Development and Evaluation of a Procedural Skills Clinic for Teaching Residents Bone Marrow Biopsies and Lumbar Punctures on Adult Hematology Patients

Background: Competency in bone marrow biopsies (BMB) and lumbar punctures (LP) is fundamental to the care of patients with hematologic diseases, and requires knowledge, technical skill and confidence. These skills are typically acquired through sporadic ad hoc bedside procedural teaching during residency leading to inconsistent training standards. We evaluated the impact of a weekly expert-run bedside procedure clinic on resident knowledge, skills and confidence in BMBs and LPs.

Methods: An innovative weekly procedural skills clinic was established at the Odette Cancer Centre in Toronto in October 2022. Each half-day clinic exposes one resident to approximately four procedures, including BMBs and LPs with intrathecal chemotherapy. Residents completed a pre-clinic survey evaluating their confidence levels with BMBs and LPs, and their knowledge of the procedural technique and relevant hematopathology testing. This was followed by brief didactic teaching on these topics and supervised or assisted completion of the procedures with immediate feedback. A post-clinic survey was then completed. The survey therefore tested levels 1 and 2 of the Kirkpatrick Model of training evaluation.

Results: Approximately 51 residents joined the clinic, 38 of whom completed pre- and post-clinic surveys. Twenty five (66%) were core internal medicine residents (7 post-graduate year (PGY)-1, 13 PGY-2, 7 PGY-3), 11 (29%) were adult hematology residents (10 PGY-4 and 1 PGY-5), and 2 were from other programs (hematopathology and medical microbiology). 19 (50%) and 31 (82%) had previously received formal instruction on BMBs and LPs, respectively. Fifteen (39%) had never previously done a BMB, whereas 11 (29%), 8 (21%) and 4 (11%) had done 1-3, 4-9 or ≥10 BMBs, respectively. Twenty-three (62%) had previously done 1-3 LPs. Thirty seven residents gained exposure to ≥1 BMB and 24 residents performed a LP. On the post-clinic survey, global confidence ratings for performing BMBs “independently and unsupervised” increased by ≥1 point on a 3-point scale (not, somewhat, or very confident) in 27 (71%), with the majority (76%) being “somewhat confident” by the end of clinic. Of the 24 who performed a LP, global confidence ratings improved by ≥1 point in 46%. 100% of respondents either “agreed” or “strongly agreed” that clinic participation improved their confidence in landmarking for each of these two procedures, and 100% either agreed or strongly agreed that they received valuable feedback that they intend to implement in future procedures. Seventy nine percent and 55% correctly identified the surface landmark for BMBs and LPs, respectively, on the pre-clinic survey, whereas 100% and 97% did so on the post-clinic survey, respectively. Whereas only 39% correctly identified the maximum dose of local anesthetic (lidocaine) on the pre-clinic survey, 97% did so post-clinic. At baseline, only 34% and 45% correctly indicated how to prevent or treat a post-LP headache, respectively, whereas 97% and 89% did so on the post-clinic survey, respectively. Pre-clinic, 66% incorrectly believed that platelets <10 was a contraindication to a BMB. The remaining knowledge assessments will be presented in full. Overall, free-text comments from residents on the clinic experience was strongly positive and emphasized an appreciation for expert coaching and feedback.

Conclusion: A weekly expert-run procedural skills clinic improved resident confidence in performing BMBs and LPs, and improved specific skillsets such as landmarking, corresponding to levels 1 and 2 of the Kirkpatrick model, respectively. However, among this cohort of mostly PGY-1-3s, most did not reach full confidence for independence after a single clinic. Baseline knowledge of maximal doses/volumes of local anesthetic was poor amongst trainees, but this knowledge gap was corrected with direct feedback. Sample sizes are too small to evaluate hematology PGY4-5s independently, but this is ongoing. The clinic has been incorporated as a longitudinal component of the adult hematology training program at the University of Toronto, and is planned for replication at other academic hospitals in Toronto.