An experienced attending general internist at an academic health center is called by a first-year resident to supervise a bedside thoracentesis. On this particular day, the attending has only this one first-year resident present—the other residents are unavailable because of illness, postcall days, or academic responsibilities. The resident has performed the procedure with ultrasound guidance only once before and so has requested supervision from the staff. The attending is a highly regarded educator and researcher but has not previously performed the procedure with ultrasound guidance and has only performed two thoracenteses independently within the last three years. What should the attending and resident do to complete this semiurgent procedure?
This scenario, based on experiences at our institution, represents a situation that is not infrequent, though rigorous data are lacking. In an era of increasing transparency and attention to patient safety, we may simply be more aware of these situations, or, alternatively, the frequency may truly be increasing.
Why might the incidence of such situations be increasing? First, with reductions in resident work hours, increasing admissions, and an endless push for efficiency, faculty are taking on more direct responsibilities in patient care.1 Junior faculty, having recently completed training, are typically accustomed to performing bedside procedures; however, more senior faculty may find themselves needing to supervise procedures that they have not performed in many years. Second, the rise of different career tracks in academia has resulted in faculty primarily focused on either patient care, research, education, or administration. While having specialized faculty holds many benefits, it also comes with drawbacks, including a large number of faculty who are only part-time clinicians and who may have difficulty maintaining procedural competence (i.e., proficiency in performing bedside procedures on general medical wards). Third, a drive for efficiency and subspecialization has pushed some traditional bedside procedures to the realm of other specialists. Gone are the days when a medical team could dedicate two to three hours to performing a bedside procedure while admissions, discharges, and family meetings were delayed. Thus, inpatient teams have less opportunity to teach, observe, and practice procedures. Despite this, procedural retraining for faculty remains nonstandardized across most academic health centers.
The resulting lack of procedural competence among faculty creates a number of challenges for the different parties involved. In the following sections, we address the various difficulties for the parties involved (i.e., faculty and academic health centers), medicolegal ramifications, and the challenges it poses to the faculty–trainee relationship. We then suggest several strategies to delineate and resolve this problem.
Challenges for Faculty
In the scenario presented above, the attending has been asked to supervise a bedside procedure performed using a technology for which she has not received formal training (ultrasound). Currently, residents’ training in performing bedside procedures is arguably more rigorous and standardized than it was in the past, as medical education moves from the model of “see one, do one, teach one” to formalized methods of training and competency assessment2 which have resulted in improved resident performance and patient safety.3,4 Similar training in both old and new methods for bedside procedures is not routinely available to faculty and, when it is available, is less regimented. Thus, many questions concerning faculty retraining remain to be answered. For example, to what extent should we require faculty to train in new methods that have emerged since they have entered clinical practice? How much training is reasonable? And how should procedural competence be assessed? It is easy to envision a system where the burden of retraining could become overwhelming for faculty.
A physician’s procedural competence is largely related to his or her volume of exposure to that procedure, and maintaining a high procedural volume is a major challenge faced by many academic faculty. At our institution, for example, faculty may have as little as 8 to 12 weeks per year on clinical service, with the remainder of their time dedicated to research, administration, and/or education. To further compound the problem, the performance of bedside procedures has been shifted from ward teams to interventional radiologists, subspecialists, and dedicated procedure teams who can perform these tasks unfettered by the competing obligations of the ward internist managing a large census of perhaps 20 to 30 patients.1,5 As a result, only 50% of traditional bedside procedures, such as paracentesis, are performed by general internal medicine and its subspecialties in U.S. university centers.6 In addition, in large academic health centers that hire dedicated inpatient attendings (hospitalists), nonhospitalist general internists are much less likely to perform traditional bedside procedures, such as lumbar puncture, thoracentesis, and paracentesis, when compared with hospitalists (11% of hospitalists were found to perform these core procedures compared with only 3% of nonhospitalists).7 It is therefore no surprise that Wigton and Alguire’s5 2007 study demonstrated that the volume and type of procedures performed by academic internists have declined over recent decades, with an average of only 7 types of procedures being performed by internists in 2007, down from 16 types in 1986. In particular, those internists practicing in larger cities or academic health centers and those with less patient contact performed the fewest procedures.
