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Meliagros P, Chopski B, Garber A, Dow A, Forrest R. Procedural Decision Making by Hospitalists: The Need for a Team Approach. South Med J 2024; 117:347-349. [PMID: 38830591 DOI: 10.14423/smj.0000000000001690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Affiliation(s)
- Pete Meliagros
- From the Department of Internal Medicine, Hospital Medicine, Virginia Commonwealth University Health, Richmond
| | - Benjamin Chopski
- From the Department of Internal Medicine, Hospital Medicine, Virginia Commonwealth University Health, Richmond
| | - Adam Garber
- From the Department of Internal Medicine, Hospital Medicine, Virginia Commonwealth University Health, Richmond
| | - Alan Dow
- From the Department of Internal Medicine, Hospital Medicine, Virginia Commonwealth University Health, Richmond
| | - Rebecca Forrest
- From the Department of Internal Medicine, Hospital Medicine, Virginia Commonwealth University Health, Richmond
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Mohanty S, Mohanty A, Cool JA, Fainstad B. Validation of an Educational Tool for Skin Abscess Incision and Drainage by Delphi and Angoff Methods. J Gen Intern Med 2023; 38:3093-3098. [PMID: 37592118 PMCID: PMC10651594 DOI: 10.1007/s11606-023-08205-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 04/07/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Bedside incision and drainage (I&D) of skin abscesses is a common medical procedure performed in a variety of medical settings. Yet, there is a paucity of published validated educational tools to teach and assess competency for this procedure. OBJECTIVE To validate an educational tool to teach and assess competency for bedside I&D of skin abscesses via the Delphi consensus and Angoff standard setting methods. DESIGN Expert consensus on the importance of each procedural step in the educational tool was obtained using the Delphi method, consisting of four rounds of iterative revisions based on input from a panel of experts. The passing cut-off score for a proficient provider was determined using the modified dichotomous Angoff method. PARTICIPANTS All participants met the minimum criteria of active involvement in resident education and performance of at least 20 skin abscess I&D's within the past 5 years. Participant specialties included general surgery, emergency medicine, and internal medicine. MAIN MEASURES The primary outcome was consensus on procedural steps and errors, defined as an interquartile range ≤ 2 on a 9-point Likert scale. A cut-off score was determined by the average across all respondents for the anticipated number of errors that would be committed by a provider with the level of proficiency defined in the survey. Qualitative input was incorporated into the educational tool. KEY RESULTS At the end of four rounds of review via the Delphi process, participants achieved consensus on 93% of items on the clinical checklist and 85% of errors on the assessment checklist. Via the modified dichotomous Angoff method, the determined passing cut-off for competency was 6 out of 22 errors. CONCLUSION An educational and evaluation tool for bedside I&D of skin abscesses was validated via the Delphi and Angoff methods.
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Affiliation(s)
- Sudipta Mohanty
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Aditya Mohanty
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joséphine A Cool
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Brandon Fainstad
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Montane B, Abraham A, Bustamante S, Vachharajani T, Ayad S, Devarajan J, Thompson D, Lee R, Rampersad P, Gage B, Reznicek E, Luo C, Wardrop R. Implementing an Interdisciplinary Procedure Curriculum. Cureus 2023; 15:e44851. [PMID: 37809158 PMCID: PMC10559997 DOI: 10.7759/cureus.44851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
INTRODUCTION This curriculum was designed to improve access to procedures for our internal medicine residents. METHODS We created an interdisciplinary procedure course (IDPC) composed of two simulation sessions and a one-week procedural rotation supervised by multiple specialties including nephrology, cardiology, cardiothoracic anesthesiology, general anesthesiology, and interventional radiology. After the course, residents completed two surveys documenting the number of procedures and their level of confidence on a Likert scale (1 = very unconfident to 5 = very confident) prior to and after completing the curriculum. RESULTS Sixteen residents participated in the course from September 2021 to June 2022. The collective number of procedures performed by these 16 residents increased from 176 to 343 after a one-week rotation. For arterial lines, the proportion of residents that reported an improvement in confidence scores was 0.44 (95% confidence interval 0.23 to 1, p-value of 0.60). The proportion of residents that had an increase in their confidence performing central lines was 0.63 (95% confidence interval 0.39 to 1, p-value of 0.23). For intubations, the proportion of residents that reported an improvement in confidence was 0.94 (95% confidence interval 0.72 to 1, p-value of 0.0006). CONCLUSION By collaborating with multiple specialties, residents almost doubled the number of procedures performed during training and reported an increased level of confidence in procedural performance for airway intubation. We learned residents want to improve their access to procedures and described a curriculum that was easily implemented.
