Gynecologic Procedural Workshops on a Shoestring Budget

Sanford Lax, MDSt. Joseph Mercy LivingstonFamily Medicine Program

slax@ipcmd.com

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

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

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..

• 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

Changing Epidemiology

• Change in Cytologic definitions • Consensus Guidelines ASCCP• Aging Population• HPV Vaccines• ACOG PAP/HPV Guidelines

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.

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

Simulation Model Creation

R&DModel and Hypothesis

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

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.

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

Developing the Model

• Requirement: simplicity and minimal cost• Ability to produce multiple units for large

workshop• Ease of use• Adaptability for multiple procedures

Inception

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

The Workshop

R&D

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

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

Speculum

Chicken Breast with TCA Markings

Endometrial Biopsy Model

Endometrial Pipelle Placement

Cervical/Uterine Simulator for Endometrial Biopsy

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

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

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?

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.

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.

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

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

Experimental Trials

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.

• 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.

Acknowledgements

Faculty and Residents St. Joseph Mercy

Livingston Family Medicine Residency