Our survey response rate was 56% (367/653) and ranged from 31–72% across sites. Respondents were evenly distributed across residency year; differences in gender and career aspirations were similar to national residency profiles20
. Responders and non-responders did not differ significantly in gender or residency year, but response rate by site was a significant source of responder variation (Table ).
Procedure Volume The median number of procedures reported by each resident increased with each successive postgraduate year. Most residents had performed fewer than five of each procedure at the end of the PGY-1 year, but had performed at least ten for nearly every procedure by the end of their training. Thoracentesis was consistently the least often performed procedure. The range of experience for each procedure was wide, demonstrating a variable experience of residents even within the same program. Residents reported little experience with procedure simulation, with only 4% of residents having experience with simulation for paracentesis, thoracentesis and lumbar puncture, and 21% having experience with CVC insertion simulation (Table ).
Median Procedure Volume by Resident Year
Comfort Performing Procedures
Resident comfort increased with the number of procedures performed (p
0.001, Fig. ). More than three-fourths of residents reported being comfortable (our defined “comfort threshold”) with paracentesis, lumbar puncture and femoral CVCs after having performed three to four, thoracentesis after having performed five to six and IJ and subclavian CVCs after seven to nine. Nearly all residents were comfortable after having performed ten procedures. The residency year at which trainees surpass the comfort threshold is seen in Figure .
Figure 2 Resident comfort with procedure supervision. (a) Percentage of residents reporting being “comfortable” or “very comfortable” supervising each procedure based on numbers of procedures performed. (b) Percentage of residents (more ...)
In multivariable models adjusting for PGY year, gender, training site and whether the trainee was planning a procedural specialty, the number of procedures remained strongly independently associated with meeting the comfort threshold. The adjusted odds ratio for each incremental procedure yielding comfort was 2.48 (95% CI: 1.81, 3.40) for paracentesis, 2.31 (95% CI: 1.85, 2.87) for thoracentesis, 2.34 (95% CI: 1.79, 3.05) for lumbar puncture, 2.31 (95% CI: 1.80, 2.96) for femoral CVCs and 1.90 (95% CI: 1.65, 2.20) for IJ or subclavian CVCs, all significant at the p
0.05 level. Neither pursuit of invasive subspecialty career, nor use of a simulator, nor report of a complication was a significant predictor of comfort. Resident year had only a very limited impact, being only associated with increased comfort for PGY-3s performing femoral CVCs (OR 3.55, CI 1.01–12.53). Interestingly, male gender was associated with a two- to three-fold statistically significant increase in comfort for all procedures except paracentesis (OR 2.60–2.78). Site-specific variations in comfort were also noted, though these differences were based on small numbers of procedures reported within each subgroup at each site.
Figure 1 Resident comfort with procedure performance. (a) Percentage of residents reporting being “comfortable” or “very comfortable” performing each procedure based on numbers of procedures performed. (b) Percentage of residents (more ...) Procedure Supervision
Ninety-eight percent of residents reported peer supervision for or independent performance of paracentesis, thoracentesis and lumbar puncture, while 70% reported peer supervision or independent performance of CVC insertion. By the end of PGY-2 year, more than 60% of residents had supervised thoracencenteses and CVC insertion, and more than 80% had supervised paracentesis and lumbar puncture. By the end of PGY-3 year, more than 80% of residents had supervised all procedures. Satisfaction with the levels of supervision was high for all procedures and did not vary significantly by reported supervisor or by resident year. Despite the large number of residents reporting that their responsibilities include supervision of procedures, comfort supervising was only achieved by the end of the PGY-2 year for lumbar puncture and femoral CVCs, and by the end of the PGY-3 year for thoracentesis and IJ/subclavian CVCs, the latter procedures being those with the highest complication rates14
. A sizable proportion of residents reported supervising a procedure prior to feeling comfortable with the procedure themselves (Fig. , Table ).
Supervision Practices of Residents
Complications The majority (64%) of residents’ reported a complication with a procedure (defined as arterial puncture, arterial hematoma, cerebrospinal fluid leak requiring intervention, epidural hematoma, guide wire/catheter tip embolism, hemorrhage, hemothorax, inadequate analgesia, organ puncture, pneumothorax, venous hematoma). Of the 439 complications reported, 140 (32%) were instances of inadequate analgesia, 109 (25%) arterial puncture, 69 (16%) venous hematoma, 49 (11%) pneumothorax, 30 (7%) arterial hematoma, 18 (4%) CSF leak requiring intervention, 7 (2%) each of hemothorax and hemorrhage, and ≤4 (≤1%) each of bowel perforation, epidural hematoma, guide wire embolism and death. Eighty-eight percent of these residents felt that the complication could have been avoided.When asked to select factors that would have prevented complications, 89% of residents felt that that quality of supervision had no role in avoiding the complications. The most commonly reported factors that could have avoided complications were better analgesia (20%), better patient positioning (15%), use of ultrasound (11%), better training in proper procedure technique (10%) and better characterization of anatomy (10%). Those who reported a complication had no differences in their comfort performing or supervising a procedure.