Dermatology Procedural and Surgical Skills Workshop for Medical and Physician Assistant Students

doi:10.4236/jcdsa.2013.33A2011

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Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 44-48

Published Online November 2013 (http://www.scirp.org/journal/jcdsa)

http://dx.doi.org/10.4236/jcdsa.2013.33A2011

Open Access JCDSA

Dermatology Procedural and Surgical Skills Workshop for

Medical and Physician Assistant Students*

Julie Martin, Sheila Z. Jalalat, Richard F. Wagner#

The University of Texas Medical Branch, Galveston, USA.

Email: #[email protected]

Received October 22nd, 2013; revised November 16th, 2013; accepted November 23rd, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Evidence indicating the limited amount of hands-on experience in the current era of medical training has

raised concern regarding students’ development and potential deficiencies in the performance of basic procedural skills.

Studies have demonstrated the value of surgical workshops for medical students; however evaluation of improved stu-

dent performance during future clerkships or residencies has yet to be assessed. We initiated and evaluated a resi-

dent-led surgical skills wo rkshop for students thro ugh the Department of Dermatology. Methods: Participants received

instructions on surgical tools/techniques followed by hands-on practice. Anonymous surveys administered to 24 medi-

cal and physician assistant students assessed their skill level, confidence lev el, and likelihood of using surgical skills in

future practice pre- and post-wor kshop using a 1 - 5 Lik ert scale. Overall experience was also assessed. Non-parametric

bivariate tests were used for analysis to account for non-normal distribution of the data. Results: There was a statisti-

cally significant change in skill (p = 0.0001) and conf iden ce (p = 0.0001) level post work shop. There was no signif icant

difference in utility. There were also no statistically significant differen ces based on the year of medical stud ent train ing,

medical student versus physician assistant student responses, or number of procedures performed prior to the workshop.

Estimated cost per participant was $5.65. Conclusions: Research supports our finding that workshop learning experi-

ences increase students’ ability to p erform common procedu ral skills, th eir confidence, and desire to practice such skills.

Further studies are necessary to determine the impact of these skills workshops on long-term clinical performance in

future clerkships and residencies.

Keywords: Procedural Skills; Workshop; Dermatology; Resid e nts; Medical Students

1. Introduction

Recent studies have shown trends towards an increas-

ingly limited amount of hands-on experience for medical

students in the current era of medical training [1-10].

This observation increases concern regarding students’

development and potential inadequacies in basic skills

performance. The commonest reported obstacles to

teaching basic technical skills include faculty and resi-

dent time constraints, medicolegal concerns such as mal-

practice liability, costs, students’ safety includ ing disease

transmission, and patient preference [11]. Given the ex-

panding role of multiple surgical procedures in derma-

tology clinical practice, sources highlight that resident

training in procedural skills must be con tinually assessed

to keep pace with changes in the specialty [12]. Recent

evidence suggests that residents as teacher-trainers im-

prove resident attitudes and perceptions toward teaching

as well as their theoretical knowledge, skills, and teach-

ing behavior [11,13]. Furthermore, it has also been

shown that medical students ascribe one-third of their

clinical education to the teaching of interns and residents

and consider them to be important role models and men-

tors [14-18]. Training opportunities during clinical years

have been shown to promote skill instruction when they

are most likely to contribute to accelerating clinical learn -

ing [19]. In addition, student experiences, such as acting

internships, have also been designed to provide valuable

practice in learning procedural skills [20]. Given the in-

formation gathered from recent literature, we decided to

show our recent experience with resident-led surgical

skills workshops for medical and physician assistant stu-

*Presented in part at the Semiannual Meeting of the Dermatology

Teachers Exchange Group, Chicago, Illinois, September 27, 2013.

#Corresponding author.

Dermatology Procedural and Surgical Skills Workshop for Medical and Physician Assistant Students 45

dents through the Department of Dermatology.

2. Background

Recent Accreditation Council for Graduate Medical Edu-

cation requirements mandate documentation of compe-

tency in procedural skills [21]. In addition, it has been

reported that little change has occurred in the teaching

and evaluation of technical skills in half of US medical

schools since 1993 [11]. Results from medical student

surveys demonstrated the value of incorporating pre-

paratory surgical workshops in the medical school cur-

riculum [1,22]. This suggests the need for further re-

search to determine if such workshops improve future

student performances during subsequent training. Over

the past 14 years, one institution reported th at the nu mber

of procedural workshops have increased from 11 to 31,

and currently involve clerkship faculty from family

medicine, internal medicine, and pediatrics [20]. We ret-

rospectively reviewed the medical literature using Pub-

Med, searching the terms procedural skills, workshop,

dermatology, residents, and student. Subsequently, sev-

eral articles describing models for procedural skill work-

shops we r e r e t rieved (Table 1).

