Are Hospitalists Losing Their Procedural Acumen?

Marcia Frellick

April 25, 2019

Procedural competency is slipping among hospitalists and general internists, and the decline is putting patients at risk, experts contend in an article published this week in Annals of Internal Medicine.

Jonathan T. Crocker, MD, from Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, Massachusetts, and colleagues have identified experience and comfort gaps among hospitalists performing core bedside procedures in their own institution, and they say the pattern is indicative of a nationwide problem.

The core competencies they refer to are arthrocentesis, central venous catheter placement, lumbar puncture, abdominal paracentesis, and thoracentesis.

In a simulation program of mastery learning, some hospitalists at Beth Israel reported that they were only moderately comfortable performing certain core procedures and were less comfortable teaching them.

Using validated checklists, the authors assessed hospitalists' competence on simulators and found "only half of participants achieved passing scores at baseline and skills decayed back to baseline levels in the months after training.

"Most sobering, though, was that all participants had already been granted privileges to do these procedures on actual patients through our institution's processes," the authors write.

Lack of National Standards

The authors point to a lack of national standards, noting that neither the Joint Commission nor the Centers for Medicare & Medicaid Services set such bars for training or competence for performing core procedures.

Internal medicine residents "are now required only 'to be competent with regard to their knowledge' of procedures," write Crocker and colleagues, citing American Board of Internal Medicine policies.

Therefore, they say, "[t]he burden falls on hospitals to ensure that practitioners demonstrate the required skills."

However, that leads to wide variation in standards. Beth Israel, the authors write, requires billing audits or medical record documentation to show that hospitalists have performed a certain number of procedures in a credentialing cycle. Other hospitals rely on physicians self-reporting the number of procedures they perform, and some hospitals may have no set number of required procedures needed to gain privileges.

Recommended Changes

For smaller services in which proceduralists are not routinely available, the authors recommend that hospitals formalize a mandatory simulation-based training program with mastery learning with assessment at regular intervals. Regional continuing medical education or academic society precourses can help keep costs lower, they suggest.

Another recommendation is for hospitalist groups to "establish a core subgroup of 'proceduralists,' whose collective responsibility is to perform or supervise procedures for the group and to maintain a procedural volume that mitigates risk for skill decay."

For academic centers, the authors recommend that proceduralists be employed for resident supervision and training.

The authors recognize that implementing such recommendations requires funding, changes to hospitals' infrastructure, and a substantial research base to identify proficiency gaps and track progress.

Moreover, they acknowledge running into practical barriers with this work at their own institution, including scheduling problems, limited availability of simulation facilities, and limited financial support. These problems persisted even after they decided not to include evaluation of ultrasonography skill, despite its routine use in procedures.

Brian Bossard, MD, a hospitalist in Lincoln, Nebraska, who owns and manages several hospitalist practices of varying sizes, told Medscape Medical News that the fact that Beth Israel, with relatively large resources, has encountered financial and other barriers in raising their bar makes what the authors are proposing daunting.

"Where else would there be more support?" he asked. 

Crocker told Medscape Medical News that he and his coauthors had limited access to a hospital-owned simulation center, and they acknowledge that for others, access to simulation models such as mannequins may be a much bigger challenge.

Such mannequins typicallly cost at least $2500 each, he said. There are ways to cut costs, he said, including using expired procedural kits multiple times for trainees and using simulation innovations, such as a chicken breast–based central venous line training model or an easy-to-make thoracentesis simulator.

"Let's Prove It"

Bossard said he's in complete agreement regarding the problems the authors have identified, and he agreed that hospital patients can be at risk, but he said an evidence-based financial case would need to be made before hospitals — especially smaller hospitals — could make such changes.

He also noted that it is assumed that enacting those extra measures would improve outcomes, but there is no evidence that that is the case.

"It seems like it makes sense," Bossard said. "Let's prove it, and then if we prove it, let's standardize it."

It's also unclear how many procedures need to be performed to maintain competency, he said.

Establishing a core group of "proceduralists," as the authors suggest, he said, would be prohibitively expensive for small hospitals especially, and "the benefit would not be certain."

Simulation-based training may be a more viable and important option for maintaining skills, he said.

Jeffrey H. Barsuk, MD, professor of medicine and director of simulation and patient safety at Northwestern University Feinberg School of Medicine in Chicago, Illinois, agrees.

He told Medscape Medical News that multiple studies have shown that simulation-based mastery learning is superior to traditional education for improving clinical skills and patient outcomes.

"In our institution, hospitalists participate in simulation-based mastery learning interventions if they wish to perform core procedures on patients," he said. "After demonstrating a high level of competency on the simulator, hospitalists are observed performing several procedures on patients before they are allowed to practice independently."

He added that simulation-based mastery learning is cost-effective.

"Three studies performed by researchers at Northwestern have shown return on investment from simulation-based mastery learning ranging from 277% to 636%," he said.

The authors and Bossard report no relevant financial relationships. Barsuk has received research support from Simulab Co.

Ann Intern Med. Published online April 22, 2019. Abstract

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