Bruce Peyser, MD, FACP
Provider, Duke Primary Care Pickett Road
Professor of Medicine, Duke University School of Medicine
Director of Education and Teaching, Duke Primary and Urgent Care
What are some effective ways we can teach our learners how to properly complete procedures in the outpatient setting? The short answer is this can be complicated and will require extra attention and time from the preceptor to perfect best practices.
As a bit of background, I would first emphasize that many of our learners want to watch and practice and learn procedures that we carry out in our clinics. Some of these “procedures” are better defined as portions of the physical examination of our patients. A breast exam, a digital rectal exam, even a proper thyroid exam are all “procedures” that many of us carry out on a daily basis. I encourage you to involve your students, when possible, as you carry out these tasks, and try to watch and help them so they can perfect their physical examination techniques and skillsets. Many students have helped complete a pelvic examination (of course, after permission is obtained from the patient), but I often find they have not had experience actually inserting the speculum. It’s important to review with learners what they have done and observed previously so you know where they are on their particular learning trajectory. Also, I have learned a lot while watching learners measure blood pressures, and I recommend observing that when you get an opportunity.
Also, there are some tasks we (or our colleagues) carry out in our offices that are fairly mundane procedures but important enough that students should observe and practice, if possible. These include things such as vaccinations, ear irrigation, and completion of ECG or pulmonary function testing. It would be quite reasonable to have a learner spend a half-day with your rooming staff on occasion as we know they carry out these procedures usually better than we do.
There are some rather simple procedures I think most learners enjoy practicing. These include suture and staple removal. Needless to say, you need to be present to supervise the activity. Another relatively easy skin procedure involves the use of cautery, and, again, supervising the use of liquid nitrogen is something that can be gratifying for all involved. Most of my patients have been quite willing to have students involved in this procedure as long as I am present, supervising, and teaching the student as we complete the procedure together in order to ensure their technique is correct.
Occasionally, we are challenged by more intricate procedures that have to be carried out in our offices. There are times when we need to drain an abscess or a furuncle, and it can be quite instructive (and actually helpful) to have a student assist you while you carry out this procedure. Perhaps the student could help with prepping the site or applying bandaging at the end of the procedure. A joint injection is another procedure that students like to watch and help with.
As is evident, there are a number of ways to involve students in the completion of procedures in our offices. I urge you to try to involve them as much as you can. Many are very willing and desiring to learn procedures, and I think many will appreciate the time and extra effort that it takes to teach a procedure or technique in your office.
Also, as mentioned last month, I have been increasingly aware of the different backgrounds and skillsets that some of our students possess. Without overgeneralizing, I do think that there have been a number of instances when my NP or PA students are quite obviously more adept at completing certain procedures than some of our medical students; if you can verbalize and endorse those skill sets, I know that will strengthen and enhance the learning atmosphere in your clinic.
Regarding informed consent, when carrying out a procedure with a learner, I always check with the patient ahead of time to obtain permission and make sure it’s OK to involve the student in the procedure. When I do this, I explain what portion of the procedure will be carried out by the learner. Also, I try to involve the patient in the teaching process and usually try to elicit feedback once the procedure is over. This collaboration goes a long way to creating a safe and positive learning environment for our learners and our patients.
If you are interested in reading more about teaching procedures in the office, look at chapter seven of Teaching in Your Office, written by Patrick Alguire, et al. This is an excellent paperback book now in its second edition. If you do not have the book and would like a copy, please let me know.
Finally, on rare occasions, a student or even a staff member might be exposed to bodily materials inadvertently during a procedure or exam, even if appropriate gowning and barrier techniques are employed. This happened at one of our teaching sites several months ago. Though the attending supervised the entire procedure properly and felt the possible exposure was minimal, the exposure to bodily fluids was understandably distressing to the student. After the procedure was completed, the attending instructed the student to contact Duke Employee Occupational Health and Wellness. Here is what the School of Medicine Policy says:
“If a student experiences a biological or chemical occupational exposure at Duke or while studying away, he/she must call the Duke Employee Occupational Health and Wellness safety hotline available 24 hours a day to report the incident and follow the directions given by the staff member. The number is 919-684-3136.”
Please, if someone is exposed to blood or other bodily materials while under your supervision, instruct the student or employee to contact EOHW within 24 hours of the incident. Taking this step ensures we provide the proper care in a timely manner consistent with our best practices at Duke.