Procedures remain essential to internal medicine training, but the ways residents learn to do them have evolved as the American Board of Internal Medicine's (ABIM) procedural requirements for board certification have changed.
“There are so many different learners, so many different learner types, and so many different interests, and I think it's hard to train a monolithic internal medicine resident,” said May M. Lee, MD, a clinical associate professor of medicine at the Keck School of Medicine of the University of Southern California in Los Angeles.
As of the 2019-2020 academic year, ABIM still required all residents to perform procedures during training. However, the certification requirements state that “Not all residents need to perform all procedures,” as the specific procedures they complete will vary based on their subsequent subspecialty or choice of an inpatient or outpatient career path. In other words, procedural training for today's trainees may be customized to the individual.
The most recent requirements, which ABIM established after seeking input from program and fellowship directors, recent graduates, health systems, and medical societies, also give program directors more discretion in how they evaluate procedural skills. “This may vary from resident to resident depending on interest,” said Dr. Lee. “I think building avenues where people who are interested in getting procedural training within a program [could do so] would be very helpful in facilitating these types of skills development.”
Doing procedures early on is especially helpful for residents who are considering entering a procedurally based subspecialty after residency, she said. As a pulmonary and critical care fellowship director, she said she looks favorably upon applicants who've done a lot of procedures. And for those who want to become hospitalists, Dr. Lee noted that procedurally competent hospitalists are potentially valued and compensated more than those who don't do procedures.
Plus, residents are still the workhorses of the hospital on nights and weekends. At some institutions, they may even be called upon to do procedures out of necessity, said Joshua D. Lenchus, DO, RPh, FACP, regional chief medical officer at Broward Health Medical Center in Fort Lauderdale, Fla. “They may not do [them] when they get out of training, but certainly in training, there is a need to have residents perform these procedures because they're not being performed by attendings in many of the training institutions around the country,” he said.
Residents have the benefit of more attending supervision than in the past and increasing use of simulation-based training. Although ABIM isn't requiring as much procedural expertise as it used to, some residency programs have been going a cut above the requirements by using simulation and establishing procedure service rotations.
Going beyond requirements
In the early 2000s, ABIM required residents to successfully perform a minimum number (three to five) of certain invasive procedures, such as lumbar puncture, abdominal paracentesis, central line placement, and thoracentesis.
Historically in the U.S., residents performed procedures at the bedside without attending supervision, said Grace C. Huang, MD, FACP, an associate professor of medicine at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center in Boston. “Back then, there was very little supervision, and if it occurred, it was the person the next level up,” she said.
Then, in 2006, ABIM changed its requirements for certification to state that residents are expected to understand and be able to explain (but no longer perform a certain number of) such procedures. Instead, residents are required to safely perform a smaller subset of procedures, including advanced cardiac life support as well as more outpatient-based procedures, such as drawing blood and doing Pap smears.
Under the most recent requirements, program directors can customize their procedural evaluations using direct observation and simulation as appropriate, according to ABIM. Given the evidence supporting simulation and competency-based approaches (such as mastery learning) for teaching procedures, such as a systematic review and meta-analysis published in the April 2016 BMJ Quality & Safety, more residency programs are using these techniques.
At the University of Miami Miller School of Medicine, Dr. Lenchus created a simulation-based invasive bedside procedural curriculum that uses mannequins and an ultrasound machine to teach trainees. The main procedures include lumbar puncture, thoracentesis, paracentesis, central venous catheterization, and knee arthrocentesis.
To standardize the way procedures are taught, Dr. Lenchus trained a handful of attendings in performing the procedures, supervising the residents, intervening when necessary, and providing feedback. “We used a critical skills checklist to assess the performance of the procedure, both in the sim lab and at the bedside, and every procedure was directly supervised by hospital medicine attendings,” he said.
Northwestern University Feinberg School of Medicine in Chicago also uses simulation to “go above and beyond the ABIM guidelines,” said Jeffrey H. Barsuk, MD, MS, professor of medicine and medical education and the director of simulation and patient safety. Residents learn how to do procedures through a simulation-based mastery learning curriculum and must reach mastery before doing them at the bedside.
“Before the end of training, all learners are required to reach a very high level of skill that's determined by an expert panel to be safe for independent patient care. Residents have to demonstrate this level of skill on the simulator before they are even allowed to perform the procedure supervised on patients,” Dr. Barsuk said.
Hands on patients
Residents who, due to career plans or general interest, want hands-on experience in invasive procedures often must learn while rotating through the ICU or a procedure service (if the hospital has one), said Dr. Lee. But in the ICU, the ability to do procedures is restricted. “Residents don't always get to do them. Sometimes it's the fellow or the attending because, if the situation is dire enough, it just needs to get done,” she said.
A procedure service can help interested trainees get intensive hands-on experience while offloading procedural work from their resident colleagues directly caring for the patients, Dr. Huang noted, adding that her colleague C. Christopher Smith, MD, FACP, started one of the first procedural service rotations in the country in 2004 at Beth Israel Deaconess.
“This allowed residents to do a one- to two-week rotation where all they were doing was procedures. . . . This essentially became a consultative service so that residents who cannot pause their workday for a few hours to perform a procedure could request the procedure team to manage the whole process. This involves independently reviewing the indications, obtaining consent, monitoring for complications, and following up on results,” she said. “That educational structure has been in place here for more than 15 years now and I think has basically been propagated around the country as well.”
At the University of Miami, residents who complete simulation training move on to a procedure service rotation that Dr. Lenchus created in 2007 to give them a critical mass of experience. The four-week rotation began as an elective and has since become a mandatory rotation for all internal medicine and medicine-pediatrics residents, he said.
Calls to the service come from any service in the hospital, such as the ED and the ICUs. “Anyone could call our team to perform the procedure like they could call interventional radiology . . . In fact, we took over the education of procedures for most of the hospital,” Dr. Lenchus said. For example, the service team trained surgeons how to put in central lines and trained neurologists how to do lumbar punctures, he said.
Northwestern has also been planning to start an elective procedure service rotation and will require residents to complete the simulation training beforehand, according to Dr. Barsuk. “My guess is that residents who are going to be more procedure-based will want to do it,” he said.
For hospitals that want to start a procedure service, the most resource-heavy component will be arranging for direct supervision in addition to equipment like mannequins and a portable ultrasound machine, said Dr. Lenchus, who has shared his program with several other institutions. “The financial resources in getting this off the ground in the beginning is getting the equipment that's needed, and then having some semblance of a ‘train-the-trainer’ session,” he said.
The decision of which clinicians should train others on the service will depend on the skill level of staff, said Dr. Lee, who created and served on a procedure service at Mount Sinai Hospital Medical Center in Chicago. “I think it can be owned by internal medicine if you have procedurally based hospitalists, or it can be owned by pulmonology/critical care or even a surgical service,” she said.
But not every institution is ripe for a team-based service, as opposed to one or two trained individuals who can supervise and train other people, Dr. Lenchus said. “In a large hospital . . . having a team is warranted because the volume is so high, and you could actually carve out a dedicated attending to supervise the performance of those procedures,” he said. “But a hospital that has 100 or 200 beds may not have the volume to warrant a full-blown team.”
Nonetheless, Dr. Lenchus said that standardized procedural training should be manageable for any hospital that wants to move beyond the old training model of “see one, do one, teach one.” “I think it's absolutely doable for every institution, regardless of size, to conduct the training,” he said.