Perspectives of Recent Graduates on Clerkship Procedural Skill Training at a Canadian Medical School: an Exploratory Study

Abstract

The implementation of competency-based medical education in Canada has presented both unique opportunities and challenges for improving undergraduate procedural skills curricula. Despite the recognized importance of procedural skills, there remains a lack of national congruency in procedural training across medical schools that must be addressed. When undertaking such curricular development, obtaining learner feedback is a crucial step that can facilitate practical changes and address disparities. The purpose of the current study is to explore the perspectives and insights of recent medical graduates surrounding the clerkship procedural skills curriculum at a Canadian medical school. Six residents from a variety of program specialties participated in a semi-structured focus group interview discussing key aspects of procedural skill training. The focus group was later transcribed and qualitatively analyzed for themes. The results highlight barriers to competency-based procedural skill training involving time constraints and obtaining required evaluations, and the ability of students to self-advocate for learning opportunities. Participants note few opportunities to practice nasogastric tube insertion and casting in particular. Recommendations for curricular improvement are discussed, including options for curricular remediation and resident perspectives on which procedural skills undergraduate trainees should achieve competency in by graduation.

Introduction

Procedural skills are an integral part of professional competency for modern physicians. Early in their training, resident physicians are expected to perform numerous procedures that range from intramuscular injections to airway management and endotracheal intubation. As such, it is widely recognized that educating and assessing medical students on procedural skills are essential for training safe and skilled physicians [1, 2].

While many medical schools in Canada offer procedural skills curricula, undergraduate training is inconsistent across programs. A recent survey of the 17 Canadian medical schools [3] found that, of the 12 respondents, only eight reported procedural skills curricula for clerkship students, and four had pre-clerkship curricula. An earlier study [4] found significant variation in the procedural skills that were taught in North American medical schools. Unstructured procedural skill teaching can lead to inconsistencies in experience and learning that is based on opportunity rather than educational goals [5, 6]. Conversely, structured skill training with concrete objectives has been shown to create safer, more competent doctors and can help to reduce learner anxiety [7–9]. In the era of competency-based medical education, many have thus identified the need for a national procedural skills curriculum for medical students [2, 10].

With the advent of Entrustable Professional Activities (EPAs) in 2016, the Association of Faculties of Medicine of Canada (AFMC) reiterated the importance of procedural skills education. EPAs have been accepted by Canadian medical schools as a common set of abilities expected of all medical graduates [1]. However, EPA 11, “Perform general procedures of a physician,” gives little guidance on which skills should be taught and how best to assess them [2]. This gap is deepened by the observation that most schools do not publish their procedural skills curricula, leading to a lack of national congruency in procedural skill training.

Eliciting student feedback is an essential part of curriculum development, helping to prevent disengagement and to ensure success of the program. Furthermore, such feedback is especially important in competency-based curricula where students have increased individual responsibility for attaining their educational objectives [11]. Despite this understanding, little is known about the perceptions of recent medical graduates regarding procedural skill training in clerkship. As part of a multi-project effort aimed at improving procedural skills education and building on previous work, we conducted an exploratory qualitative study to gather the perspectives of recent medical school graduates on the clerkship procedural skills curriculum at Queen’s University [12]. Our objective was to collect student feedback to identify barriers, successes, and potential areas for change in undergraduate procedural skill training in an effort to inform future research in this area.

Methods

Context of the Study

The Queen’s University School of Medicine has, in recent years, moved towards a competency-based medical education (CBME) curriculum for teaching and assessing procedural skills in clerkship. Part of this curriculum includes the assessment of 18 skills, divided into “group A” and “group B” skills (see Table 1). Group A refers to those skills that are assessed and must be performed independently with little or no prompting by the time of graduation. Students complete these procedures under the observation or guidance of faculty and subsequently receive formal feedback. The skill is repeated until students have reached the specified level of competency. Group B skills are those procedures that must be completed under the observation of faculty and logged by students but do not require assessment or attainment of a specified level of competency for graduation.

Table 1.

