Background: The American Board of Internal Medicine suggests residents participate in a minimum of five abdominal paracentesis (AP), central venous catheter (CVC) placements, and lumbar punctures to ensure “adequate knowledge and understanding” of procedures performed by practicing internists. Competency in these procedures is poorly defined and difficult to assess. To address the need for well-supervised, standardized training of bedside procedures, the Internal Medicine residency program at Virginia Commonwealth University (VCU)/VCU Health System developed a longitudinal procedure medicine curriculum, including a hospitalist-staffed inpatient procedure service. We hypothesized there would be a change in the volume of procedures logged and a greater level of supervision for physicians performing procedures.
Methods: We performed a retrospective analysis of procedures logged by residents in New Innovations, a web-based educational software, from 2013 to 2018. Data for each procedure included: procedure type, trainee post-graduate year (PGY), and supervisor status (resident, fellow, or attending). T-tests were used to compare data pre-implementation (2013-16) with post-implementation (2016-18) of the procedure service. We also utilized interrupted time-series analysis to evaluate trends in procedure volume per month.
Results: On an average, 78 residents/year logged procedures before and 81 residents/year after implementation. The mean procedures logged per resident did not change significantly pre and post-implementation (AP: 2.1 vs. 3.0, CVC: 4.7 vs. 4.3, LP: 1.3 vs. 1.5, all p >0.05). However, when separated by level of training, post-implementation we saw a significant (p <0.05) decline in average number of AP (4.1 vs. 0.7), CVC (4.6 vs. 2.3), LP (1.2 vs. 0.8), and total procedures (9.9 v. 3.8) logged per year by PGY1s, and a significant increase (p <0.05) in average number of AP (0.8 vs. 6.5), CVC (5.5 vs. 6.8), LP (1.0 vs. 2.6) and total procedures (7.3 vs. 15.8) logged per year for PGY2s. The mean number of procedures per year for PGY3s did not change significantly. The proportion of procedures supervised by attending physicians increased significantly post-implementation for all procedures (p <0.05) as well as AP, CVC, and LP separately (p <0.05). There was also a steady statistically significant increase in the number of procedures performed by residents/month after implementation of the procedure service.
Conclusions: While the mean number of procedures logged by residents did not change after procedure team implementation, we saw significantly more procedures logged by upper level residents and supervised by attending physicians. This indicates that less naïve physicians are both performing and supervising procedures. Future research aims to analyze resident procedural performance data and ultimately competency assessment.