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Year : 2007  |  Volume : 20  |  Issue : 1  |  Page : 9

Procedural skills: What's taught in medical school, what ought to be?

1 University of Alberta, Edmonton, Canada
2 Cross Cancer Institute, Edmonton, Canada

Date of Submission09-Mar-2007
Date of Web Publication21-Apr-2007

Correspondence Address:
S R Turner
507 Lessard Dr., Edmonton Alberta, T6M 1A9
Login to access the Email id

Source of Support: None, Conflict of Interest: None

PMID: 17647177


Background: Medical schools' instruction of skills is often found to be inadequate. In 1999, the American Association of Medical Colleges (AAMC) published a list of eight procedural skills that medical students are recommended to learn. This study aims to evaluate compliance with these guidelines and to examine the instruction of other skills to determine if the most important skills receive adequate instruction.
Methods: In 2004, surveys were sent to 138 educational representatives at North American (AAMC) medical schools and 1208 Canadian family physicians. The survey addressed the importance of selected skills. Findings were analyzed by χ2 testing.
Results: Of the eight skills recommended by the AAMC, only four were taught by all schools. All eight, except for suturing, and most of the other skills, were taught at a higher rate than they were practiced. Only digital block anesthesia was practiced more commonly than it was taught.
Conclusion: Although guidelines exist for skills instruction in medical school, they are not followed completely. Furthermore, the guidelines may reflect an emphasis on skills that are more suited to specialist rather than general practice. This may come at the expense of the instruction of other more practical skills.

Keywords: procedural skills, medical education, undergraduate

How to cite this article:
Turner S R, Hanson J, de Gara C J. Procedural skills: What's taught in medical school, what ought to be?. Educ Health 2007;20:9

How to cite this URL:
Turner S R, Hanson J, de Gara C J. Procedural skills: What's taught in medical school, what ought to be?. Educ Health [serial online] 2007 [cited 2021 Oct 18];20:9. Available from:


The importance of procedural skills to a physician is obvious. Performing an appropriate procedural skill properly can be life saving. Thus it is necessary to determine those skills that are essential for the competent physician. The proportion of schools teaching a certain skill is indicative of the emphasis placed by educators on competency in that skill. Similarly, the proportion of physicians who perform a skill in their practice is an indication of its practical value. Ideally, a skill should be emphasized by educators to a level that is reflective of its practical importance.

In North America, family practice makes up the single largest proportion of residency positions matched to students. In the 2005 Canadian residency match almost 1/3 of graduating students were selected into family practice, roughly 1/3 as a second choice or lower (CaRMS, 2004; NRMP, 2005). Since such a large proportion of undergraduate students match with family practice, it is reasonable that undergraduate medical education should, at least in part, be aimed towards the goal of training students who possess the requisite skills to become a family physician.

Prior to 1999, studies consistently found North American medical schools to be deficient in teaching skills. Nelson and Traub (1993) found that most medical schools offered no more than an introductory course in phlebotomy. In 1999, the AAMC established recommendations for teaching procedural skills to medical students. Among these guidelines is a list of eight skills (Figure 1) in which “the medical school must ensure that before graduating a student will have demonstrated” competency (Medical School Objectives Writing Group, 1999).

Figure 1: The instruction and performance of 24 procedural skills

This study has several aims. It will quantitatively examine current practices of education to reveal whether the deficiencies previously noted still exist and whether the recently introduced AAMC recommendations are being met. Current educational practices will also be compared against the practices of family physicians to measure which skills should be taught.


The study consisted of surveys which were directed to the following two groups: Associate Deans of Education (or equivalent) of all North American medical colleges comprised the first group or educators group and a sample of 1208 Canadian family physicians made up the second group. A list of potentially important procedural skills was generated from a review of the literature. Of a total of 152 skills mentioned in the 13 studies selected, 24 had been cited four or more times and were chosen for study (APM, 2003; Dire & Kietzman, 1995; Engum, 2003; GMEC, 1998; House & House, 2000; Hunskaar & Seim, 1983; Kowlowitz et al., 1990; Ladak, n.d.; Lawrence et al., 1983; Nelson & Traub, 1993; Reznik et al., 1988; Spike & Veitch, 1990; Taylor, 1997).

The survey was designed using the online survey service “Survey Monkey”. The “MD Select” database was used to obtain email addresses for the family physicians contacted; the sample was made up of those family physicians who provided their email addresses to the database.