Group A and B skills of the Queen’s University School of Medicine procedural skills curriculum that were utilized in the focus group to assess barriers or challenges to training opportunities

Group A skills: Skills expected to perform independently with little or no prompting	Group B skills: Skills requiring logged completion but not formal evaluation or a level of competency
Facemask ventilation	Endotracheal intubation
Peripheral intravenous cannulation	Participates in a perineal repair
Casting/back slab	Glucometer sampling
Nasogastric tube insertion	Ophthalmoscopy
Foley catheter (male)	FHR Doppler
Foley catheter (female)	Dipstick urinalysis
Intramuscular/subcutaneous injection	Participates in a spinal anesthetics or lumbar puncture
Punch biopsy/skin biopsy
Pap smear
Child otoscopy
Suturing

Design, Participants, and Data Collection

We conducted a retrospective, cross-sectional qualitative study at a single university. We invited 22 recent graduates of the Queen’s School of Medicine completing their first year of residency at Queen’s University to participate. Using a purposive sampling approach, we deliberately invited these residents as they were uniquely positioned to comment on the barriers and impact of the procedural skills curriculum. We anticipated having three groups of seven to eight participants in keeping with previous research [13]. We conducted a single focus group in July 2019 which was audio-recorded and then transcribed verbatim. Appendix contains our focus group guide. This study received research ethics board approval (FMED-6705–19).

Analysis

Following transcription, two authors (AV and AK) independently performed line-by-line coding of transcripts. The authors then performed a secondary analysis using an inductive approach to identify themes [14]. Authors compared initial themes arising from the transcript to ensure a common language and mapped results to the research questions for clarity. Interpretations were compared and discussed between AK, AV, and AR until there were no discrepancies. Authors reached consensus regarding verbatim remarks selected to highlight the relevant themes arising from the analysis.

Results

Six of the 22 residents (27%) invited were available and agreed to participate in the focus group. Their residency programs included internal medicine (n = 3), family medicine (n = 1), anesthesia (n = 1), and ophthalmology (n = 1). Below, we summarize the findings of the focus group by research question.

1. Which of the group A procedural skills did you have the least opportunities to perform in the clinical setting? Most opportunities?

Participants agreed that they had more than six opportunities to perform five of the group A skills: facemask ventilation, peripheral intravenous cannulation, intramuscular/subcutaneous injection, child otoscopy, and suturing (see Table 2. Two skills, nasogastric tube (NG) insertion, and casting/back slab were reported to have the least opportunities with most participants describing having three or fewer opportunities to perform them. Four skills received mixed responses, with some participants describing many opportunities to perform them and others finding there to be very few Table 2.

Table 2.

Average number of opportunities to perform group A procedural skills throughout clinical rotations at the undergraduate level collected through focus group discussion

Group A skills: Skills expected to perform with little or no prompting by graduation (EPA 11)	Number of opportunities to perform the skill in a clinical setting
Facemask ventilation	> 6
Peripheral intravenous cannulation	> 6
Casting/back slab	0–3
Nasogastric tube insertion	0–3
Foley catheter (male)	Varied
Foley catheter (female)	Varied
Intramuscular/subcutaneous injection	> 6
Punch biopsy/skin biopsy	Varied
Pap smear	Varied
Child otoscopy	> 6
Suturing	> 6

2. Did you encounter any barriers in allowing you to perform any of these skills? (For example, obtaining patient consent)?

Several barriers became apparent during the focus group, including interrupting workflow, obtaining patient consent, variation in core rotations, and obtaining assessment.

Interrupting Workflow

A major theme was the difficulty of interrupting clinical activities in order to practice procedures. Participants specifically described challenges attempting casting or Foley catheter insertion because they felt that they could not or should not interfere with workflow to do so. These time constraints occurred in many hospital settings, including the emergency department, the operating room, and some clinics:

“They move through patients so quickly that they... there’s no time for you to practice.”

Discussions revealed that participants often found it challenging to ask busy residents and staff to observe them performing skills. Participants also felt that, if they were not fast enough or performed the procedure imperfectly, this would interrupt patient flow and create more work for their residents. Casting in the emergency department on their orthopedics rotation was one example of this difficulty:

“I think also casting, right. That’s especially one where it’s like if you don’t do it properly, they have to redo it which is a pain…It’s so much faster if they do it, right”.