Although it is not known precisely how many procedures physicians need to complete on a yearly basis to maintain competency, low procedural volume is known to be associated with higher complication rates in the performance of thoracenteses and other bedside procedures.8 Consequently, although many academic general internists rate competence in bedside procedures as important, their confidence in supervising these procedures is significantly lower.9 The attending in our scenario certainly could have sought out extra training on her own, but in an environment where extraclinical duties such as research and administrative work are quantifiable and more valued in academic promotion than maintaining clinical or procedural competence, a faculty member making such a decision seems impractical and inefficient. Furthermore, academic faculty are constantly encouraged to pursue further subspecialization in their field which decreases their familiarity with the more common procedures in that specialty.
Challenges to Academic Health Centers
Scenarios like the one presented challenge the tripartite academic health center model of requiring physicians to be experts in clinical care, education, and research, a model that is increasingly being called into question.10,11 The attending in our scenario is a well-respected educator and researcher who has followed the traditional route for success in an academic health center, but in doing so, her procedural skills, and thus competence, have lapsed. This kind of scenario directly challenges the idea that the model currently employed by many academic health centers can meet the needs of patient care as well as scholarly output.
An additional challenge to academic health centers directly affects division chiefs and department chairs and relates to recredentialing. When hiring new faculty, department chairs rely on standards established by residency training programs to ensure procedural competence by the end of graduation. However, although the American Board of Internal Medicine requires candidates to be involved in each of the required procedures (abdominal paracentesis, thoracentesis, central line insertion, etc.) at least five times to be deemed competent,12 a similar standard has not been established for faculty already in practice to maintain their competence. Additionally, although residents are monitored by program administration, no readily available mechanism for monitoring maintenance of or retraining in procedural skills for faculty exists, making recredentialing a difficult process. Once practicing, there is no guarantee that a minimum number of annual procedures are completed or sought by faculty to maintain competence. This places the onus on departmental or hospital chiefs to track their faculty’s abilities in performing procedures, on top of other administrative, educational, and research responsibilities. Peer review is one method by which academic health centers could monitor their faculty’s procedural competence, but its success is limited by faculty’s reluctance to admit their colleagues’ shortcomings and the time and managerial resources required to implement a successful system.13
What are the legal ramifications of our scenario? In academic health centers, trainees practice under the supervision of a staff physician who is required to be proficient in all aspects of care that are provided by the trainee, as outlined by residency accreditation councils.14 Therefore, the experienced faculty member must be able to assist trainees in procedural tasks should trouble arise. In reality, this model is nearly impossible to implement. Academic faculty within any medical discipline are a heterogeneous group with variations in skills and subspecialization. However, when they are “on service” at a large academic health center, they are expected to be able to provide any and all types of services assigned to their discipline at that center. Such an expectation is often difficult to fulfill even for common procedures, given the diversity and broad scope of practice in general medicine. Nevertheless, the hospital, faculty, and trainees under supervision are medicolegally responsible for the medical services rendered should an error occur.
Though few data are available on this issue, it is reasonable to assume that some trainees may be performing procedures on patients when the faculty member supervising them lacks the requisite skill. This leads to potentially unsafe and harmful conditions for patients, as poor supervision is known to lead to worse resident education and patient outcomes.15 Residents will commonly navigate situations in which they feel uncomfortable in their skills by seeking advice from additional sources of expertise including senior residents; instances of residents teaching residents may account for more than half of all procedural teaching done on the wards.16 This strategy has its own risks, as research has shown that as many as a quarter of resident teachers feel uncomfortable performing a given procedure prior to teaching or supervising it.17 Furthermore, residents’ self-assessments of their procedural skills may be overestimated, leading to potential risks for the patient.18
Challenges to the Faculty–Trainee Relationship
It is also important to consider our scenario from the perspective of the faculty–trainee relationship. Faculty may feel pressured to present themselves as having a certain level of skill, while trainees may feel uncomfortable discussing an attending’s proficiency because of the existing power differential. In our scenario, the attending likely recognized that she did not have the requisite skills to perform the procedure. Likewise, the resident recognized that he was unequipped to perform the procedure alone and may have intuited that his attending was not confident either. Previous research has shown that trainees often have difficulty requesting clinical support from attendings in the face of a clinical challenge.19 Extrapolating this finding to our scenario, it would thus seem even less likely that the resident would feel comfortable enough to provide feedback about the attending’s lack of procedural skills directly back to them. Unfortunately, there are few data on trainee awareness and perceptions of faculty procedural competence or on the willingness of faculty and/or trainees to discuss such issues openly.
