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Core Competencies or a Competent Core? A Scoping Review and Realist Synthesis of Invasive Bedside Procedural Skills Training in Internal Medicine

Brydges, Ryan PhD; Stroud, Lynfa MD, MEd; Wong, Brian M. MD; Holmboe, Eric S. MD; Imrie, Kevin MD; Hatala, Rose MD, MSc

doi: 10.1097/ACM.0000000000001726

Purpose Invasive bedside procedures are core competencies for internal medicine, yet no formal training guidelines exist. The authors conducted a scoping review and realist synthesis to characterize current training for lumbar puncture, arthrocentesis, paracentesis, thoracentesis, and central venous catheterization. They aimed to collate how educators justify using specific interventions, establish which interventions have the best evidence, and offer directions for future research and training.

Method The authors systematically searched Medline, Embase, the Cochrane Library, and ERIC through April 2015. Studies were screened in three phases; all reviews were performed independently and in duplicate. The authors extracted information on learner and patient demographics, study design and methodological quality, and details of training interventions and measured outcomes. A three-step realist synthesis was performed to synthesize findings on each study’s context, mechanism, and outcome, and to identify a foundational training model.

Results From an initial 6,671 studies, 149 studies were further reduced to 67 (45%) reporting sufficient information for realist synthesis. Analysis yielded four types of procedural skills training interventions. There was relative consistency across contexts and significant differences in mechanisms and outcomes across the four intervention types. The medical procedural service was identified as an adaptable foundational training model.

Conclusions The observed heterogeneity in procedural skills training implies that programs are not consistently developing residents who are competent in core procedures. The findings suggest that researchers in education and quality improvement will need to collaborate to design training that develops a “competent core” of proceduralists using simulation and clinical rotations.

Supplemental Digital Content is available in the text.

R. Brydges is assistant professor, Department of Medicine, University of Toronto, and scientist, Wilson Centre, University Health Network, Toronto, Ontario, Canada.

L. Stroud is assistant professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

B.M. Wong is associate professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

E.S. Holmboe is senior vice president for milestones development and evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois.

K. Imrie is immediate past president, Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada.

R. Hatala is associate professor, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Funding/Support: The authors are thankful for study funding provided by the Canadian Institutes of Health Research via Knowledge Synthesis Grant no. 201304KRS-132055.

Other disclosures: None reported.

Ethical approval: As this study did not involve human subjects, it was exempt from ethical review at all associated institutions.

Supplemental digital content for this article is available at

Correspondence should be addressed to Ryan Brydges, St. Michael’s Hospital and Department of Medicine, University of Toronto, 209 Victoria St, Rm 5-86, Toronto, ON M5B 1T8, Canada; telephone: (416) 864-6060, ext 77530; e-mail:

© 2017 by the Association of American Medical Colleges