“I derive a tremendous amount of enjoyment from working with my hands, from being able to provide my patients this service, from often giving them relief from excessive fluid buildup, and from being able to do these procedures at the bedside,” she says.
Reversing the recent slide of hospitalist involvement in procedures, however, may require more cohesive expectations, an emphasis on minimizing complications, identification of willing and able procedure champions, and comprehensive technology-aided training.
Confounding Expectations
Paracentesis, thoracentesis, arthrocentesis, lumbar puncture, and central line placement generally are considered “core” bedside procedures. Experts like Lichtman, however, say little agreement exists on the main procedures for which hospitalists should demonstrate competency.
“We don’t have any semblance of that,” he says. “The reality is that different groups have different beliefs, and different hospitals have different protocols that they follow.”
Pinning down a consistent list can be difficult, because HM providers can play different roles depending on the setting, says hospitalist Sally Wang, MD, FHM, director of procedure education at Brigham and Women’s Hospital and a clinical instructor at Harvard Medical School in Boston.
“You could be in an academic center. You could be in a community hospital. You could be in a rural setting where there’s no other access to anyone else doing these procedures, or you can have a robust interventional radiology service that will do all the procedures for you,” she says.
In 2007, the American Board of Internal Medicine (ABIM) revised its procedure-related requirements for board certification. Physicians still had to understand indications and contraindications, recognize the risks and benefits and manage complications, and interpret procedure results. But they no longer had to perform a minimum number to demonstrate competency. To assure “adequate knowledge and understanding” of each procedure, however, ABIM recommended that residents be active participants five or more times. The Accreditation Council for Graduate Medical Education (ACGME) followed suit in its program requirements for internal medicine.
Dr. McDonald
Furman McDonald, MD, ABIM’s vice president of graduate medical education, says the board isn’t suggesting that procedure training should be limited to “book learning.” Rather, he says, the revision reflects the broad range of practice among internists and the recognition that not all of them will be conducting bedside procedures as part of their daily responsibilities. In that context, then, perhaps more rigorous training should be linked to the honing of a subspecialty practice that demands competency in specific procedures.
“It really is one of those areas where I don’t think one size fits all when it comes to training needs,” Dr. McDonald says, “and it’s also an area where practices vary so much depending on the size of the institution and availability of the people who can do the procedures.”
Nevertheless, observers say the retreat from an absolute numerical threshold—itself a debatable standard—set the tone for many hospitalist groups and has contributed to a lack of consistency in expectations.
Dr. Barsuk
“If someone is never going to be doing these procedures in their career, we can argue whether they should be trained,” says Jeffrey Barsuk, MD, MS, associate professor of medicine at Northwestern University Feinberg School of Medicine in Chicago. But evidence suggests that internal medicine residents are still performing many bedside procedures in academic hospitals, he says. A recent study of his, in fact, found that internal medicine and family medicine-trained clinicians frequently perform paracentesis procedures on complex inpatients.2 If they’re expected to be able to do these procedures safely on the first day of residency, he says, the lack of a requirement for hands-on competency is “ridiculous.”