In the Nick of Time: Same-Day Simulation-Paired Procedure Clinic for Internal Medicine Residents

ABSTRACT

Background

Internal medicine (IM) residents face declining opportunities to perform ambulatory procedures due to increased reliance on specialty services and competing demands. While simulation-based training improves short-term skill acquisition, it does not reliably translate into clinical proficiency without timely application and feedback.

Objective

To evaluate the feasibility and educational impact of a same-day simulation-paired procedure clinic (SPPC) on procedural volume, cognitive load (CL), and resident experience.

Methods

Beginning July 2020, postgraduate year (PGY) 1 IM residents at the University of Colorado who rotated through the Veterans Affairs Rapid Access Clinic (RAC) completed weekly simulations on 4 core procedures, each followed by a same-day procedure clinic. We analyzed changes in annual procedural volume from 2017 to 2025, administered post-procedural CL surveys via REDCap, and conducted qualitative interviews with residents, from September 2021 to April 2022, to explore their experiences with skill development and the learning environment. The curriculum utilized existing space, faculty, and materials at no added cost.

Results

All 250 PGY-1 IM residents who rotated through RAC over 5 years participated in the SPPC curriculum. Residents’ average annual procedural volume for the 4 procedures increased 96% (from 560.5 to 1099) after SPPC implementation. Thirty-three of 34 (97%) PGY-1 residents completed a total of 113 CL surveys, in which germane load (mental effort directed toward learning) was consistently rated higher than extraneous load (effort irrelevant to the task). Thematic analysis of interviews (n=18) revealed 2 main effects of the SPPC: (1) systematic skill development through deliberate practice and (2) reduced distractions and improved focus for learning.

Conclusions

A same-day SPPC was feasible within existing clinical infrastructure, and was associated with increased procedural opportunities and high resident-reported learning-focused cognitive engagement.

Introduction

Procedural competency is essential for internal medicine (IM) physicians, yet training opportunities in ambulatory settings are declining.^1-3 Despite faculty and trainee interest in expanded procedural training,^4,5 residents’ hands-on experience is limited by increased reliance on specialty services, evolving ultrasound standards, and competing demands.^6-9

Although simulation-based procedural training enhances short-term skill acquisition, it does not reliably translate into clinical proficiency without clinical application and iterative feedback.^10-19 Residents must develop skills through deliberate practice and promptly reinforce these skills in clinical practice.^20-22 While inpatient procedure services increasingly offer structured pathways to link simulation with real-world application, this integration remains uncommon in ambulatory settings, where procedural experiences are often less frequent, unstructured, and dependent on variable scheduling.

In response to this need, we developed a same-day simulation-paired procedure clinic (SPPC) that combines structured simulation-based mastery learning with a dedicated procedural clinic.²³ This study evaluates the impact of the SPPC on first-year IM residents’ procedural volume, cognitive load, and overall learning experience.

KEY POINTS

What Is Known

Internal medicine residents often lack opportunities, and simulation alone does not reliably produce durable clinical proficiency without immediate clinical application and feedback.

What Is New

Implementation of a same-day simulation-paired procedure clinic (SPPC) nearly doubled internal residents’ procedural volume, promoted learning-focused cognitive load, and fostered focused skill development through deliberate practice at a single residency site.

Bottom Line

Program directors seeking to expand resident outpatient procedure training could consider a same-day SPPC model, which at one site sustainably enhanced procedural education and increased clinical opportunities within existing infrastructure.

Methods

Setting and Participants

The SPPC was implemented within the Rapid Access and Procedure Clinic (RAC) at the Rocky Mountain Regional Veterans Affairs (VA) Medical Center, affiliated with the University of Colorado IM residency program. Fifty postgraduate year (PGY) 1 and 50 PGY-3 residents rotate annually through RAC in 4-week blocks. The same-day simulation model began in July 2020 and remains ongoing; study evaluation included data collected from 2017 to 2025.

