Elsevier

The American Journal of Medicine

Volume 119, Issue 1, January 2006, Pages 71.e17-71.e24
The American Journal of Medicine

Clinical research study
AJM Online
Beyond the Comfort Zone: Residents Assess Their Comfort Performing Inpatient Medical Procedures

https://doi.org/10.1016/j.amjmed.2005.08.007Get rights and content

Abstract

Purpose

Resident physicians learn to perform inpatient bedside procedures in a manner that is neither standardized nor rigorous. As a result, residents may be unskilled and uncomfortable performing procedures. This study characterizes residents’ comfort performing medical procedures and identifies factors associated with lack of comfort.

Subjects

Study subjects were internal medicine resident physicians who performed one of four medical procedures (central line, lumbar puncture, paracentesis, or thoracentesis) on adult medical inpatients between July 1, 2003, and June 30, 2004.

Methods

This prospective cohort study was conducted at a 556-bed Boston teaching hospital. Resident physicians evaluated their comfort with 9 aspects of 4 medical procedures, recording this information in an electronic log. We also abstracted operator characteristics and patient demographic data. We analyzed residents’ comfort with each aspect of the procedure and defined “overall comfort” as comfort with each of the 9 aspects.

Results

A majority of resident physicians reported lack of comfort with at least one aspect of the procedure. Residents reported lack of comfort with 37% of unsupervised procedures. They also reported lack of comfort with the prospect of managing complications in 35% of procedures. In the multivariable analysis, overall comfort was associated with the use of a dedicated medical procedure service (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.4) and inversely associated with postgraduate year 1 status (OR 0.3, CI 0.1-0.5), first time performing the procedure (OR 0.4, CI 0.2-0.8), thoracenteses (OR 0.4, CI 0.2-0.8), and emergent procedures (OR 0.6, CI 0.3-1.0).

Conclusions

Many resident physicians are uncomfortable performing common bedside procedures. Experience and supervision mitigate some, but not all, discomfort.

Section snippets

Study Site

We studied inpatient medical procedures performed by internal medicine residents at a 556-bed tertiary care Boston teaching hospital. The internal medicine training program in 2003 and 2004 included 63 postgraduate year 1 (PGY1) residents (16 in a 1-year preliminary program), and 46 postgraduate year 2 (PGY2) and 46 postgraduate year 3 (PGY3) categorical residents. Residents completed required and elective rotations in general medicine, cardiology, oncology, emergency medicine, intensive care,

Resident Characteristics

A total of 106 (68%) of 157 residents logged procedures during the academic year (Table 1). Fifty-five residents (52%) were PGY1, 53 (50%) were female, and 94 (89%) were enrolled in the 3-year categorical program. Fourteen residents (13%) performed the index procedure for the first time, and 56 (53%) had performed the procedure 1 to 5 times previously.

Patient Characteristics

Patients had a mean age of 62.7 years (range 21-95 years). More than 50% were male, and 69% were white. Medicare (48%) was the principal insurer,

Discussion

We studied 527 procedures performed by 106 internal medicine residents at a Boston teaching hospital and found that more than half of resident physicians were uncomfortable performing at least 1 aspect of 4 common bedside procedures. First-year residents and those with the least prior experience most often said that they lacked comfort. Lack of comfort was also strongly associated with lack of supervision. In contrast, supervision by medical procedure service physicians doubled the odds that

Acknowledgments

The authors acknowledge Dr. Brett Kalmowitz for his assistance creating the procedure log and Dr. Mitchell Rabkin for reviewing a draft of this article.

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This study was supported in whole by grants from the Risk Management Foundation of the Harvard Medical Institutions and the Stoneman Center for Quality Improvement in General Medicine and Primary Care. Funding supported collection, management, analysis, interpretation of data, and preparation of the article. Dr. Weingart was supported in part by a K08 clinical scientist career development award from the US Agency for Healthcare Research and Quality.

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