Is Hospitalist Proficiency in Bedside Procedures in Decline?
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Hospitalists learn techniques in invasive procedures and portable ultrasound at HM10 in Washington, D.C. The four-hour training pre-courses routinely rank as annual-meeting favorites.
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Hospitalists learn techniques in invasive procedures and portable ultrasound at HM10 in Washington, D.C. The four-hour training pre-courses routinely rank as annual-meeting favorites.
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Hospitalists learn techniques in invasive procedures and portable ultrasound at HM10 in Washington, D.C. The four-hour training pre-courses routinely rank as annual-meeting favorites.
It’s 3:30 p.m. You’ve seen your old patients, holdovers, and an admission, but you haven’t finished your notes yet. Lunch was an afterthought between emails about schedule changes for the upcoming year. Two pages ring happily from your belt, the first from you-know-who in the ED, and the next from a nurse: “THORA SUPPLIES AT BEDSIDE SINCE THIS AM—WHEN WILL THIS HAPPEN?” The phone number on the wall for the on-call radiologist beckons…
An all-too-familiar situation for hospitalists across the country, this awkward moment raises a series of difficult questions:
Should I set aside time from my day to perform a procedure that could be time-consuming?
- Do I feel confident I can perform this procedure safely?
- Am I really the best physician to provide this service?
- As hospitalists are tasked with an ever-increasing array of responsibilities, answering the call of duty for bedside procedures is becoming more difficult for some.
A Core Competency
“The Core Competencies in Hospital Medicine,” authored by a group of HM thought leaders, was published as a supplement to the January/February 2006 issue of the Journal of Hospital Medicine. The core competencies include such bedside procedures as arthrocentesis, paracentesis, thoracentesis, lumbar puncture, and vascular (arterial and central venous) access (see “Core Competencies in Hospital Medicine: Procedures,” below). Although the authors stressed that the core competencies are to be viewed as a resource rather than as a set of requirements, the inclusion of bedside procedures emphasized the importance of procedural skills for future hospitalists.
“[Hospitalists] are in a perfect spot to continue to perform procedures in a structured manner,” says Joshua Lenchus, DO, RPh, FACP, FHM, associate director of the University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety. “As agents of quality and safety, hospitalists should continue to perform this clinically necessary service.”
Jeffrey Barsuk, MD, FHM, associate professor of medicine at Northwestern Feinberg School of Medicine in Chicago and an academic hospitalist at Northwestern Memorial Hospital (NMH), not only agrees that bedside procedures should be a core competency, but he also says hospitalists are the most appropriate providers of these services.
“I think this is part of hospital medicine. We’re in the hospital, [and] that’s what we do,” Dr. Barsuk says. Other providers, such as interventional radiologists, “really don’t understand why I’m doing [a procedure]. They understand it’s safe to do it, but they might not understand all the indications for it, and they certainly don’t understand the interpretation of the tests they’re sending.”
Despite the goals set forth by the core competencies and authorities in procedural safety, the reality of who actually performs bedside procedures is somewhat murky and varies greatly by institution. Many point to HM program setting (urban vs. rural) or structure (academic vs. community) to explain variance, but often it is other factors that determine whether hospitalists are actually preforming bedside procedures regularly.
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Team Hospitalist member Josh Lenchus, DO, RPh, FACP, SFHM (right), associate director of the Center for Patient Safety at the University of Miami-Jackson Memorial Hospital, explains advanced ultrasound techniques to a trainee.
Where Does HM Perform Procedures?
Community hospitalists, with strong support from interventional radiologists and subspecialists, often find it more efficient—even necessary, considering their patient volumes—to leave procedures to others. Community hospitalists with ICU admitting privileges, intensivists, and other HM subgroups say that being able to perform procedures should be a prerequisite for employment. Hospitalists in rural communities say they are doing procedures because they are “the only game in town.”
