Instructor Joshua D. Lenchus, DO, (center) assists Syed Irfan Qasim Ali, MD, (middle) in guided ultrasound technique on volunteer Kristin Wish, MD, during a hands-on pre-course at HM12 at the Gaylord Natonal Resort & Convention Center in National Harbor, Md.
On his way to a recent conference, David Lichtman, PA, stopped to talk with medical residents at a nearby medical center about their experiences performing bedside procedures. “How many times have you guys done something that you knew you weren’t fully trained for but you didn’t want to say anything?” asked Lichtman, a hospitalist and director of the Johns Hopkins Central Procedure Service in Baltimore, Md. “At least once?”
Everyone raised a hand.
When Lichtman asked how many of the residents had ever spoken up and admitted being uncomfortable about doing a procedure, however, only about 20% raised their hands.
It’s one thing to struggle with a procedure like drawing blood. But a less-than-confident or unskilled provider who attempts more invasive procedures, such as a central line insertion or thoracentesis, can do major harm. And observers say confidence and competence levels, particularly among internal medicine residents, are heading in the wrong direction.
Two years ago, in fact, three hospitalists penned an article in The Hospitalist lamenting the “sharp decline” of HM proficiency in bedside procedures.1 Co-author Joshua Lenchus, DO, RPh, FACP, SFHM, associate director of the University of Miami-Jackson Memorial Hospital Center for Patient Safety and medical director of the hospital’s Procedure Service, says the trend is continuing for several reasons.
“One is internal medicine’s willingness to surrender these bedside procedures to others,” Dr. Lenchus says, perhaps due to time constraints, a lack of confidence, or a perception that it’s not cost effective for HM providers to take on the role. Several medical organizations have loosened their competency standards, and the default in many cases has been for interventional radiologists to perform the procedures instead.
Another reason may be more practical: Perhaps there just isn’t a need for all hospitalists to perform them. Many new hospitalist positions advertised through employment agencies, Dr. Lenchus says, do not require competency in bedside procedures.
“The question is, did that happen first and then we reacted to it as hospitalists, or did we stop doing them and employment agencies then modified their process to reflect that?” he says.
For hospitalists, perhaps the bigger question is this: Is there a need to address the decline?
For Lichtman, Dr. Lenchus, and many other leaders, the answer is an emphatic yes—an opportunity to carve out a niche of skilled and patient-focused bedside care and to demonstrate real value to hospitals.
“I think it makes perfect sense from a financial and throughput and healthcare system perspective,” he says. The talent, knowledge, and experience of interventional radiologists, Dr. Lenchus says, is far better spent on procedures that cannot be conducted at a patient’s bedside.
It’s also a matter of professional pride for hospitalists like Michelle Mourad, MD, associate professor of clinical medicine and director of quality improvement and patient safety for the division of hospital medicine at the University of California San Francisco.