PGY-1s were the targeted learners, and PGY-3s served as near-peer teachers during simulation sessions. This dual-level involvement was designed to reinforce skills PGY-3s developed as PGY-1s and reduce faculty teaching burden.

Intervention

In July 2020, we replaced our standard Tuesday morning clinic with a 90-minute simulation-based mastery learning session, followed immediately by a dedicated procedure clinic (Figure 1). This SPPC was designed to increase procedural opportunities and reinforce learning through immediate clinical application.

Figure 1.

Workflow of the Simulation-Paired Procedure Clinic (SPPC)

Note: Residents independently review the recommended TeachIM procedure video and complete a brief formative quiz prior to the simulation session. Residents participate in a 90-minute simulation-based mastery learning session covering one core procedure, followed immediately by a dedicated ambulatory procedure clinic. Each simulation includes review of indications, demonstration, guided practice, and peer assessment. The same procedure is then performed in clinic, reinforcing skills through immediate clinical application.

Local specialists in orthopedics, interventional radiology, hepatology, dermatology, and physical medicine and rehabilitation collaborated to develop the simulation curriculum and train primary care faculty, ensuring practice consistency. These departments supported the SPPC as a strategy to expand veterans’ access to low-complexity procedures in primary care, thereby freeing specialty capacity for higher-complexity care.

The curriculum draws from theoretical frameworks of deliberate practice, mastery learning, and cognitive load (CL) theory. Deliberate practice emphasizes goal-directed repetition with feedback¹³; mastery learning establishes the additional expectation that all learners achieve high-performance standards without exception.¹⁴ Cognitive load theory posits that curricula should reduce extraneous load (distractions and effort irrelevant to the task) while maximizing germane load (effort directed toward learning), recognizing that intrinsic load (effort related to task complexity) is relatively stable.^24-26 To optimize cognitive load, procedural steps, materials, and instruction were standardized across simulation and clinic settings. We made all educational materials (videos, checklists, quizzes, and DIY task-trainer instructions) publicly available on TeachIM.org.²³

Each week, residents rotated through 1 of 4 core procedures: knee injection, subacromial space injection (“shoulder injection”), large volume paracentesis (“paracentesis”), or skin biopsy. Before each simulation, residents independently reviewed the recommended procedural video and completed a short formative quiz with immediate feedback. Quizzes were designed to prime learning and were not analyzed as measures of competence. The simulation began at 7:30 am and included case-based practice, discussion of indications and contraindications, demonstration, guided practice, and formal assessment. Using a checklist, PGY-1 residents completed deliberate practice with feedback from PGY-3s, each working in a paired instructor-learner format under the supervision of at least one faculty lead who guided group discussion and oversaw all simulation activities. All PGY-3 instructors had previously completed the same simulation-based procedural training as PGY-1s and were directly observed by faculty during their teaching sessions to confirm procedural mastery and consistent use of the assessment checklist. We incorporated peer-assisted learning into simulations, drawing on evidence that near-peer teaching fosters cognitive congruence, improves learner engagement, and reduces faculty burden without compromising quality.^27,28 These studies also show that peer-teachers strengthen their own procedural knowledge as novice learners benefit from feedback provided by those with recent, shared experience acquiring similar skills.^27,28 When PGY-1s felt ready for assessment, PGY-3s used a REDCap-based tool to confirm that all procedural steps were performed correctly (online supplementary data 1).²⁹ Demonstrating procedural mastery was required to complete the session. That same morning, residents performed the corresponding procedure in clinic. Over the 4-week rotation, residents completed all 4 simulation-clinic pairings.

The SPPC leveraged existing clinic space, faculty, and expired medical supplies to avoid additional costs. We partnered with a VA supply manufacturer to create low-cost sterile joint injection kits and developed an electronic consult to streamline referrals from providers across the Eastern Colorado VA system.

