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More on procedures

June 2019

I ENJOYED the article highlighting the procedure service at the University of Rochester Medical Center (“Hospitalists take back bedside procedures,” April). I fully agree that the educational benefits for residents and the job satisfaction of learning to perform bedside procedures are significant and will undoubtedly improve career longevity by reducing burnout.

Previously, the ABIM and the ACGME (RRC-IM) required residents to document that they had successfully performed a minimal number (five) of the following procedures to graduate from their training program: leading a code (ACLS), abdominal paracentesis, arthrocentesis, drawing an ABG, central venous line placement, nasogastric tube placement, lumbar puncture, Pap smear and thoracentesis.1 Since 2006, however, the requirements have been reduced to ACLS, drawing an ABG, drawing venous blood, performing a Pap smear and placing a peripheral IV.2 That means that more than a decade of internal medicine-trained hospitalists are practicing without prior experience in performing common and crucial procedures, and it is no surprise when physicians report being uncomfortable doing so.3,4

Instead, other specialties—like interventional radiology—are consulted to perform these procedures, while emergency medicine has also increased its procedural numbers. Patients commonly receive all the necessary diagnostic and therapeutic procedures in the ED before a patient is admitted or a hospitalist or internist is even consulted. This trend of having a patient “fully packaged for admission” has benefited the emergency medicine residents to the detriment of internal medicine residents’ training and experience.

One suggestion to reverse this trend is to have internal medicine residents go to the ED earlier to get involved in the necessary evaluation and stabilization of patients who will clearly be admitted to their service. This strategy would also improve the sense of ownership of the patient as well as the communication between the treatment teams (emergency medicine and internal medicine) and between the hospitalist service and a patient’s family members, who may be long gone by the time the patient is brought upstairs.

~Joseph Shiber, MD
Jacksonville, Fla.

1) American Board of Internal Medicine. Policies and Procedures for Certification. Philadelphia, PA: ABIM;2005.

2) American Board of Internal Medicine. Policies and Procedures for Certification. Philadelphia, PA: ABIM;2006.

3) Wigton RS, Alguire P; American College of Physicians. The declining number and variety of procedures done by general internists: a resurvey of members of the American College of Physicians. Ann Intern Med. 2007;146(5):355-360.

4) Mourad M, Kohlwes J, Maselli J, Auerbach AD. Supervising the supervisors—Procedural training and supervision in internal medicine residency. J Gen Intern Med. 2010;25(4):351-356.

Published in the June 2019 issue of Today’s Hospitalist
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