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Affiliation(s)
- Bryce Montane
- Internal Medicine, Washington University School of Medicine, St. Louis, USA
| | - Abey Abraham
- Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, USA
| | | | - Tushar Vachharajani
- Nephrology, John D. Dingell Department of Veterans Affairs Medical Center, Detroit, USA
| | - Sabry Ayad
- Outcomes Research, Cleveland Clinic, Cleveland, USA
- Anesthesiology, Cleveland Clinic, Cleveland, USA
| | | | | | - Ran Lee
- Cardiovascular Medicine, Cleveland Clinic, Cleveland, USA
| | | | - Brian Gage
- Internal Medicine, Washington University School of Medicine, St. Louis, USA
| | | | - Chongliang Luo
- Surgery, Washington University School of Medicine, St. Louis, USA
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Effectiveness of training primary care internal medicine residents in etonogestrel implants and impact on their future practice: A cross-sectional study. Contraception 2022; 115:31-35. [PMID: 35917931 PMCID: PMC9994633 DOI: 10.1016/j.contraception.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the impact of an etonogestrel implant training program within a primary care Internal Medicine residency training program. STUDY DESIGN We surveyed graduates of our primary care Internal Medicine residency program in the Bronx, New York who performed implant procedures though the first 32 months after implementation of a monthly faculty-supervised resident implant clinic. We assessed the number of implants placed and removed per graduate, and surveyed graduates' satisfaction with the implant training program, perceived competence with implant procedures, and intent and ability to perform implant procedures and barriers to performing implant procedures postgraduation. RESULTS Between July 2017 and February 2020, 14 residents placed a total of 34 devices and removed four. All 14 program graduates completed the survey in August 2020. All but one respondent felt this training was valuable and 11 felt competent placing implants without supervision. Although 10 planned to provide implants following graduation, none have been able to, largely because of credentialing and clinic-practice level barriers. CONCLUSIONS The primary care Internal Medicine program graduates we surveyed (n = 14) valued our etonogestrel implant training program and perceived competence, particularly with implant placement. However, even those who intended to provide etonogestrel implants postgraduation were unable to do so. IMPLICATIONS Internal Medicine residents trained to place and remove etonogestrel implants are most comfortable with implant placement. However, these physicians may face barriers related to credentialing and ambulatory practice scope when attempting to provide this care in clinical practice.
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LoPresti CM, Schnobrich D, Novak W, Fondahn E, Bardowell R, O'Connor AB, Uthlaut B, Ortiz J, Soni NJ. Current Point of Care Ultrasound Use and Training Among Internal Medicine Residency Programs from the 2020 APDIM Program Director's Survey. Am J Med 2022; 135:397-404. [PMID: 34890562 DOI: 10.1016/j.amjmed.2021.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/17/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Charles M LoPresti
- Section of Acute Medicine, Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Ohio; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Daniel Schnobrich
- Department of General Internal Medicine, University of Minnesota School of Medicine, Minneapolis
| | - William Novak
- Department of Medicine, University of Rochester School of Medicine and Dentistry, NY
| | - Emily Fondahn
- Department of Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Rachel Bardowell
- Department of Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Alec B O'Connor
- Department of Medicine, University of Rochester School of Medicine and Dentistry, NY
| | - Brian Uthlaut
- Department of Medicine, University of Virginia Health System, Charlottesville
| | - Jordan Ortiz
- Alliance for Academic Internal Medicine, Alexandria, Va
| | - Nilam J Soni
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, Tex
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Swartz S, Umpierrez De Reguero A, Puetz JR, Voigt L, Cuzovic N, Bielecki M, Franco Sadud R. Advancing Internal Medicine Training: Experience of a Bedside Procedure Service as a Resident Elective. Hosp Top 2021; 101:127-134. [PMID: 34607537 DOI: 10.1080/00185868.2021.1984863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 2007, the American Board of Internal Medicine eliminated numeric procedure requirements for licensing. The level of exposure to procedures during residency, and subsequent competence of graduating residents, is variable. In 2015, our institution developed a bedside procedure service (BPS) with the intent to teach ultrasound guidance and procedural training to internal medicine residents with direct supervision of technique by Hospital Medicine faculty to optimize learning, increase confidence, and improve patient safety. OBJECTIVE In this study, we review the number and complication rates of resident procedures on a dedicated internal medicine bedside procedure service (BPS) as a resident elective. METHODS In this retrospective, observational, single-center study, we reviewed internally collected data from BPS procedures performed from 2015-2019. The BPS offers a variety of procedures done with ultrasound guidance at an adult tertiary care referral center. BPS services are available to all inpatient hospital services. A rotation with the BPS was offered as a stand-alone resident elective for the first time in 2015. RESULTS 69 residents performed a total of 2700 ultrasound-guided/assisted procedures and 146 diagnostic ultrasound scans from 2015-2019. Residents performed an average of 40 procedures during their elective month. There were 5 resident performed procedural complications with an overall complication rate of 0.19%. CONCLUSIONS Our BPS increased procedural opportunities for residents and allowed for real-time feedback by an experienced faculty member in a one-on-one setting. A dedicated rotation allows the time to focus on becoming proficient in invasive procedures with expert supervision.
