Dr. Joseph Esherick Monthly Blog – February 2012
Are you a hospitalist who would like to incorporate procedures into your practice but don’t feel competent or confident in your skills? Are you a hospitalist who does procedures so infrequently that you feel more comfortable referring your patients to a specialist for such procedures? Are you a hospitalist who believes that you can get better reimbursement seeing more inpatients rather than incorporating hospital procedures into your practice? Are you a hospitalist who believes that doing procedures will decrease your job satisfaction? These are a few of many scenarios and myths that prevent hospitalists from performing bedside procedures.
Hospitalists who perform procedures enjoy their jobs more than those who do not. In one Canadian study of over 19,000 physicians, the degree of job satisfaction was directly linked to the range of procedures performed by the physician.
Additionally, patients feel better when the bedside procedures are performed by their primary physician with whom they have developed a rapport. There are a few reasons for this. Frequently, procedures performed by a specialist, especially an interventional radiologist, require that the patient has long waits, is taken away from their room, their nurse, and their family. Furthermore, patients have often developed a relationship and trust with their primary inpatient physician and feel more comfort when they are performing the procedure rather than a complete stranger.
The American College of Physicians reported a disturbing decline in the number and variety of procedures done by general internists between 1986 and 2007. This analysis demonstrated that on average general internists are performing 50% fewer procedures in 2007 compared with 1986. This trend prompted the Society of Hospital Medicine to identify in 2008 that, “performing procedures is one of the skills all hospitalists should be able to demonstrate.” In addition, the American Board of Internal Medicine mandates that all internal medicine residents must demonstrate core manual skills in “establishing venous access and performing advanced cardiac life support (including endotracheal intubation, central venous access, and cardiac defibrillation).”
These organizations echo the same sentiment that procedural training is critical. But, how can we assure that hospital procedures are performed competently and safely? Simulation-based training is the best way to train inpatient physicians how to perform hospital procedures safely and efficiently. Simulation-based procedural training has also been shown to improve physician confidence and reduce their anxiety about performing procedures. Simulation-based training has been used for years to teach surgical skills and is based on established theories of the ways in which motor skills are acquired and ingrained: this type of training develops the cognitive base underlying a procedure; then integrates this knowledge through deliberate practice and direct feedback; and finally trains physicians how to automate the process allowing the development of procedural precision and efficiency.
Hospitalists need to be able to perform bedside procedures safely and the best way to acquire or refine those procedural skills is through a simulation-based procedural training course. Roughly 10% of medical inpatients on the hospital wards will require at least one bedside procedure and the percentage is considerably higher for critically ill patients. Among these patients, nearly 50% will require this procedure emergently or during “off hours” when specialists and interventional radiologists are not available. Studies have shown that simulation-based procedural training decreases the rate of complications, procedural time, and improves patient satisfaction and physician confidence in central venous catheterization, thoracentesis, endotracheal intubation, paracentesis, and lumbar puncture.[8-13]
Bedside training can also teach physicians how to perform point-of-care ultrasound, arterial line placement, tube thoracostomy, ultrasound-guided procedures, and tube thoracostomy. I encourage all hospitalists to consider simulation-based training so that bedside procedures can become a routine part of your practice which will increase your reimbursement and improve your job satisfaction!
Joseph Esherick, MD, FAAFP is the Associate Director of Medicine and the Medical ICU Director at the Ventura County Medical Center in Ventura, California. He is also an Associate Clinical Professor of Family Medicine at The David Geffen School of Medicine at UCLA. He received his medical degree from Yale University School of Medicine, New Haven, Connecticut, and completed a family practice residency at the Ventura County Medical Center, Ventura, California. He is board certified in family medicine and the author of the Tarascon Primary Care Pocketbook and the Tarascon Hospital Medicine Pocketbook. He is one of the lead instructors of the Hospitalist and Emergency Procedures Courses for Hospital Procedures Consultants. He is also an editorial board member for Tarascon Publishing and for Elsevier's First Consult.
Dr. Esherick is the author of some of Tarascon Publishing’s best-selling titles including:
Tarascon Medical Procedures Pocketbook, Tarascon Hospital Medicine Pocketbook and Tarascon Primary Care Pocketbook. Hospital Medicine and Primary Care are also available for mobile (iPhone, Android and Blackberry).
 Rivet C et al. Hands On: Is there an association between doing procedures and job satisfaction? Canadian Fam Physician, 2007; 53: 93.
 Wigton RS et al. 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.
 Dillard B. Those Who Do. The Hospitalist, February, 2008: 1.
 American Board of Internal Medicine. Policies and Procedures for Certification in Internal Medicine for 2006. Accessed at www.abim.org
 Stewart RA et al. A CRASH course in procedural skills improves medical students’ self-assessment of proficiency, confidence, and anxiety. Amer J Surgery, 2007; 193: 771.
 Reznick RK et al. Teaching Surgical Skills – Changes in the Wind. NEJM, 2006; 355: 2664.
 Lucas BP et al. Impact of a bedside procedure service on general medicine inpatients: a firm-based trial. J Hosp Med. 2006; 2: 143.
 Wayne DB et al. Mastery Learning of Thoracentesis Skills by Internal Medicine Residents Using Simulation Technology and Deliberate Practice. J Hosp Med. 2008; 3: 48.
 Khouli H et al. Performance of Medical Residents in Sterile Techniques During Central Vein Catheterization. Chest. 2011; 139: 80.
 Barsuk J et al. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009; 37: 2697.
 Mayo PH et al. Achieving House Staff Competence in Emergency Airway Management: results of a teaching program using computerized patient simulator. Crit Care Med. 2004; 32: 2422.
 Issenberg SB et al. Simulation technology for health care professional skills training and assessment. JAMA. 1999; 282: 861.
 Shanks D et al. Use of simulator-based medical procedural curriculum: the learner’s perspectives. BMC Medical Education. 2010; 10: 77.