We could envision our scenario progressing down one of two different paths. In one course of action, the attending may permit the resident to proceed with the procedure despite not having the requisite skills to perform or troubleshoot the procedure. In this case, an unexpected complication may arise during the procedure, causing the resident to abort it, leading not only to patient harm but also to a delay in the successful completion of the procedure. In the other, and preferred, course of action, the attending would acknowledge to the resident that she had not performed a thoracentesis independently in many years and does not feel comfortable supervising the resident. Not only does this dialogue prevent a potentially harmful procedure from occurring but it also models outstanding professional behavior to the resident with regard to honesty and openness. Working together, the resident and attending could identify another faculty member who might be available to assist in completing the procedure. We suggest that the responsibility for a positive outcome in this scenario, given the power differential in the faculty–trainee relationship, lies primarily with the attending.
Our clinical scenario poses a unique problem that requires unique solutions. Barriers to solving this problem include physicians’ own reluctance in admitting shortcomings and the costs associated with retraining faculty. We therefore suggest several strategies to help delineate and resolve the problem of maintaining procedural competence among faculty. We advocate for future investigation into the basic epidemiology of this problem. For example, simple single-center surveys would be useful, given the current paucity of data. Simultaneously, we suggest the consideration of modest, low-cost interventions as follows.
First, we recommend initiating an open dialogue about procedural competence among academic faculty. Given that this area is sensitive and may even be embarrassing for some faculty, this dialogue should be nonjudgmental and inclusive, and should involve physicians from all levels of practice. We believe that our academic health centers are stronger when senior clinician–leaders continue to practice in some manner, recognizing their procedural competence weaknesses. Rather than enforcing punitive measures for faculty lacking in procedural skills, academic health centers should maintain a positive culture that encourages or even incentivizes retraining. Normalization of the culture of retraining must come from departmental heads and chiefs who should not only recognize procedural competence weaknesses among their staff but also find ways to promote discussion about the issue. For example, departmental heads can arrange regular educational rounds for faculty to discuss procedural competence and to develop plans to tackle weaknesses.
Second, we suggest that academic health centers ensure that all clinical practice groups have backup systems in place. Having clear protocols in place should prevent unsafe and uncomfortable situations for faculty, trainees, and patients. We therefore advocate that each clinical unit develop concrete plans for procedure supervision in anticipation of scenarios such as the one we described above. Such systems could involve procedural service teams, subspecialists, or interventional radiologists, or simple agreements among small clinical practice groups to assist with procedures whenever needed, as is the practice between surgical services. Development of such agreements should begin with a discussion about common and uncommon clinical scenarios that require urgent or emergent intervention, and can be facilitated by maintaining procedure logs. Procedure service teams are another option that provide timely and safe access to common procedures and have been shown to be effective solutions to the presented problem.20 Interventional radiology is an attractive solution because it centralizes procedures in well-equipped suites with a full complement of imaging technologies (such as ultrasound, CT scan, and fluoroscopy) but has the disadvantage of shifting procedures away from clinical teams. Additionally, because procedures performed by interventionalists are more costly, having them as a backup option may be unsustainable.21 Using subspecialists as supervisors for procedures on general internal medicine wards may allow for trainees and faculty to perform procedures in a safe environment but creates logistical challenges as subspecialists often have multiple clinical responsibilities and may have limited ability to perform procedures in a time-sensitive manner.
Third, all faculty should be given opportunities to retrain, with the recognition that for many, finding time for regular training in rarely performed procedures may be impractical and inefficient. Although some faculty may be highly interested in retraining, for many faculty with significant educational, administrative, or research programs, the costs of retraining may be burdensome. Although it is difficult to make retraining in procedures mandatory, academic health centers must create environments where such opportunities are easily accessible, with the understanding that continuing medical education involves more than just the area of procedural competency. For those faculty who require retraining, hospitals, departments, and divisions as well as specialty societies can all offer simulation programs proven to be successful in educating trainees.22 Such programs have been used in clinical settings to retrain physicians after they have had a hiatus from practice and are highly regarded as positive experiences.23 For example, DeMaria and colleagues24 found that a program aimed at anesthesiologists returning to work, consisting of a two-day simulation-based session, provided an effective assessment and retraining tool. Simulation has also been proven as a technique for improving technical skills and reducing cost in a variety of medical areas, including bedside procedures, and can be employed to retrain attendings.2,25 Retraining opportunities may be organized among faculty only, in conjunction with residents, or in conjunction with other interprofessional team members learning similar skills. At our own institution, we have found that even experienced clinicians with busy research programs are interested and enthusiastic about retraining when such programs are offered.
