Hospitalist Bradley Rosen, MD, has become something of a celebrity lately. Dr. Rosen, assistant director of the Procedures Center at Cedars-Sinai Medical Center in Los Angeles, is making news as the prime example of physicians carving new turf by becoming experts in performing medical procedures.
But it’s his center’s eye-popping statistics that are generating interest from patient safety groups and hospitals around the country. Dr. Rosen has documented a complication rate of less than 1% for procedures performed at the center. Published data for similar procedures done elsewhere sets the rate at between 3% and 5%.
The statistics don’t surprise Dr. Rosen. “The more you do something, the better you are going to be at it, and the better you are able to deal with the unexpected,” he explains.
Stories on proceduralists have also generated interest from hospitalists, who wonder if becoming experts in procedures can make them a more valuable part of the healthcare team and make their jobs more varied.
—Bradley Rosen, MD, assistant director, Procedures Center, Cedars-Sinai Medical Center, Los Angeles
The evolution of proceduralists is first and foremost a patient safety measure. Many internists have given up doing procedures, concerned that they don’t do enough of them to stay proficient. In a study published in The Annals of Internal Medicine, internists reported that they do 50% fewer procedures today than they did 18 years ago. And the American Board of Internal Medicine has reduced the number of procedures required for certification, saying internists should focus on core procedures they are likely to do frequently. Proceduralists are moving in to fill the void.
Also driving the proceduralist movement is concern that residents don’t get enough experience in doing today’s more complicated procedures and are being trained by other residents.
“Unfortunately, training in procedures hasn’t progressed much from when I was a resident,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. “When I had to do a thoracentesis, for example, a junior resident was teaching me, and we would get three or four kits because I knew that I would screw up. We had no notion of cost, and although I felt bad sticking a patient a bunch of times, it was the way it worked in the teaching hospital. Unfortunately that is still the way it’s done in the overwhelming majority of medical schools today.”
The Trend Spreads
Simply put, proceduralists perform procedures. They may perform them all or part of the time and may teach others how to do them. Depending on where they work and how they’ve been trained, they perform thoracentesis, paracentesis, lumbar punctures, central line and arterial line placement, difficult IVs, percutaneous tracheostomy, chest tube insertion, skin biopsy, intubations, and conscious sedation.
Cedars-Sinai is the only hospital to establish a dedicated proceduralist center. Four proceduralists, with the help of a nurse practitioner and 14 nurses, perform about 24 medical procedures, according to Dr. Rosen.
The center was created in 1991 by Mark Ault, MD, FACEP, director of the division of general internal medicine at Cedars-Sinai, whom Dr. Rosen calls “the godfather of proceduralists.” Dr. Ault started the center after he found patients stayed in the hospital longer than necessary while waiting for procedures, Dr. Rosen says.
The early proceduralists came from critical and pulmonary care, and later from the academic hospitalists ranks. Proceduralists spend between 50% and 75% their time performing procedures and the rest on academic hospitalist duties such as supervising and teaching procedures to residents, working in clinics, rounding, and research.
In addition to working in the center, physicians perform procedures at the bedside using a mobile cart stocked with everything they need. “The advent of the portable ultrasound has really transformed vascular access and allows us to do procedures at the bedside, without having to move a patient,” Dr. Rosen says.
At Beth Israel Deaconess, 20 of the hospital’s 24 hospitalists have received advanced training and feel comfortable doing procedures. They also teach and supervise residents, according to Dr. Li.
“When a patient needs a procedure, the resident or physician pages 9-4-TAP, and we arrange a time to supervise the resident doing the procedure,” Dr. Li explains. “In about 80% of the cases, the resident does the procedure without my intervention. About 20% of the time I need to step in and do the procedure.”
The University of Chicago Pritzker School of Medicine started a procedures service five years ago, which is run by the critical care faculty and intensivists from 8 a.m. to 5 p.m. on weekdays. Hospitalists work as proceduralists to fill in the gaps at other times of the day and night and on weekends, according to Nilam Soni, MD, instructor of medicine in the school’s section of hospital medicine.
Dr. Soni received advanced training in procedures and says he enjoys doing procedures for the patients he sees as a hospitalist. “Being able to do procedures gives you a sense of confidence that you can take care of your patients without having to worry about finding someone to do a procedure,” Dr. Soni says.
Northwestern University Feinberg School of Medicine in Chicago is focusing on developing procedure-training programs for residents using advanced simulation, according to Jeffrey Barsuk, MD, FACP, assistant professor of medicine in the division of hospital medicine.
Small But Growing
The proceduralist movement makes up in enthusiasm what it lacks in numbers. There may be only 20 to 30 physicians in the country calling themselves proceduralists. However, countless physicians do procedures without the title. Interventional radiologists, intensivists, critical care physicians, pulmonologists, and surgeons to do procedures in larger hospitals. At small community hospitals, “Everyone does everything,” Dr. Soni says.
Fueled by patient safety concerns and the need for advanced training, there is a growing demand for experts to do procedures. Because hospitalists staff hospitals round the clock, they are the obvious physicians to move into the field. “Hospitalists are in the best position to take ownership of procedures because we are in the hospital 24/7,” Dr. Soni says. “We can zip down to the patients’ rooms and take care of a problem before it becomes serious.”
Another advantage is that a hospitalist is likely to have seen a patient before a procedure is needed. Dr. Soni believes it’s not as frightening for a patient to have a procedure done at bedside by someone they have met. “And we can educate patients about the procedure and answer follow-up questions because we are there,” he notes.
However, physicians doing procedures may not agree that hospitalists should take over the service. In some institutions the idea of establishing a proceduralist service or center has met roadblocks from physicians who see proceduralists an interlopers.
At Cedars-Sinai this hasn’t been a problem. “Our interventional radiologists and surgeons have been supportive because they have as much as they can handle,” Dr. Rosen explains. “They are content to focus on the more complicated procedures.”
Hospitalists specializing in procedures say it adds variety to their usual routines. “It takes a different mentality and different skills,” Dr. Rosen explains. “It’s much like surgery. You get a feeling of accomplishment when you’re done and then you go on to something else. It’s very satisfying,”
From a revenue standpoint, hospitalists can bill for the procedures they perform, although reimbursement for the typical procedure is not “jaw-dropping,” Dr. Rosen says.
For hospitalists, developing procedure skills may lead to career advancement. “The more you have to offer, the more valuable you are,” Dr. Soni advises. “By becoming a proceduralist you generate money for the hospital instead of being just an expense.”
Training and Standards
Whether hospitalists or other physicians do procedures, most of them agree there is a need for training and certifying of proceduralists. “Currently there are no standards for mastery in performing procedures,” Dr. Li says. “We measure mastery by personal belief. You ask me if I feel comfortable doing a certain procedure, and I say ‘Yes’ or ‘No.’ ”
SHM has identified performing procedures as one of the skills all hospitalists should be able to demonstrate, according to Dr. Li. To that end, an advanced procedures training course will be held at Hospital Medicine 2008, SHM’s Annual Meeting in April. For the first time, procedure experts will train hospitalists using different simulators, portable ultrasound, and other equipment.
“The future growth of proceduralist services and centers will come from being closely associated with and staffed by hospitalists,” Dr. Rosen says. He believes it’s an opportunity for hospitalists to supply another value-added service and have more variety in their work. TH
Barbara Dillard is a medical journalist based in Chicago.