity or quality of teaching procedural skills resulting from workshops or seminars. However, in the areas of addiction and acquired immunodeficiency syndrome, two studies did show that both teaching and clinical practice were enhanced by short faculty development interventions.'7'18 Evaluation of our workshop indicated participants thought it very useful. Six months after the workshop we noted a trend toward an increase in the reported number of minor surgical procedures performed and taught and in faculty members' perceptions of their competence in performing and teaching these procedures. However, self-assessment of clinical competence does not necessarily reflect true ability,9"9 nor do self-reports on teaching skills adequately measure change.2' To truly evaluate the effectiveness of this type of workshop, we need to collect more objective data from observations or structured examinations. Also, we need to study residents' perceptions and ability to perform the procedures after being taught Feedback obtained from the evaluation allowed the Surgery Subcommittee to make changes to the workshop, which is now being held annually for residents. Endometrial biopsy and IUD insertion have been combined, decreasing the number of stations to six. This has permitted more time in each station with greater opportunity to practise each procedure.

Conclusion Teaching minor surgical procedures is an essential part of the curriculum in a family medicine residency program. Faculty members often require additional training in this area. Our workshop offered such training and appears to have had a positive effect on the competence of participants. Acknowledgment We thank the members of the Surgery Subcommittee of the Department of Family Medicine at McGill University for their involvement in the workshop.

Correspondence to: Dr L. Nasmith, Department of Family Medicine, McGill University, 517 Pine Ave W Montreal, QC H2W 1S4

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1991. BrJ Gen Pract 1994;44:364-5. 12. Milne R. Minor surgery in general practice. BrJ Gen Pract 1990;40:175-7. 13. Pringle M, Hasler J, De Marco P. Training for minor surgery in general practice during preregistration surgical posts. BMJ 1991;302:830-2. 14. Berry DP, Harding KG. Potential pitfalls of minor surgery in general practice. BrJ Gen Pract 1993;43:358-9. 15. Smith MA, Klinkman MS. The future of procedural training in family practice residency programs: look before you LEEP. Fam Med 1995;27:535-8. 16. Cox NH, Wagstaff R, Popple AW. Using cinicopathological analysis of general practitioner skin surgery to determine educational requirements and guidelines. BMJ 1992;304:93-6. 17. O'Connor PG, Bigby J, Gallagher D. Substance abuse and AIDS: a faculty development program for primary care providers.J Gen Intern Med 1993;8:266-8. 18. Fleming MF, Barry KL, Davis A, Kahn R, Rivo M. Faculty development in addiction medicine: Project SAEFP, a one-year follow-up study. Fam Med 1994;26:221-5. 19. Jansen JJM, Tan LHC, van der Vleuten CPM, van Luijk SJ, Rethans JJ, Grol RPTM. Assessment of competence in technical skills of general practitioners. Med Educ 1995;29:247-53. 20. Hitchcock MA, Stritter FT, Bland CJ. Faculty development in the health professions: conclusions and recommendations. Med Teach 1993;14:295-319.

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