Criteria for Excellence | Chapter 9D: Procedural training in family medicine residencies

Build a structured, competency-based approach to procedural training.

Authors: Roger D. Garvin, MD; John D. Gazewood, MD, MSPH; Debbie Lupeika, MD; Randy Pearson, MD

Why procedural training matters in family medicine residency

Office-based procedures are a core component of family medicine practice. They improve patient satisfaction by offering greater convenience, continuity of care and access, particularly in rural and underserved settings where family physicians may be the primary source of procedural services. Performing procedures can also enhance professional satisfaction and contribute meaningfully to practice sustainability. For applicants selecting a family medicine residency program, procedural training is a key consideration.

The scope of procedures performed by family physicians continues to expand, driven by patient demand and learner interest. When developing a procedural curriculum, residency programs must distinguish between procedures that can be performed in family medicine and those that should be included in residency training, considering factors such as financial implications, feasibility and relevance.

Develop a competency-based procedural curriculum

A family medicine residency program’s curriculum should include procedures that meet the following criteria:

  • Are relevant to broad family medicine practice

  • Align with patient needs, community context and graduates’ scope of practice goals

  • Can be performed in a cost-effective manner, including equipment considerations

  • Can be reliably assessed for resident competency

Traditional models—such as “see one, do one, teach one”—do not provide a consistent, standardized path to procedural competency.¹ In addition, neither procedural volume nor postgraduate year reliably predicts competency.² Programs of Excellence implement a structured curriculum designed to ensure that all graduates achieve competency in procedures required by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Family Medicine (ABFM), as well as additional procedures that align with program goals and residents’ anticipated scope of practice. Frameworks for procedural training such as Sawyer’s Learn, See, Practice, Prove, Do and Maintain method³ can help programs organize their curriculum across skill development stages.

Core components of procedural training in residency

A comprehensive procedural curriculum should define the instructional components residents need to acquire, practice and apply procedural skills. These components include the following:

  1. Didactic learning provides the foundational knowledge residents need to acquire and transfer procedural skills and integrate them into practice. Content should include the following4:
    1. Background, including relevant anatomy and pathophysiology
    2. Indications and contraindications
    3. Alternatives
    4. Complications and management
    5. Informed consent and patient counseling
    6. Patient preparation
    7. Anesthesia, analgesia and sedation, as appropriate
    8. Patient monitoring and resuscitation
    9. Equipment selection, use, care, cleaning and maintenance
    10. Patient positioning
    11. Technique and procedure steps
    12. Aftercare
    13. Outcome evaluation
    14. Pathology recognition, as appropriate
    15. Documentation and procedure tracking
    16. Practice management aspects, including billing and coding
  2. Simulation-based training allows residents to develop technical skills in a safe, controlled environment before performing procedures on patients. A key principle of this training is deliberate practice, which includes the following elements5,6:
    1. Clear learning objectives
    2. Defined, measurable performance elements
    3. Repetitive, focused skill practice
    4. Direct observation
    5. Real-time, actionable feedback
  3. Supervised clinical practice requires residents to apply procedural skills in real clinical settings under direct supervision and progress toward independent performance.

Programs of Excellence implement these core components using multiple instructional modalities (e.g., simulation labs, workshops, videos, certification courses).

Best practices for implementing a procedural curriculum

Implementation translates a residency program’s procedural curriculum into consistent learning experiences across training settings. Programs of Excellence tailor implementation to their local resources, faculty expertise and patient population while also supporting achievement of all required competencies.

Residents’ procedural competency cannot be assessed through retrospective sign-off alone, so faculty engagement is essential. All faculty—which may include core and specialty-trained clinicians—must meet institutional credentialing requirements and maintain competence for the procedures they teach. Programs should invest in faculty development to support technical skills and effective teaching, observation and coaching skills.

Programs of Excellence provide the infrastructure needed to sustain consistent procedural training—including didactic learning, simulation-based training and supervised clinical practice—across sites. This includes the following:

  • Institutional support
  • Protected time for teaching and performing procedures
  • Standardized protocols for delivery, supervision, documentation and tracking of procedural training
  • Adequate equipment and trained support staff
  • Sufficient patient volume (through referral networks, if necessary)

Residents should have repeated exposure to procedures through structured clinical opportunities, including the following:

  • Dedicated procedure clinics
  • Continuity clinic procedures with supervision
  • Rotations (e.g., women’s health, emergency medicine, dermatology, orthopedics)

Spaced learning (also known as distributed practice) is a technique for improving long-term retention by presenting and reviewing information in focused sessions separated by planned intervals.⁷ This approach leads to better skill acquisition and retention than one-time workshops (i.e., massed practice).⁸˒⁹ Residency Program Solutions recommends that procedural training be longitudinal rather than episodic to maximize skill retention.