The percentage of schools that recommend or require the instruction of a skill was compared to the proportion of family physicians who performed that skill via χ2 analysis.

The study was approved by the University of Alberta’s ERB.


Completed surveys were received from 79 educators (response rate =57%) and 475 family physicians (response rate =39%).

A minority of the skills investigated were taught by all schools. These included four of the AAMC recommended skills (Foley catheterization, IV starting, NG tube insertion and suturing). Among the other skills, CPR, dressing wounds, urinalysis, pap/vaginal smear and throat swab were taught by 100% of the respondents.

Fifteen of the 24 skills investigated were taught at a significantly higher rate than they were practiced by family physicians. The only skill that was taught at a significantly lower rate than it was practiced was digital block anesthesia. Eight skills had rates of instruction that were not significantly different from their rates of practice.


This study found several areas in which procedural skills education was lacking and not all schools taught the eight AAMC recommended skills. This may have resulted from a lack of awareness of the guidelines, or an inability or refusal to comply. In any case, it appears that steps must be taken if these guidelines are to be upheld.

The majority of the skills studied were taught at a higher rate than they were practiced. This reflects an emphasis being placed on skills that are employed in specialties other than family practice, which includes seven of the eight AAMC skills. This may result from a bias in undergraduate medical education towards training specialists and not general practitioners.

Some of the skills in this group, such as intubation or tracheostomy are skills that would be useful for any physician to know in an emergency, but may occur so infrequently in general practice that the opportunity never arises to employ them. Several other of the skills studied would only be useful in an inpatient setting, and as such might be useful to several specialties but less so to family practice. However, teaching resources are limited and their use to teach these skills may come at the expense of skills that would be useful to a greater proportion of students.

Our study identified one such skill that may be an example of this effect, i.e. digital block anesthesia which was a skill that was practiced commonly but taught at a lower rate. This is one skill that might benefit from a redistribution of teaching resources. Further research may identify other skills that are likewise taught at a lower level than appropriate.

The remaining skills where no difference was found between the rates of instruction and practice indicate areas in which education was best matched to the needs of family practice.

It is the stated aim of many medical schools to train physicians to be competent in general medicine. However, current AAMC guidelines and general educational tendencies may over-emphasize certain skills that are not germane to this goal. An adjustment to and stronger implementation of national guidelines could avoid some of these discrepancies.

This study has several limitations. The response rate, especially among family physicians, was low. Despite sample sizes large enough to determine several significant results, it is also unclear how representative the sample of family physicians used is of North American family physicians or how representative the sample of educators is.


Mr. Turner’s funding is provided by the Office of Undergraduate Education and the Department of Surgery at the University of Alberta. Mr. Hansen and Dr. de Gara are funded by the Department of Surgery at the University of Alberta.


Association of professors of medicine (APM) (2003). Medical students and procedural skills. American Journal of Medicine, 114, 343-345.

Canadian Resident Matching Service (CaRMS) (2004). Match Results of Canadian Graduates by Discipline Preference 2004 Match First Iteration. Retrieved June 21, 2005, from

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Graduate Medical Education Committee (GMEC) (1998). Prerequisite objectives for graduate surgical education: a study of the graduate medical education committee American college of surgeons. Journal of American College of Surgeons, 186, 50-62.

HOUSE, A.K. & HOUSE, J. (2000). Improving basic surgical skills for final year medical students: the value of a rural weekend. Australian and New Zealand Journal of Surgery, 70, 344-347.

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LAWRENCE, P.F., ALEXANDER, R.H. & BELL, R.M. (1983). Determining the content of a surgical curriculum. Surgery, 94, 309-316.

Medical School Objectives Writing Group (1999). Learning Objectives for Medical School Education—Guidelines for Medical Schools: Report I of the Medical School Objectives Project. Academic Medicine, 74, 13-18.

National Resident Matching Program (NRMP) (2005). Programs, Positions Ranked and Filled in 2005 (U.S. Seniors) . Retrieved June 21, 2005, from

NELSON, M.S. & TRAUB, S (1993). Clinical skills training of U.S. medical students. Academic Medicine, 68, 926-928.

REZNIK, R.K., BREWER, M.L. & WESLEY, R.M. et al. (1988). The practicing doctor’s perspective on the surgical curriculum. American Journal of Surgery, 156, 38-42.

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