Outcomes and Analysis

We evaluated feasibility based on clinic resource use, scheduling logistics, and faculty participation. We assessed procedural volume by comparing logs from all IM residents enrolled during the 2 most recent pre-SPPC academic years (July 2017 to June 2019, excluding the COVID-19 pandemic impacted year) to those from residents enrolled during the 2 most recent academic years following SPPC implementation (July 2023 to June 2025). Procedural logs included all 150 IM residents (50 per PGY) on every rotation, not just RAC. This post-SPPC period was selected to capture the curriculum’s impact after full implementation, when all PGY-1–PGY-3 residents had completed SPPC as PGY-1s, enabling evaluation of sustained effects on procedural activity across training years. Percent changes and significance were assessed with chi-square analysis.

To evaluate educational quality, we collected cognitive load surveys and conducted qualitative interviews. Between September 2021 and April 2022, immediately after completing a knee injection, shoulder injection, or paracentesis, PGY-1s were asked to complete an anonymous REDCap survey evaluating their intraprocedural cognitive load.²⁹ The 12-item instrument assessed intrinsic, extraneous, and germane load on an 11-point scale and was adapted for this procedure from the multidimensional cognitive load instrument developed by Leppink et al,²⁴ which has been previously modified for procedural training contexts where it demonstrated construct validity (online supplementary data 2).^30,31 Skin biopsies were excluded due to low procedure volume.

During the same period, PGY-1s were recruited for semistructured interviews through convenience sampling via email invitations sent in the final 2 weeks of their rotation (interview guide is provided as online supplementary data 3). Interested residents signed up using a scheduling link. To maintain confidentiality, no identifiable information was collected, and interviews were conducted by research assistants unaffiliated with the SPPC or residency program. Data collection was halted when no new concepts were identified.³² We used a rapid qualitative analysis approach, selected for its suitability in operational and educational interventions where timely, practice-informed insights are needed. This approach uses structured interview summaries and matrix analysis to identify patterns across participants while maintaining methodological rigor. Audio files, transcripts, and field notes were used as source data to summarize key points of each interview in a team-developed template. These summaries were then used to build a matrix with participants in rows and topics in columns.^33,34 Using a deductive approach informed by cognitive load and deliberate practice theory, 2 authors (B.F., M.B.) analyzed the matrix independently, then compared notes to construct themes through iterative discussions.

This study was reviewed and approved by the Colorado Multiple Institutional Review Board. Consent was obtained from participants prior to participating in both the cognitive load survey and interviews.

Results

Since SPPC implementation in 2020, the number of patients scheduled has increased annually (Figure 2), faculty engagement has broadened from 3 to 6 core procedural faculty, and the number of procedures offered has expanded from 4 to 12 (Box).

Figure 2.

Number of Procedure Clinic Visits by Year

Note: Number of procedure clinic visits completed by internal medicine residents during each academic year (AY) from 2021 to 2025. Visit volume increased steadily following implementation of the simulation-paired procedure clinic, reflecting sustainability and institutional integration of the model.

Box Types of Procedures Offered in the Simulation-Paired Procedure Clinic (SPPC)

Core procedures (paired with simulation curriculum)

• Large volume paracentesis

• Knee injection

• Subacromial injection

• Skin biopsy (shave and punch)

Expanded procedures (not paired with simulation curriculum)

• Thoracentesis

• Trochanteric bursa injection

• Pes anserine bursa injection

• Trigger finger injection

• Ultrasound-guided glenohumeral joint injection

• Ultrasound-guided acromioclavicular joint injection

• Excision cyst removal

• Incision and drainage

Note: The SPPC initially focused on 4 core procedures—each paired with a simulation-based curriculum. As faculty skills and health system demand grew, the clinic expanded to include additional procedures not linked to simulation training. This evolution reflects the clinic’s increasing capacity to meet procedural training needs in an ambulatory setting.