3. Materials and Methods

Fifteen medical students and nine physician assistant stu-

dents participated in skills workshops during the 2012-

2013 academic year. Th e students in the study comprised

of students enrolled in any of the one-month dermatology

electives and Dermatology Interest Group members.

There were a total of six workshops held throughout the

year. The workshop started with an anonymous pre-

workshop questionnaire (Appendix 1). This was fol-

lowed by a ten-minute PowerPoint presentation about

how to set up for biopsy, basic surgical instruments,

safety precautions, sutures, and suturing techniques. Af-

ter the presentation, hands-on practice with resident su-

pervision began with skills including injection of local

anesthetic, tangential and punching biopsies using pig

feet, suturing/wound closure and knot tying. The work-

shop concluded with an anonymous post-workshop ques-

tionnaire (Appendix 2). The total time of the workshop

was 90 minutes. Internal departmental educational activi-

ties are not subject to Institutional Review Board review.

In the anonymous surveys administered for the pre and

post skills workshop, respondents were asked to assess

their skill level, confidence level, and likelihood of use of

surgical skills in future practice (utility). Th e results were

recorded using 1 - 5 Likert scales. Respondents were also

asked to assess overall experience after the surgical sk ills

workshop using a 1 - 5 Likert scale. The Wilcoxon

Signed Rank non-parametric bivariate test was used to

compare the medians for pre- vs. post-workshop survey

Table 1. Procedural skills teaching models.

Model Description

Theory-based

method [23]

Four-step method:

1) Demonstration

2) Deconstructio n

3) Formulation

4) Perform ance

Modem

instructional

design [24]

Nine events of instruction approach:

1) Getting attention

2) Informi n g t h e learner of the objectiv e s

3) Stimulatin g recall of prerequisite learning

4) Presenting stimulus materia l

5) Providing learner guidance

6) Eliciting the performance

7) Providing feedback and performance correction

8) Assessing performance

9) Enhancing re t e n t i o n and transfer of kn o w ledge

10) Enhancing retention and transfer o f k nowledge

Prerequisite

knowledge [25]

Ensuring prerequisite knowledge using an

Extended Match Questionnaire (EMQ) before

proceeding to practical skills

Microskills and

station-based

deconstructed [26]

Training based o n three concepts:

1) Skill

2) Microskill actions derived from deconstructi on

of each skill

3) Tuition in structured educational stations

Microskills with

learning

preference [27]

Categorizing learners as visual, auditory,

and tactile learners for specialized

procedural skills workshop

questions. The Kruskal Wallis non-parametric bivariate

test was used to compare the medians for pre- vs. post-

workshop survey questions specifically by year and

number of procedures. The Wilcoxon Mann-Whitney-

non-parametric bivariate test was used to compare re-

sponses by the medical and physician assistant students.

These tests were used to account for non-normal distri-

bution of the data using SAS software, version 9.3. The

supplies and estimated cost for each participant for the

worksho p wa s $5.65 (Table 2).

4. Results

Results using the Wilcoxon Signed Rank Test showed a

statistically significant change in skill (p = 0.0001) and

confidence level (p = 0.0001) post workshop (Table 3).

There was no significant difference in utility and there

were no statistically significant differences based on the

year of training, medical vs. physician student responses,

or number of procedures performed prior to the work-

shop. More medical students (67%) had previously par-

ticipated in a surgical skills workshop than physician

assistant students (56%).

5. Conclusions

There was a statistically significant change in student

Open Access JCDSA

Dermatology Procedural and Surgical Skills Workshop for Medical and Physician Assistant Students

Table 2. Supplies and estimated cost per student.

Pig foot $1.00

Tomato $0.50

Marshmallow $0.05

Number 15 blade $0.31

Derma blade $1.28

Punch biopsy $1.67

1 Prolene suture $5.48*

1 Vicryl suture $8 - 11.00*

Plastic bag (used as placemat) $0.15

Antiseptic wipe $0.09

Local anesthesia (2% lidocaine with epinephrine) $0.15*

Non-sterile gloves $.2 0

1 cc syringe $0.30

30 G ×12 needle $0.10

Estimated total cost per participant $5.65

*Expired supply item, cost not totaled.