Obtaining Patient Consent

In general, the participants agreed that difficulty obtaining patient consent to attempt procedures was not a commonly encountered barrier. Rather, this appeared to be a barrier specifically related to gender bias. Male participants sometimes found it difficult to complete procedures such as Pap smears and female Foley catheter insertion due to patients asking them to leave the room. While participants noted that this was not a major barrier to learning, they acknowledged that it may be a cause for some variation among students in opportunity to practice and be assessed on certain skills. A female participant noted:

“I had no problem [to attempt female Foley insertion]; right. It was same… same thing with the Pap smear. The same… the gender bias is huge there in that a ton of times male students get asked to leave.”

Variation in Family Medicine Rotations

Participants noted that many of the group A and B skills were best suited for completion during family medicine rotations. However, discussions revealed that preceptor and location variation on their rotation contributed to disparities in procedural skills opportunities among students. It was noted that some family medicine preceptors had practices that focused primarily on a particular area of medicine, which made completion of other skills challenging:

“For example, I was with a family doctor who only did obstetrics which I was like this is my family block!”

A suggestion was made that preceptors agreeing to take students for a family medicine rotation should have at least a one-third general family medicine practice in order to ensure more consistency among student experiences and opportunities. Participants also noted that the different rotation locations-rural or urban-may have led to a variation in opportunity for skills:

“I think that the fact that a few of these [skills] are gained - or can be gained - on your family medicine rotation really contributes to the variability because we are all in such different places.”

Obtaining Assessment

In addition to barriers to performing required procedures, participants also noted significant obstacles in obtaining the corresponding evaluations from instructors. The challenge in obtaining proper feedback led to difficulty demonstrating appropriate competency for procedures required for graduation.

“A lot of the barriers for me was not performing the skill but obtaining the documentation.”

Participants reported that having paper evaluations completed was often difficult as they had to have a physical evaluation sheet on hand at all times, and there were often time restrictions following procedures for faculty members to complete these evaluations. Evaluations were often left unfilled and lost if not immediately completed following a procedure:

“You could hand it to them and they would walk away and you’d never see it again.”

Once online assessments were implemented (triggered by the student and emailed to the preceptor to be filled out at their convenience), one participant noted that these provided much more in-depth feedback. However, there was significant agreement among the group that online assessments were just as often, or even more often not completed by staff, requiring multiple follow-up attempts.

“We have it electronic; it’s still something that I’m noticing is …there’s some resistance to docs filling out evals. Just cause it’s an unnecessary, unincentivized part of the evaluation process. Nobody wants to do those cause it’s a time sink.”

3. How much responsibility should be placed on the student to actively seek opportunities? Should students be expected to ask for the assessment and follow up on triggered assessments that have yet to be completed?

Discussions revealed that, according to participants, medical students should be primarily responsible for seeking out opportunities to learn and practice the required procedural skills in clerkship. Self-advocacy was a prevalent theme in the discussion. Many participants not only agreed that it was important for medical students to develop, but also acknowledged that students may not always feel comfortable advocating for their own educational opportunities and that this should not hinder overall learning.

“I think it should be completely our responsibility to seek these things out like I honestly didn’t feel uncomfortable asking... and I don’t think it’s unreasonable to be an advocate for your own learning. I think it’s a skill that every medical student should be able to do regardless of how uncomfortable they feel doing it. So, I think that’s important to keep on the student.”

There was consensus among participants that medical students should hold the majority of responsibility for triggering assessments to be completed by faculty members after performing a skill. Participants agreed that students should follow up on incomplete evaluations and contact program administrators after failed attempts to contact instructors for their completion. However, participants indicated that students should also be flexible when possible, and that certain skills may need to be repeated in order to meet the rotation requirements if evaluations remain uncompleted.

4. It is expected that students can perform group A skills with little or no prompting by graduation. What do you consider appropriate remediation for unsuccessfully meeting these graduation requirements?

Discussions revealed two main suggestions for remediation of incomplete skills prior to graduation. The first was to hold a half-day simulation session whereby students could perform and practice those skills they had been unable to perform in the clinical environment. Participants noted that this would work well for skills, such as injections, Foley catheter insertion, and NG tube insertion, but would be difficult for skills such as Pap smears. The second suggestion was for an off-service remediation day. During this day, students would spend time in a particular service or with a particular preceptor where they would be able to obtain the missing skill. Examples given were spending a day in the child outpatient clinic for those unable to obtain child otoscopy or in the cancer center for skin punch biopsy. This would help to address inconsistencies in opportunity due to assigned subspecialty or location placements. Such opportunities might also include interdisciplinary teaching, such as spending an afternoon with the casting nurse in a fracture clinic.