Over 5 academic years, all 250 (100%) PGY-1 IM residents who rotated through RAC participated in the SPPC curriculum. Annual averages of procedural volume for the 150 IM residents increased from 364 to 523 paracenteses (44% increase), 22.5 to 56.5 skin biopsies (151% increase), and 174 to 519 joint injections (198% increase), totaling 560.5 to 1099 (96%; Table 1). Between September 2021 and April 2022, 33 of 34 (97%) PGY-1s who participated in the SPPC completed 113 post-procedure cognitive load surveys. The average scores for each category of CL per procedure are presented in Table 2. The average germane score across all 3 procedures was 5.5 times greater than extraneous. Pre-curriculum cognitive load scores were not available.

Table 1.

Resident Procedural Volume Before and After Implementation of SPPC

Procedure Type	Pre-SPPCb			Post-SPPC			% Change	Significance
	AY 2018	AY 2019	1-Year Average, AY 2018-2019	AY 2024	AY 2025	1-Year Average, AY 2024-2025
Paracentesis	289	439	364.0	537	509	523	44	P<.001
Skin biopsy	27	18	22.5	49	65	57	153	P<.001
Joint injectionsa	211	137	174.0	494	544	519	198	P<.001
Totals	527	594	560.5	1080	1118	1099	96	P<.001

^aDue to changes in resident logging options for joint-site specification during the study period, shoulder injections and knee injections were combined for analysis.

^bDue to the potential impacts of the COVID-19 pandemic on clinical practice opportunities, data from AY 2019-2020 were excluded from the pre-SPPC period.

Abbreviations: SPPC, simulation-paired procedure clinic; AY, academic year.

Note: Comparison of University of Colorado internal medicine residents’ procedural volume in the 2 years pre-SPPC (annual and averaged) versus the most recent academic year. Percent changes and statistical significance were assessed via chi-square analysis.

Table 2.

Average Cognitive Load (CL) Scores for Each Procedure Type

Procedure Type	No. of Encounters	Average Extraneous CL	Average Intrinsic CL	Average Germane CL	Ratio of Germaine to Extraneous CL
Paracentesis	38	1.3	2.8	5.9	4.5
Subacromial injection	30	0.9	2.2	6.2	6.9
Knee injection	45	1.1	2.2	5.9	5.4
Totals	113	1.1	2.4	6.0	5.5

Note: Comparison of self-reported cognitive load scores separated by type (extraneous, intrinsic, and germane) and procedure. Scores range from 1 to 11.

Qualitative

Two themes were identified from the interviews, describing learners’ perceived impact of the SPPC (quotes provided as online supplementary data 4).

Theme 1: Systematic Skill Development Through Deliberate Practice in SPPC:

In the SPPC, learners experienced clear goal setting, actionable feedback, and repetition; these processes align with Ericsson’s deliberate practice framework, which involves iterative skill refinement through structured and intentional learning opportunities.¹³

“Just having the simulations makes a big difference because we get to ask any questions we have and practice the positioning of our hands and little nuances of the procedure…and when you actually do it with a patient you are just following the same protocol you had just done in the simulation.” (Interview 17)

Residents noted that rehearsing procedures immediately before performing them clinically reduced the cognitive gap between learning and application—a key feature of deliberate practice.

“It’s especially important for a complex procedure like [paracentesis]. Having simulation right before is very nice because it is easy to forget one of those steps and having it fresh to then be able to go solidify it with a real patient is as close to an ideal first experience.” (Interview 18)

Theme 2: Reducing Distractions and Enhancing Focus for Procedural Learning in SPPC:

According to learners, the SPPC reduced extraneous load by providing dedicated time for simulation and procedural practice away from distractions. This differed from prior experiences performing procedures in other environments, where acquisition of supplies, clinical interruptions, and anxiety about time pressure distracted from their attention to learning the procedure.