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Affiliation(s)
- Sheila Swartz
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Lara Voigt
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nikola Cuzovic
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew Bielecki
- Department of Medicine, Apogee Physicians Medical Group, Waukesha, WI, USA
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Impact of Risk and Volume on Procedural Traning of Pulmonary and Critical Care Fellows. ATS Sch 2021; 2:212-223. [PMID: 34409416 PMCID: PMC8362760 DOI: 10.34197/ats-scholar.2020-0110oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 01/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Invasive procedures are a core aspect of pulmonary
and critical care practice. Procedures performed in the intensive care unit
can be divided into high-risk, low-volume (HRLV) procedures and low-risk,
high-volume (LRHV) procedures. HRLV procedures include cricothyroidotomy,
pericardiocentesis, Blakemore tube placement, and bronchial blocker
placement. LRHV procedures include arterial line placement, central venous
catheter placement, thoracentesis, and flexible bronchoscopy. Despite the
frequency and importance of procedures in critical care medicine, little is
known about the similarities and differences in procedural training between
different Pulmonary and Critical Care Medicine (PCCM) and Critical Care
Medicine (CCM) training programs. Furthermore, differences in procedural
training practices for HRLV and LRHV procedures have not previously been
described. Objective: To assess procedural training practices in PCCM and
CCM fellowship programs in the United States, and compare differences in
training between HRLV and LRHV procedures. Methods: A novel survey instrument was developed and
disseminated to PCCM and CCM program directors and associate program
directors at PCCM and CCM fellowship programs in the United States to assess
procedural teaching practices for HRLV and LRHV procedures. Results: The survey was sent to 221 fellowship programs, 168
PCCM and 34 CCM, with 70 unique respondents (31.7% response rate). Of the
procedural educational strategies assessed, each strategy was used
significantly more frequently for LRHV versus HRLV procedures. The majority
of respondents (51.1%) report having no dedicated training for HRLV
procedures versus 6.9% reporting no dedicated training for any LRHV
procedure (P < 0.001). For HRLV
procedures, 76.9% of respondents indicated that there was no set number of
procedures required to determine competency, versus 25.3% for LRHV
procedures (P < 0.001). For LRHV
procedures, fellows were allowed to perform procedures independently without
supervision 21.7% of the time versus 3.9% for HRLV procedures
(P = 0.004). Program
directors’ confidence in their ability to determine fellows’
competence in performing procedures was significantly lower for HRLV versus
LRHV versus HRLV procedures
(P < 0.001). Conclusion: Significant differences exist in procedural training
education for PCCM and CCM fellows for LRHV versus HRLV procedures, and
awareness of this discrepancy presents an opportunity to address this
educational gap in PCCM and CCM fellowship training.
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Souleymane M, Rajendram R, Mahmood N, Ghazi AMT, Kharal YMS, Hussain A. A survey demonstrating that the procedural experience of residents in internal medicine, critical care and emergency medicine is poor: training in ultrasound is required to rectify this. Ultrasound J 2021; 13:20. [PMID: 33847823 PMCID: PMC8044269 DOI: 10.1186/s13089-021-00221-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/25/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Training in procedural skills is often suboptimal. The aim of this study was to quantify the needs of residents in internal medicine (IM), critical care (CC), and emergency medicine (EM) for instruction in ultrasound-guided procedures. METHODS All IM, EM and CC residents (n = 200) at King Abdulaziz Medical City, Riyadh, Saudi Arabia, were invited to participate in a questionnaire-based survey to identify skill and experience gaps. The contribution of procedural skills to patient care (i.e. applicability) and proficiency in the sterile technique required to perform ultrasound-guided procedures were rated on Likert scales. Data on training, accreditation, and experience with and without ultrasound were collected. RESULTS The overall response rate was 72% (IM 91%, CC 100%, EM 40%). Although the sample reported that procedural skills were very applicable, 19% (IM n = 25, EM n = 2) had not performed any procedures. However, five residents were accredited in point-of-care ultrasound, 61% of the sample had performed ultrasound-guided procedures and 65% had used landmark techniques. Whilst more internists had performed procedures using landmark techniques, CC and EM residents had performed more ultrasound-guided procedures. Whilst CC residents had not missed any opportunities to perform procedures because supervisors were less available, EM (6) and IM (89) residents had. Whilst skill gaps were only identified in the IM residency programme, experience gaps were present in all three residency programmes. The IM residency programme had larger experience gaps than the CC and EM programmes for all procedural skills. DISCUSSION Residents in IM, CC and EM perceive that ultrasound-guided procedures are relevant to their practice. However, the IM residents performed fewer procedures than CC residents and EM residents at least partly because internists also lack skills in ultrasound. Training in ultrasound-guided procedures may reduce the use of landmark techniques and improve patient safety. Residents in IM, CC and EM therefore require training in ultrasound-guided procedures.
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Affiliation(s)
- Mamdouh Souleymane
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Rajkumar Rajendram
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.
- College of Medicine, King Saud Bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia.
| | - Naveed Mahmood
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Amro M T Ghazi
- Department of Intensive Care, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | | | - Arif Hussain
- Department of Cardiac Sciences, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
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Ricotta DN, McSparron JI, Huang GC. Raising the Bar for Procedural Competency Among Hospitalists. Ann Intern Med 2019; 171:524-525. [PMID: 31569242 DOI: 10.7326/l19-0449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Daniel N Ricotta
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts (D.N.R., G.C.H.)
| | | | - Grace C Huang
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts (D.N.R., G.C.H.)
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