{"id":1809,"date":"2015-11-13T15:20:14","date_gmt":"2015-11-13T20:20:14","guid":{"rendered":"http:\/\/blogs.nejm.org\/general-medicine\/?p=1809"},"modified":"2015-11-13T15:20:14","modified_gmt":"2015-11-13T20:20:14","slug":"procedural-competency","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2015\/11\/procedural-competency\/","title":{"rendered":"Procedural Competency"},"content":{"rendered":"
\"Briana<\/a>

Briana Buckner, MD, is a 2015-16 Chief Resident in Internal Medicine at the University of Pennsylvania in Philadelphia.<\/p><\/div>\n

It’s 2 am, and the patient\u2019s blood pressure is beginning to rapidly decrease. Every IV line is occupied by an antibiotic or IV fluids, and we are in need of a vasoactive medication. The nurse comes to my computer and sternly states, \u201cWe can no longer avoid it. I think the patient needs a central line.\u201d I quickly say “OK,” but I don\u2019t move. I am momentarily frozen by my unease with the bedside procedure ahead. My mind is racing and questioning whether I can make any other treatment or management decision to avoid this procedure. I\u2019ve got nothing. This is definitely what the patient needs. The nurse asks, \u201cAre you signed off?\u201d<\/p>\n

I reply earnestly, with a strong \u201cyes,\u201d to convey to her that I am confident in my skills and comfortable. The honest reality is that I am nervous\u00a0about doing this central line procedure and am finally\u00a0facing my procedural comfort level straight on. Although I met the institutional requirement for quantity of this procedure needed for unsupervised performance of this skill, my comfort had waned in the few months since I had performed the procedure.<\/p>\n

\"resident<\/a>

By Artur Bergman (CPMC Surgery), via Wikimedia Commons<\/p><\/div>\n

The real question I faced that night as a second-year resident was whether my level of comfort reflected my competency and ability to complete the procedure safely. If we assume that comfort reflects competency, our current quantitative benchmarks for performing unsupervised procedures may not be enough. In one prospective study of residents’ comfort with\u00a09 aspects of 4 common bedside procedures, the residents reported lack of comfort in at least one aspect of 51% of procedures performed over the course of a year (1).\u00a0Higher procedure numbers and direct supervision were associated with greater comfort.<\/p>\n

What feels like a recent development of more physicians being less comfortable with bedside procedures may really be a result of procedures transitioning primarily into the hands of specialists. A survey of internists\u00a0from the American College of Physicians showed that\u00a0\u00a0primary internists\u00a0regularly performed\u00a016 in-office procedures\u00a0in 1986,\u00a0versus 7 in 2004\u00a0(2). There has also been a recent movement\u00a0to provide\u00a0procedure-service models on many inpatient services that serve as exemplary models of procedure execution. These models offer expert supervisors, consistent teaching technique, and a controlled environment for the patient. Although these models are a plus for the patient, some would argue procedure services are performing procedures that previously would have been performed by trainees \u2014 the same trainees who must develop into our next generation of experts.<\/p>\n

So\u00a0how do these issues\u00a0affect our\u00a0journey to procedural safety for our patients and the training of future procedural experts? In recent years, the American Board of Internal Medicine has transitioned away from quantitative requirements to determine if\u00a0physicians-in-training\u00a0are ready for unsupervised performance of\u00a0skills and has implemented milestone-based assessments<\/a>. These milestone- and competency-based assessment tools require\u00a0trainees to demonstrate effective mastery of needed technical skills and to\u00a0understand and be able to manage complications\u00a0(in addition to\u00a0reaching a defined number of each procedure). Although the ABIM has embraced milestone-based evaluation, many of our training programs continue the longstanding \u201csigned off\u201d culture after 5 or so of a common procedure\u00a0are performed. Which, in my case, was not the point of comfort and may have not been the point of competency. As procedural training often is\u00a0considered one of the most important aspects of training, I hope with innovation and diligence we can continue to train competent procedural experts.<\/p>\n

Do you have thoughts on bedside procedural comfort or competency? How can we improve procedural training? Please feel free to share your comments. <\/em><\/p>\n

References:<\/p>\n

    \n
  1. Huang GC et al. Beyond the comfort zone: Residents assess their comfort performing inpatient medical procedures.\u00a0 Am J Med 2006 Jan; 119:71.e17<\/a>.<\/li>\n
  2. Wigton RS and\u00a0Alguire 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 Mar 6; 146:355<\/a>.<\/li>\n<\/ol>\n

     <\/p>\n","protected":false},"excerpt":{"rendered":"

    It’s 2 am, and the patient\u2019s blood pressure is beginning to rapidly decrease. Every IV line is occupied by an antibiotic or IV fluids, and we are in need of a vasoactive medication. The nurse comes to my computer and sternly states, \u201cWe can no longer avoid it. I think the patient needs a central […]<\/p>\n","protected":false},"author":1272,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[31,34,35,37,40],"class_list":["post-1809","post","type-post","status-publish","format-standard","hentry","category-about-residency","tag-patient-care","tag-residency","tag-resident-autonomy","tag-resident-experience","tag-student-experience"],"yoast_head":"\nProcedural Competency Among Residents<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2015\/11\/procedural-competency\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Procedural Competency\" \/>\n<meta property=\"og:description\" content=\"It’s 2 am, and the patient\u2019s blood pressure is beginning to rapidly decrease. 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