The present study provides data on internal medicine trainee comfort level with regard to performance of selected procedures. In this study, the number of procedures trainees needed to perform to feel comfortable for central venous line placement, knee joint aspiration, lumbar puncture, and thoracentesis exceeded the number currently required by the ABIM. For arterial puncture for blood gases and pelvic exam/Pap smear, trainee comfort occurred at numbers less than those recommended by the ABIM. Also, four procedures for which the ABIM currently has not made recommendations (ACLS, endotracheal intubation, joint splint application, and skin biopsy), required five or more procedures to establish comfort. Residents required more than 20 flexible sigmoidoscopies to achieve comfort, correlating with published recommendations for certification.12,13
Interestingly, among procedures without specific ABIM requirements, the residents' comfort threshold surpassed prior published recommendations for attaining competence among practicing internists.1
Of practicing general internists, a minimum (25th percentile) estimate of the number required to attain competence for flexible sigmoidoscopy was 10, with 8 and 2 for endotracheal intubation and skin biopsy, respectively.1
Although comfort level was most strongly related to procedure number, other factors sometimes related to trainee comfort level independent of the number of procedures performed. For example, women were less comfortable than men in doing endotracheal intubation regardless of the number done. While the reason for these differences may be complex, published data suggest that men may feel more self-confident with technically invasive or aggressive procedures in the medical environment.15,16
Because first-year residents receive formal ACLS training at the end of internship in these hospitals, it is not surprising that senior residents feel more comfortable performing ACLS independent of number done. The greater comfort of community-based residents over university-trained residents for skin biopsy may reflect the fact that the community-based program either trained a higher proportion of first-year preliminary house officers transitioning into dermatology in their second year or had more skin biopsy experience in their training program.
While most trainees in their final year of training met or exceeded requirements for the ABIM required procedures, for some procedures a significant minority had not. For example, for knee joint aspiration, a relatively low fraction of university-trained third-year trainees (74%) had performed at least three, and 7% had performed none. Experience was less for procedures not required by the ABIM. For example, 48% of the third-year residents had never performed a flexible sigmoidoscopy. However, exposure to this procedure depended on site of training; all of the military-trained residents had done at least 6 flexible sigmoidoscopies, and 50% had done more than 20. By contrast, 22% and 61% of the community-based and university-based trainees, respectively, had done none. Many internists have no interest in performing flexible sigmoidoscopy, so universal training requirements may not be necessary. For skin biopsies, all of the military-trained residents had done at least 1, while 22% and 33% of the community-based and university-trained residents, respectively, had performed none. Differences in procedural experiences may reflect more opportunity among military residents to do procedures, differences in emphasis on trainee procedural competence at various sites, or differences in reliance upon specialists in dermatology and gastroenterology in the various programs.
Several limitations should be considered in interpreting the results of this study. First, competence in performing a procedure is the primary goal for trainees and training programs alike; comfort is likely distinct from competence in performing a procedure. Although the comfort threshold was arbitrarily defined (the number of procedures at which two thirds of respondents report comfort or high comfort levels), the strong associations between comfort threshold and desire for further training in that procedure support our definition. Comfort is only a proxy, and perhaps a weak one, for competence. It could be argued that our arbitrarily defined comfort level is not sufficiently stringent since one third of residents still do not feel comfortable with the procedure. Second, the survey required trainees to remember the number of procedures they had performed and choose from a listed range of experiences. Not only could memories be inaccurate, they could also be subject to recall bias. For example, residents who feel uncomfortable with a procedure may report having performed fewer than they actually performed, while residents who are comfortable with a procedure may report having performed more. Third, because our data are based on group averages, they may not be applicable at the individual level. For example we defined comfort as the level at which two thirds felt comfortable. The other one third may have required a much higher number of procedures to achieve comfort. Fourth, our results reflect the experiences of selected programs, and may not be generalizable to internal medicine programs across the country or to other non-internal medicine specialties. Fifth, because the survey was administered 6 to 9 months into the final training year for third-year trainees, the results do not reflect the PGY 3 senior residents' experiences in their last months prior to graduation. Sixth, our study is cross-sectional, and causal relationships between associated variables have not been demonstrated. Seventh, although our study had a high response rate, nonrespondents may have differed from respondents in ways that were unmeasured and resulted in unrecognized selection bias. Finally, our analyses cannot account for intrinsic differences in residents with regard to their individual interests, skills, and desires in performing procedures. For example, it is possible that there is a subset of “procedure-loving” residents with lower thresholds for doing procedures and with greater interest and comfort in doing procedures.
In summary, the results of our study suggest that trainees require more experiences to achieve comfort in several procedures commonly performed by practicing internists than are currently recommended by the ABIM, regardless of the type of training program. Some procedures are not commonly performed by a high percentage of trainees. Greater emphasis on the performance of such procedures appears to be indicated in some of the internal medicine training programs studied. Future research should focus on correlating comfort level with achieving demonstrable procedural competence.