Table 3. Comparison of medians for pre- vs. post-anony-

mous survey questions (Wilcoxon signe d ra nk te st).

Pre (n = 24)

Median (IQR) Post (n = 24)

Median (IQR) Change

Median (IQR)p-value

Skill 2 (1 - 3) 4 (3 -4) 1 (1 - 2) 0.0001

Confidence 3 (2 - 4) 4 (3 - 5) 1 (0 - 2) 0.0001

Utility 5 (5 - 5) 5 (5 - 5) 0 (0 - 0) 1.000

Overall

Experience 5 (5 - 5)

Legend: IQR (interquartile rang e).

skill level and confidence level post-workshop. Students

unanimously expressed that the workshop was an overall

good experience. Research supports our finding that

workshop learning experiences increase students’ ability

to perform common procedural skills, their confidence,

and their desire to practice such skills [20]. However,

additional studies are necessary to determine the impact

of these skills workshops on long-term procedural per-

formance in future clerkships and residencies.

Limitations of our study include the small number of

participants, not inqu iring about the students’ anticipated

future career or specialty, and not comparing internal vs.

visiting students. In the future, an alternative to pre- and

post-self-surveys could be used, for example the 12-Step

Performance Grading Instrument created by Wang et al.

in order to measure the impact of the workshop using

objective grading and documentation of competency. In

addition, although pigs’ feet ha ve traditionally been used

to teach procedural skills in dermatology, technology has

allowed the development of additional simulators which

could be considered in future workshops [21]. The need

for improvement in procedural skills is evident in the

literature and has been affirmed to be an important learn-

ing process, therefore, these workshops may be benefi-

cial for specialties like dermatology [21].

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Dermatology Procedural and Surgical Skills Workshop for Medical and Physician Assistant Students

Appendix 1. Anonymous Pre-Workshop

Self-Survey

Year (MS1, MS2, MS3, MS4 or PAS): ________

I have participated in a surgical skills workshop in the

past

1) Yes

2) No

Regarding the number of biopsies and suturing oppor-

tunities, I have participated in:

1) <5

2) 5 - 10

3) >10

My skill level (biopsies, suturing, etc.) prior to par-

ticipation in surgical skills workshop

1) No experience

2) Below average

3) Average

4) Excellent

I feel confident performing procedures under supervi-

sion during my clinical rotations

1 2 3 4 5

(1 = completely disagree, 2 = somewhat disagree, 3 =

neutral, 4 = somewhat agree, 5 = completely agree)

I am likely to use surgical skills du ring a clinical rota-

tion and in the future as a practitioner

1 2 3 4 5

(1 = completely disagree, 2 = somewhat disagree, 3 =

neutral, 4 = somewhat agree, 5 = completely agree)

What would you like to learn/improve upon during this

surgical skills workshop?

____________________________________________

______________________________________________

____

Legend: MS1 (first year medical student), MS2 (sec-

ond year medical student), MS3 (third year medical stu-

dent), MS4 (fourth year medical student), PAS (physi-

cian assistant student).

Appendix 2. Anonymous Post-Workshop

Self-Survey

Year (MS1, MS2, MS3, MS4 or PAS): ________

My skill level (biopsies, suturing, etc.) improved after

participation in surgical skills workshop

1 2 3 4 5

(1 = completely disagree, 2 = somewhat disagree, 3 =

neutral, 4 = somewhat agree, 5 = completely agree)

I feel confident performing procedures under supervi-

sion during clinical rotations

1 2 3 4 5

(1 = completely disagree, 2 = somewhat disagree, 3 =

neutral, 4 = somewhat agree, 5 = completely agree)

I am likely to use surgical skills d uring my clinical ro-

tations and in the future as a practitioner

1 2 3 4 5

(1 = completely disagree, 2 = somewhat disagree, 3 =

neutral, 4 = somewhat agree, 5 = completely agree)

Overall, the surgical skills workshop was a good ex-

perience

1 2 3 4 5

(1 = completely disagree, 2 = somewhat disagree, 3 =

neutral, 4 = somewhat agree, 5 = completely agree)

How well were your goals met during this surgical

skills workshop?

____________________________________________

______________________________________________

Any addition s you would recommend for future surgi-

cal skills workshops?

____________________________________________

______________________________________________

Additional comments: _________________________

_______________________________________

Legend: MS1 (first year medical student), MS2 (sec-

ond year medical student), MS3 (third year medical stu-

dent), MS4 (fourth year medical student), PAS (physi-

cian assistant student).

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