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.”