Medical doctors routinely undertake a number of practical procedures and these should be performed competently [1
]. Knowing which procedures are required in daily practice is important for those involved in planning training programmes and for accreditation bodies. However the challenge to achieve and maintain procedural competence for all clinicians is significant, with high volume alone no longer accepted as an adequate guarantee of competency. In addition there has been a recent decline in the total number of procedures performed by hospital general medicine practitioners [3
]. and a drive to shorten the average duration of medical training despite continued widespread perception that procedural competency is important[4
The new UK Postgraduate Medical Education and Training Board (PMETB) curriculum introduced in October 2007 expanded the previous list of specific procedures that the trainee is expected to be competent in by the end of core medical training. The new requirements are:
• Cannula insertion including large bore
• Arterial blood gas sampling
• Lumbar puncture*
• Pleural tap and aspiration*
• Intercostal drain insertion (Seldinger technique)*
• Ascitic tap*
• Abdominal paracentesis*
• Central venous cannulation*
• Initial airway protection: chin lift, guedel airway, nasal airway, laryngeal mask
• Basic and subsequently advanced cardio respiratory resuscitation.
• DC cardioversion*
• Urethral catheterisation
• Nasogastric tube placement
• Knee aspiration*
• Temporary cardiac pacing by internal wire or external pacemaker*
• Skin biopsy (this is not mandated for all trainees but opportunities to become competent in this technique should be available especially for trainees who subsequently wish to undertake specialist dermatology training)
The procedures common between the previous and new requirements are noted with asterisks. The previous version also included the use of continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) support, as well as caring for an existing tracheostomy. These are omitted from the new training curriculum.
Achieving initial procedural competence is the subject of numerous training initiatives including a change from the traditional bedside "see-one, do-one" approach to that involving initial skill-lab and subsequent decreasing levels of supervised support at the bedside. However, maintaining competence may also require significant effort, particularly in an environment where the total number of procedures performed is decreasing. There is a complex relationship between procedural competence and confidence. Confidence can be used as a marker of competence but the correlation is poor [5
]. However, procedural confidence is of intrinsic importance through influence on the practitioner's willingness to undertake procedures, accurate self-assessment of their skills, and willingness to ask for support [8
]. Procedural confidence also independently affects performance and is per se
an important target for maintaining competency [9
Furthermore, practitioners should not be required in their routine practice to perform procedures for which they do not feel confident of their own competence, as this would breach of the principles of Good Medical Practice.
The level of confidence amongst hospital practitioners to perform these "key" procedures is unknown. Clearly, it is unrealistic to expect all doctors to perform all procedures with competence and confidence at all levels of training, however guidance on what would represent an acceptable standard is limited. No specific standards are available for consultants although it is expected that those taking part in the medical rota should be able to assist a trainee should an emergency arise, themselves supported by relevant specialists (anaesthetists, cardiologists, interventional radiologists etc.). The UK Government Department of Health has identified continuing professional development and training as crucial to achieving high quality patient care [10
]. However current NHS consultant appraisal documentation makes no special provision to demonstrate continuing competence in performing medical procedures [11
]. The current and previous systems of UK medical training are shown in supplementary figure 1
. Specialist registrars ([SpR] equivalent to ST3 and above) are required be competent in performing these procedures as well as instruction, appraisal and assessment of junior doctors' performance. Senior house officers ([SHO] equivalent to ST1 and ST2) are required to gain experience of these procedures in order to attain independent competence. Foundation Year 1 (F1) doctors are required to be competent and confident to perform, and competent to teach undergraduates on; venepuncture and cannulation, arterial puncture, blood culture from central or peripheral sites, subcutanous, intradermal, intramuscular and intravenous injections, IV medication preparation and administration, performing ECG, spirometry and peak flow, urethral catheterisation, airway care (including simple adjuncts), and nasogastric tube insertion. Foundation year 2 (FY2) doctors are expected to maintain and improve their skills in the above procedures and expend the range of procedures they do such as aspiration of pleural fluid or air, skin suturing, lumbar puncture, insertion of a central venous line and aspiration of joint effusion [12
We primarily set out to describe existing levels of procedural confidence. As secondary aims we set out to describe the factors affecting procedural confidence, and to assess the wider views on whether these procedures should be core competencies for all doctors. A cross-sectional questionnaire survey of hospital practitioners in East Anglia, UK was undertaken.