5. What skills do you believe are important to be able to perform with little or no prompting upon entering a residency program regardless of specialty?

Participants believed every incoming resident should be competent in performing face-mask ventilation, suturing, peripheral intravenous catheterization, NG tube insertion, intramuscular injections, and fetal heart rate Doppler. There was a lot of discussion surrounding NG tube insertion, which was described as having few or no opportunities (0–3) for practice in clerkship. The participants noted that, despite the lack of opportunity, it was a skill that they had performed many times in residency and for which graduating medical students should achieve competence.

Two participants also suggested that point-of-care ultrasound (POCUS) should be added to the list of skills, as a group B skill. They noted that, for many specialties, residents are now expected to have a basic knowledge of POCUS. Participants also suggested a third category of skills that included chest x-ray interpretation, electrocardiogram reading, and presenting oral reports. While not counting as procedures, the participants suggested that these would be key skills to be formally observed and assessed in clerkship.

Participants also suggested that Pap smears do not necessarily require a certain level of competency for graduates and that glucometer, urine dipstick, perineal repair, and lumbar puncture should not be required skills in the curriculum at all. They felt that these skills were either too specialized or rarely performed.

Discussion

We employed a qualitative approach to collect medical resident perspectives on current procedural skills curricula at Queen’s University. While illustrating the importance of student feedback, our study has helped identify procedural skills that are problematic for students to obtain competency in during clerkship. Participants in our study described difficulty meeting competency requirements for two skills in particular: nasogastric tube insertion and casting. Notably, nasogastric tube insertion was not only reported as an important skill for all incoming residents, but also reported to have the least opportunities to perform in clerkship due to lack of exposure. The discrepancy in exposure between residency and clerkship may indicate that medical students are not being made aware of when such procedures are taking place. If this is the case, informing faculty of the required procedural skills may help to increase exposure for students. Further, our focus group revealed that there was sufficient casting exposure, but that time constraints made it challenging for students to achieve competency for the skill. According to our recent graduates, casting is not a skill that all residents must be able to perform without prompting at the start of residency. Faculty opinions should be gathered to see whether they align with trainee suggestions that casting, pap smear, glucometer, urine dipstick, perineal repair, and lumbar puncture are skills that medical students need not perform independently by graduation.

Procedures outside the scope of the current curriculum were also proposed, highlighting the evolving landscape of procedural skills in medicine. A notable example was POCUS, a skill not previously part of the curriculum at Queen’s. Residents emphasized the growing need for POCUS training in medical school, which aligns with steps that most Canadian undergraduate programs have taken to integrate POCUS into the curriculum [15, 16]. They also suggested the inclusion of several “interpretive” skills into the structured procedures curriculum. Research supports that graduates should practice these skills in their clinical clerkship though the level of competency that should be required remains unclear [2].

Many of the themes emerging in our study as barriers to learning are applicable to competency-based medical curricula in general. A significant barrier to learning was the interruption of workflow to practice skills. To mitigate this barrier, instructors can be made aware of skills requiring completion by clerks in advance so that appropriate opportunities for practice may be identified during the rotation. If feasible, trainees could be assigned to a half-day or full-day clinic during which there are opportunities to perform a specific procedural skill, with minimal impact on the workflow. For example, clinical clerks at Queen’s University are assigned to an outpatient ophthalmologic surgery list for a full day during their anesthesiology rotation, which provides numerous opportunities to insert a peripheral intravenous catheter with minimal impact on the flow-through of patients. This gives students ample opportunity to practice a skill in the clinical environment without the challenge of trying to seek out these opportunities themselves. The importance of pre-clinical training in procedures should also not be forgotten in this context. Pre-clinical exposure to procedural skills, such as on simulation models, can help to improve students’ confidence and competence prior to entering the clinical environment [10, 17–19].

