Background:
In recent years, procedural competency requirements for Internal Medicine graduates have become less stringent, however several institutions still require competency in certain procedures. The ACGME does not specify procedures required for Internal Medicine residents, while the ABIM notes residents must have the opportunity to develop competency in procedures which will further their development as fellows in their chosen subspecialty or as independent practitioners in their intended fields. The UCSD Internal Medicine Residency requires a minimum of 5 supervised abdominal paracenteses, arterial lines, arthrocenteses, central venous line placements, lumbar punctures, pap smears, and 1 peripheral line placement and central line removal for graduation promotion.
With a decrease in procedures performed by general internists over the last thirty years, and the rise of proceduralists, opportunities for hands-on training among residents may be limited. Previous studies have identified barriers to confidence and competence among trainees and have developed interventions such as procedural services and resources such as training kits to address these barriers. This project aims to identify and address barriers to procedural training among UCSD Internal Medicine Residents. We also sought to evaluate trainee confidence and efficiency in procedure preparation, before and after implementation of a centralized Procedure Checklist resource.
Methods:
A Needs Assessment was distributed to trainees to assess barriers to procedural training and identify what was seen as potentially helpful to address these barriers. Self-reported confidence and efficiency in procedure preparation were also evaluated. The “Essential Bedside Procedures Checklist” was developed as a centralized resource which identifies necessary supplies for common inpatient procedures with image references, video links, and troubleshooting tips. The resource included the following procedures: arterial line placement, central venous line placement, central line removal, abdominal paracentesis, and lumbar puncture. The resource was introduced briefly at didactic sessions and via email, and is accessible on the residency blog (ucsdim.com) and via QR codes in the work rooms.
Results:
33 residents (17 females, 16 males; 14 PGY1, 5 PGY2, 13 PGY3, 1 PGY4) completed the Needs Assessment. The most common limitations or barriers to receiving training in or performing procedures included other patient care duties taking priority (90%), case/volume for certain procedures low (77%), time required to perform the procedure itself (63%), and time required to collect materials and prepare for the procedure (50%) (Table 1). The most common features identified by trainees that may be helpful to improve procedural training and experience included Procedural rotation or service (83%), standardized checklist to help identify and collect materials needed before the procedure (63%), and protected time for procedure opportunities (60%) (Figure 1). Efficiency in procedure preparation is displayed in Figure 2. Confidence in procedure preparation is displayed in Figure 3.
Next Steps:
A standardized checklist to help identify and collect procedure materials was one of the most commonly requested interventions (63%) to help address barriers to procedural skill development amongst our respondents. As a result, we implemented standardized procedure checklists as an accessible resource for key internal medicine bedside procedures. We are currently collecting post-implementation data to evaluate the impact of this resource on user self-reported efficiency and confidence. Looking ahead, we plan to create more accessible hands-on training kits that can be utilized before or after procedures to reinforce learning and further support the procedural training experience among residents.
