Whatever the reasons, observers say, fewer well-trained hospitalists are performing bedside procedures on a routine basis.
“I think we’re seeing a trend away from an expectation that all residents are going to be comfortable and qualified to perform these procedures,” says Melissa Tukey, MD, MSc, a pulmonology critical care physician at Lahey Clinic in Burlington, Mass., who has studied procedural training and outcomes. “That is reflected in the literature showing that a lot of graduating residents, even before these changes were made, felt uncomfortable performing these procedures unsupervised, even later into their residency.”
By changing their requirements, however, she says the ABIM and ACGME have effectively accelerated the de-emphasis on procedures among internal medicine generalists and put the onus on individual hospitals to ensure that they have qualified and capable staff to perform them. As a result, some medical institutions are opting to train a smaller subset of internal medicine physicians, while others are shifting the workload to other subspecialists.
Lichtman says he’s frustrated that many medical boards and programs continue to link competency in bedside procedures to arbitrary numbers that seem to come out of “thin air.” While studies suggest that practitioners aren’t experienced until they’ve performed 50 central line insertions, for example, many guidelines suggest that they can perform the procedure on their own after only five supervised insertions. “My thought is, you need as many as it takes for you, as an individual, to become good,” Lichtman says. “That may be five. It may be 10. It may be 100.”
Robert L. Vogelzang, MD
Virtually all of us started doing this because we were asked to do cases that couldn’t be done by others because we had imaging—usually ultrasound guidance—and that yielded superior results. —Robert L. Vogelzang, MD, FSIR, professor of radiology, Northwestern University Medical School, Chicago, and past president, Society for Interventional Radiology
Complicating Factors
Central venous line placement has been a lightning rod in the debate over training, standardization, and staffing roles for bedside procedures, Lichtman says, due in large part to the seriousness of a central line-associated bloodstream infection, or CLABSI. In 2008, the Centers for Medicare and Medicaid Services deemed the preventable and life-threatening infection a “never” event and stopped reimbursing hospitals for any CLABSI-related treatment costs.
“If I’m trying to stick a needle in your knee to drain fluid out, there’s a really low risk of something catastrophically bad happening,” he says. But patients can die from faulty central line insertion and management. Stick the needle in the wrong place, and you could cause unnecessary bleeding, a stroke, or complications ranging from a fistula to a hemopneumothorax.
If discomfort and concern over potential complications are contributing to a decline in hospitalist-led bedside procedures, many experts agree that the role may not always make economic or practical sense either. “It doesn’t make sense to train all hospitalists to do all of these procedures,” Dr. Lenchus says. “If you’re at a small community hospital where the procedures are done in the ICU and you have no ICU coverage, then, frankly, that skill’s going to be lost on you, because you’re never going to do it in the real world in the course of your normal, everyday activities.”
Even at bigger institutions, he says, it makes sense to identify and train a core group of providers who have both the skill and the desire to perform procedures on a consistent basis. “It’s a technical skill. Not all of us could be concert pianists, even if we were trained,” Dr. Lenchus says.
Dr. Wang says it will be particularly important for hospitalist groups to identify a subset of “procedure champions” who enjoy doing the procedures, are good at it, have been properly trained, and can maintain their competency with regular practice.