Programs of Excellence do the following to support long-term skill development and prepare residents for independent practice:

  • Provide ongoing simulation opportunities, especially for low-volume procedures
  • Integrate procedural experiences into continuity clinic and rotations
  • Use a coaching approach that encourages reflection and iterative improvement
  • Offer periodic refresher training
  • Continue appropriate supervision after initial competency determination to reinforce mastery

Assess procedural competency in family medicine residents

Ensuring procedural competency is fundamental to full-spectrum family medicine training. ACGME and ABFM requirements define core procedural expectations, and evolving competency-based medical education frameworks emphasize outcomes and entrustment. Competency assessment must extend beyond residents’ technical skills to include cognitive, clinical and systems-based capabilities aligned with ACGME core competencies.

The following domains translate the curriculum’s instructional content into observable capabilities residents must demonstrate for each included procedure:

  • Explain the procedure’s role within the scope of family medicine
  • Identify indications, contraindications and potential complications
  • Determine appropriate timing
  • Obtain informed consent and provide patient counseling
  • Select, manage and maintain equipment
  • Prepare and lead the procedural environment
  • Perform the procedure safely
  • Recognize and manage complications
  • Ensure proper specimen handling and safety protocols
  • Provide aftercare and follow-up guidance
  • Document procedures accurately, including billing and coding
  • Engage in self-evaluation and reflective debriefing with staff and faculty

Determination of procedural competency is longitudinal. It requires repeated observation, ongoing feedback and progressive entrustment, not a single evaluation event. Not all domains need to be assessed in every encounter, but residency programs must ensure that each domain is evaluated over time.

Programs should develop procedure-specific assessment tools and entrustment forms that faculty can use to evaluate and document residents’ performance across the domains of procedural competency. These instruments should cover the following performance areas:

  • Clinical knowledge and decision-making
  • Patient education and consent
  • Technical execution
  • Aseptic technique and safety practices
  • Use of assistants and teamwork
  • Postprocedural care
  • Documentation and coding
  • Ability to integrate procedures into future practice

Build an intentional, longitudinal procedural training program

A Program of Excellence has a high-quality procedural curriculum that is intentional, longitudinal and competency based. It integrates didactics, simulations and supervised clinical experiences, all of which are supported by sufficient training infrastructure, ongoing faculty development, and structured assessment and entrustment processes.

Residency programs that invest in comprehensive procedural training enhance patient care, improve their residents’ experience, and strengthen the scope and sustainability of family medicine practice.

Authors’ note: Generative artificial intelligence (AI) tools were used in the development of this chapter. All content was reviewed and validated by the authors, who are responsible for its accuracy and integrity.

  1. Lenchus JD. End of the "see one, do one, teach one" era: the next generation of invasive bedside procedural instruction. J Am Osteopath Assoc. 2010;110(6):340-346.
  2. Barsuk JH, Cohen ER, Feinglass J, et al. Residents' procedural experience does not ensure competence: a research synthesis. J Grad Med Educ. 2017;9(2):201-208.
  3. Sawyer T, White M, Zaveri P, et al. Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine. Acad Med. 2015;90(8):1025-1033.
  4. American Academy of Family Physicians. Procedural skills training, residency criteria. September 2022. Accessed June 19, 2026.
  5. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15(11):988-994.
  6. Wayne DB, Barsuk JH, O'Leary KJ, et al. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med. 2008;3(1):48-54.
  7. Van Hoof TJ, Sumeracki MA, Madan CR. Science of Learning Strategy Series: article 1, distributed practice. J Contin Educ Health Prof. 2021;41(1):59-62.
  8. Cheng A, Nadkarni VM, Mancini MB, et al. Resuscitation education science: educational strategies to improve outcomes from cardiac arrest: a scientific statement from the American Heart Association. Circulation. 2018;138(6):e82-e122.
  9. Jørgensen HK, Vamadevan A, Konge L, et al. Distributed training vs. massed practice for surgical skills training–a systematic review. Surg Endosc. 2025;39(1):39-63.