“Having the simulation beforehand was really nice, also just having more time especially when you’re learning…when it’s in a more busy situation in the hospital you’re just more stressed and not as focused on learning the procedure, you’re just focused on getting through it and like not messing anything up or hurting the patient…during the procedure clinic you have all of this extra time and overall it is a better environment for learning and really solidifying these procedures and how to do them on your own.” (Interview 6)

They noted that simulations and accessible instructional aids broke down each procedure into manageable steps, enhancing germane load. Immediate clinical application of simulated skills enabled learners to link procedural knowledge with practical application, strengthening their mental models.

“Having the videos beforehand and then also checklists that you can quickly refer back to is super helpful. I think it takes away a lot of the stress of performing the procedures and you can focus more on the minute details.” (Interview 1)

Feasibility

Our local feasibility was enhanced by leveraging existing resources that may not be available elsewhere. To inform efforts to replicate this model, we estimated the cost of equipment, supplies, and faculty time (online supplementary data 5).

Discussion

This study demonstrates that integrating same-day simulation with procedural clinic experiences can meaningfully enhance procedural education in IM residency. By intentionally aligning simulation-based mastery learning with immediate clinical application, the SPPC addresses a longstanding gap between procedural training and real-world performance, particularly in ambulatory settings where such integration is rare.

The SPPC combines principles of deliberate practice, mastery learning, and cognitive load theory to create an optimized environment for procedural skill acquisition. Quantitative data showed substantial increases in procedural volume across all core procedures, while cognitive load assessments revealed that learners experienced high levels of germane load relative to extraneous load. Qualitative analysis reinforced these findings, highlighting residents’ perceptions of structured skill development, improved focus, and reduced cognitive distractions.

In addition to educational benefits, the SPPC has expanded over the past 5 consecutive years and remains active, demonstrating sustainability and institutional integration. During this period, procedural opportunities, faculty participation, and the range of procedures offered all expanded, reflecting the program’s ability to maintain engagement and operational support. While these outcomes occurred in parallel with the SPPC’s implementation, we do not infer direct causation. Rather, we view this expansion as evidence of the model’s feasibility and value within the health system. Near-peer teaching contributed to feasibility by reducing faculty workload while maintaining high learner engagement and satisfaction. The model was implemented without additional funding and has continued to grow, with expanded faculty involvement and procedural offerings over 4 years. Furthermore, all educational and clinical operations resources are publicly available, enhancing the model’s scalability to other programs seeking to replicate this approach.²³

This study has several limitations. Pre-intervention cognitive load data were not available for comparison, limiting causal inference. Although PGY-3s provided guidance under direct faculty supervision, their teaching competence and interrater reliability were not formally evaluated and remain an important focus for future quality assurance efforts. Procedural volumes were self-reported, introducing possible recall or reporting bias. Additionally, our single-institution study may limit generalizability. However, the consistency of outcomes across procedural types and the sustained adoption of the model over multiple years suggest practical applicability.

Future research should include patient-centered outcomes and directly observed assessment of resident competence with comparison groups to better assess the SPPC’s impact on clinical quality and safety. Longitudinal studies are also needed to evaluate the program’s impact on long-term procedural competency, skill retention, and patient access.

Conclusions

The same-day simulation-paired procedure clinic was feasible to implement within existing clinical infrastructure and has remained in continuous operation for more than 5 years. It was associated with increased procedural opportunities for residents and high resident-reported learning-focused cognitive engagement.

Author Notes

Disclaimer: Dr Fainstad is an unpaid board member and editor for TeachIM, Inc, a 501(c)(3) nonprofit organization that provides open-access medical education resources. Dr Brett is an unpaid editor for TeachIM, Inc. Educational resources from TeachIM.org are referenced in this manuscript. Neither author receives financial compensation or other personal benefit from the organization. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.

Preliminary quantitative data from this study was presented at the Society of General Internal Medicine Annual Conference, May 10-13, 2023, Aurora, Colorado, USA.

Funding: Funding for this study was provided by the University of Colorado Department of Medicine Program for Academic Clinician Educators. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Conflict of interest: The authors declare they have no competing interests.

Editor’s Note

The online supplementary data contains the assessments and surveys used in the study and further information from the study.