Our BPS demonstrates the success of a bedside procedure team teaching model in providing residents with a high volume of a variety of procedures with a low complication rate of 0.19%. On average, residents were able to perform almost 40 procedures per month during their rotation. For the most basic internal medicine procedures of lumbar puncture, paracentesis, and thoracentesis, the numbers were well above the average numbers cited by residents in other studies and the number of 7–10 procedures that multiple studies have suggested is necessary for a physician to feel “comfortable” doing a procedure 3, 4, 7, 13. In addition to the techniques learned in doing the procedures themselves, the residents spent a lot of time using point-of-care ultrasound to evaluate lung, abdomen, vasculature, and soft tissues as part of decision-making process before any procedure (with the exception of bone marrow biopsies). As we often emphasize on the rotation, understanding when NOT to do a procedure is as important as knowing the technical skill of how to do it. The volume of encounters during the rotation provide them with ultrasound and procedural skills that will serve them well regardless of their ultimate practice environment. For this study, we have focused on procedural attempts by the residents as our proxy for measuring educational success in our program. As mentioned earlier, success is difficult to measure as it possesses a very subjective component, resident comfort, but we believe that number of procedures can be a simple measure of this success given previous studies.
A study by Huang et al evaluating resident comfort with common inpatient medical procedures including lumbar puncture, thoracentesis, paracentesis, and CVC placement found that more than half of resident physicians were uncomfortable with at least one of these procedures with thoracentesis having the lowest comfort status. Rotation on a medical procedure service doubled the odds that a resident was comfortable with the procedure suggesting that a dedicated experience with one-on-one supervision was helpful in improving competency4. A similar study by Lenhard et al evaluating resident comfort levels in invasive procedures found that there was a statistically significant increase in the number of residents who felt comfortable performing thoracentesis, CVC placement, and lumbar puncture after rotating on a procedure service. Rates of comfort for these procedures were in the 80–90% range for those who did the rotation even though the residents performed a mean of only 8.3 procedures during their time on that procedure service, suggesting there is a very high educational yield for relatively few experiences13. Our study adds to this body of evidence by providing an accurate assessment of exact numbers of procedures done by residents, approximately 40 procedures per resident. The complication rate is also acceptably low and showed a clear decline as our service matured, further supporting the role of a group of experts who supervise/train residents.
The development of a simulation-based standardized curriculum, which has been proposed by Lenchus as a way to improve invasive beside procedural instruction, is a growing area of interest and certainly an important and effective method of ensuring competency14. However, we believe that the hands-on experience afforded by a dedicated procedure service (in addition to simulation education) allows residents the repetition and real-life experience necessary to be truly comfortable with doing procedures. Additionally, point-of-care ultrasound has become the standard of care for procedures in hospital and critical care medicine with multiple position statements regarding the use of ultrasound with procedures as well as for diagnostic purposes 15–20. As well as becoming increasingly mandatory for hospitalists and intensivists, ultrasound has many applications in other subspecialties, making it important to have a strong ultrasound curriculum so that internal medicine residency graduates will have a good foundation in these skills.
There were several limitations to this study. The level of independence during the procedure was dependent on previous experience and the level of confidence of the learner. Therefore, if the resident was an early learner then the attending physician likely assisted significantly during the procedure, whereas by the end of the rotation the resident would likely be doing the procedure independently with only verbal feedback from the attending physician. There was an attending physician present and involved with each procedure, thus ensuring patient safety and direct learner feedback. This was a single-center study at a tertiary care academic medical center and may not be generalizable to other programs.