Our focus group participants expressed the importance of developing an aptitude for self-advocacy. With trainees finding it difficult to advocate for themselves under certain circumstances, medical trainees in the era of CBME may benefit from increased attention to skills of self-advocacy prior to beginning their clinical rotations. Encouraging learners to be responsible for identifying and rectifying gaps in their own knowledge is helpful in preparing them for a future career of life-long learning [20].

A second identified barrier pertaining to competency-based curricula was obtaining assessment and feedback for practiced skills. Residents noted that both paper and online assessments were often left unfilled by faculty, which may cause a delay for students in meeting the appropriate competency requirements for the course. Further, the goal of assessment in competency-based curricula is not primarily to identify incompetence but rather to support students in achieving competence-a goal that becomes challenging when feedback is provided infrequently or inconsistently [21, 22]. Research in this area has shown that assessments are more beneficial to learners when completed within two to three days of the procedure [23]. Notably though, the graduates in our focus group agreed that learners should attempt to repeat skills if triggered assessments remain incomplete.

A potential contributing factor in the lack of timely assessment completion is the concept of “feedback fatigue,” which has been previously discussed in the literature as a challenge of competency-based curricula [24–27]. In feedback fatigue, instructors may become overburdened by the increased frequency of assessments that can result from CBME curricula and fail to complete them in a timely manner or with adequate substance [24, 25]. As others have suggested, optimizing the types and lengths of assessments as well as delivery systems may help to reduce this burden [26]. Ultimately, procedural skill curricula will need to harmonize the need for frequent, specific feedback with maintaining instructor engagement and acknowledging time constraints. Feedback should be obtained from faculty regarding the issue of online assessment completion.

In light of these findings, we offer a number of recommendations for undergraduate medical education programs. When introducing procedural skills curricula at the beginning of clerkship, educators should reinforce the importance of self-advocacy in securing opportunities to attempt procedures and illustrate examples of these interactions in clinical settings. Educators should consider obtaining regular student feedback regarding the procedural skill training to identify opportunities for improvement. They should also routinely remind faculty and residents about the procedural skills curriculum and engage faculty in ways to increase the completion rate of evaluations to ensure adequate feedback for students. Finally, medical schools should also explore or invest in ways to support students who have difficulty meeting competency requirements by graduation.

Limitations

There are several limitations to our study. Firstly, we relied on a small sample of six resident physicians. This is because the study design required continuity across the educational process between undergraduate and postgraduate trainings. Given the small number of participants, this sample may not be representative of the larger postgraduate population. We were also unable to perform additional statistical analyses to uncover interactive effects within the group or triangulation. However, we feel that this sample is sufficient to draw preliminary observations which will merit further delineation in larger studies. Second, the current authors’ own understanding and experience with clerkship procedural skill training may have influenced the interpretation of the findings. The analyses and interpretations were therefore discussed and compared among authors until there was full agreement to reduce bias. Another potential limitation is the focus group interview method itself. Focus groups have previously been used as a method for examining learner feedback on medical curricula [15, 19]. As with all focus group interviews, group dynamics may have caused participants to feel uncomfortable in expressing certain viewpoints [28]. In our study, participants’ identifying information remained anonymous, and they were encouraged to speak openly in an effort to address this limitation.

Conclusion

Procedural skill training is a fundamental aspect of modern medical education, but there is little consensus on skills that should be taught and assessed. Our exploratory qualitative work revealed a number of barriers to procedural skill training in clerkship from the perspective of recent trainees, including challenges with self-advocacy, workflow interruptions, and collecting timely feedback. Future work should corroborate these views with additional resident input as well as faculty opinions across institutions and support the prospective standardization of procedural skill training and assessment at the undergraduate level.

Funding

This work was funded through a grant from the Alison B Froese Research Fund associated with the Department of Anesthesiology and Perioperative Medicine at Queen’s University.

Declarations

Conflict of Interest

The authors report the following conflicts of interest: AS holds the position of Associate Dean of Undergraduate Medical Education at Queen’s University, EK holds the position of Assessment and Evaluation Consultant at Queen’s School of Medicine, and LW is course Director of the Procedural Skills course in the Undergraduate Medical Education program at Queen's University. All other authors have no conflicts of interest to declare. The authors alone are responsible for the content and writing of the paper.