In conclusion, academic health centers should acknowledge that unrelenting pressures combined with a complex mission of research, education, and patient care can result in faculty lacking in procedural competence. If the challenges related to this problem are recognized, concrete steps can be taken to ensure that faculty and trainees are supported and procedures are performed safely. By addressing this problem, academic health centers can enhance their reputation as leaders in patient safety and ensure trainee competence in procedures moving forward.
1. Oshimura JM, Sperring J, Bauer BD, Carroll AE, Rauch DA. Changes in inpatient staffing following implementation of new residency work hours. J Hosp Med. 2014;9:640–645.
2. Ericsson KA. Acquisition and maintenance of medical expertise: A perspective from the expert-performance approach with deliberate practice. Acad Med. 2015;90:1471–1486.
3. Brydges R, Hatala R, Zendejas B, Erwin PJ, Cook DA. Linking simulation-based educational assessments and patient-related outcomes: A systematic review and meta-analysis. Acad Med. 2015;90:246–256.
4. Smith CC, Huang GC, Newman LR, et al. Simulation training and its effect on long-term resident performance in central venous catheterization. Simul Healthc. 2010;5:146–151.
5. 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;146:355–360.
6. Barsuk JH, Feinglass J, Kozmic SE, Hohmann SF, Ganger D, Wayne DB. Specialties performing paracentesis procedures at university hospitals: Implications for training and certification. J Hosp Med. 2014;9:162–168.
7. Thakkar R, Wright SM, Alguire P, Wigton RS, Boonyasai RT. Procedures performed by hospitalist and non-hospitalist general internists. J Gen Intern Med. 2010;25:448–452.
8. Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: A systematic review and meta-analysis. Arch Intern Med. 2010;170:332–339.
9. Wickstrom GC, Kelley DK, Keyserling TC, et al. Confidence of academic general internists and family physicians to teach ambulatory procedures. J Gen Intern Med. 2000;15:353–360.
11. Ramsey PG, Miller ED. A single mission for academic medicine: Improving health. JAMA. 2009;301:1475–1476.
13. Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. 2004.New York, NY: Rugged Land.
15. Farnan JM, Petty LA, Georgitis E, et al. A systematic review: The effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87:428–442.
16. Ma IW, Teteris E, Roberts JM, Bacchus M. Who is teaching and supervising our junior residents’ central venous catheterizations? BMC Med Educ. 2011;11:16.
17. Mourad M, Kohlwes J, Maselli J, Auerbach AD; MERN Group. Supervising the supervisors—Procedural training and supervision in internal medicine residency. J Gen Intern Med. 2010;25:351–356.
18. Barnsley L, Lyon PM, Ralston SJ, et al. Clinical skills in junior medical officers: A comparison of self-reported confidence and observed competence. Med Educ. 2004;38:358–367.
19. Kennedy TJ, Regehr G, Baker GR, Lingard L. Preserving professional credibility: Grounded theory study of medical trainees’ requests for clinical support. BMJ. 2009;338:b128.
20. Tukey MH, Wiener RS. The impact of a medical procedure service on patient safety, procedure quality and resident training opportunities. J Gen Intern Med. 2014;29:485–490.
21. Kozmic SE, Wayne DB, Feinglass J, Hohmann SF, Barsuk JH. Factors associated with inpatient thoracentesis procedure quality at university hospitals. Jt Comm J Qual Patient Saf. 2016;42:34–40.
22. McGaghie WC, Issenberg SB, Barsuk JH, Wayne DB. A critical review of simulation-based mastery learning with translational outcomes. Med Educ. 2014;48:375–385.
23. Khanduja PK, Bould MD, Naik VN, Hladkowicz E, Boet S. The role of simulation in continuing medical education for acute care physicians: A systematic review. Crit Care Med. 2015;43:186–193.
24. DeMaria S Jr, Samuelson ST, Schwartz AD, Sim AJ, Levine AI. Simulation-based assessment and retraining for the anesthesiologist seeking reentry to clinical practice: A case series. Anesthesiology. 2013;119:206–217.
25. Barsuk JH, Cohen ER, Feinglass J, et al. Cost savings of performing paracentesis procedures at the bedside after simulation-based education. Simul Healthc. 2014;9:312–318.