SGIM Forum

Medical Education: Part I

How to Teach Procedures? Medical Procedure Services Integrated into Residency Electives May Be the Solution

Dr. Grossniklaus ( is a hospital medicine fellow, University of Washington Medical Center, Division of General Internal Medicine, UWMC. Dr. Stiller ( is chief resident, Harborview Medical Center, Division of General Internal Medicine, UWMC. Dr. Albert ( is an assistant professor of medicine, VA Puget Sound, Division of General Internal Medicine, UWMC. Dr. Shepherd ( is clinical assistant professor of medicine, University of Washington Medical Center, Division of General Internal Medicine, UWMC. Dr. Adamson ( is associate professor, VA Puget Sound, Division of Pulmonary, Critical Care and Sleep Medicine, UWMC.

Procedural competency expectations for general internists are in flux, and current procedural training for resident physicians varies across internal medicine programs. Traditionally, general internists performed a variety of bedside procedures both in inpatient and outpatient settings. However, the number and variety of procedures performed by generalists have been steadily declining.1 The degree of bedside procedural competency an individual provider will need depends on a number of factors, including: patient population and practice setting, availability of proceduralists and subspecialists, and the provider’s own interest in performing procedures.

Recognizing this heterogeneity, the ABIM requires that all residents have the opportunity to become competent in procedures essential to their intended field of independent practice or subspecialty fellowship training. Common to all procedures, and thereby specific to the ABIM requirements, is demonstrating the ability to discuss and obtain informed consent, prepare and maintain standard and sterile fields, and apply local anesthetic.2

In this setting, it is understandable that procedural training practices in U.S. Internal Medicine (IM) Residency programs are quite variable. The majority of graduating residents report inadequate exposure to procedural skills during residency training,3 which raises concern regarding whether they are able to competently perform what were formerly considered to be core procedures. This is problematic, as many graduating residents may need to be able to safely perform beside procedures depending upon their subsequent practice settings.

Currently, most residency programs are using two training approaches to teach procedural skills: dedicated simulation-based workshops and learning procedures from more senior residents or supervisors as opportunities arise while on clinical service. Both strategies have significant shortcomings. Although workshops often include trained procedural instructors, simulation can never fully replicate performing procedures in the clinical setting. Unfortunately, learning procedures “ad hoc” while balancing other clinical service obligations provides inconsistent opportunities to learn and practice procedures. Additionally, supervising physicians may be under-qualified in teaching and performing procedures. Medical procedure services (MPS) provide an alternative approach to achieving procedural competency.

MPSs are an optimal training strategy for residents who desire to become competent in bedside procedures.3 In this model, residents are taught and supervised by procedure trained attending physicians to perform common bedside procedures in the clinical setting. MPS rotations have a dual purpose of providing timely procedures while off-loading other providers from procedural obligations. Participants are more likely to perform a greater volume and variety of procedures, education is maximized as the most effective instructors can be selected on the basis of competency and skill, and concomitant clinical responsibilities of the trainees are minimized.

To date, there have been seven such reports describing the development, implementation and evaluation of MPSs in the peer-reviewed literature, dating between 2004-18.4-10 These rotations range in length from one to four weeks. All services included training on thoracenteses, paracenteses, and lumbar punctures; an additional three services included central venous catheter placement4-6 and two services included central venous catheter placement and arthrocentesis.7,8

Reviewing these reports reveals several important themes:

  1. In five of the seven studies residents were given dedicated clinical time to participate in the services.
  2. In all of the described rotations, residents had expert supervisors available to guide them as needed (including both hospitalists and sub-specialty providers).
  3. All the electives provided supplemental didactics, with a variety of strategies ranging from video instruction,5, 7, 8, 9 simulation training,7, 8, 10 dedicated didactic sessions,8, 10 discussion of key concepts,7 Web-based curriculum7 to dedicated ultrasound-specific training.10

Reported outcome measures were also variable, spanning from resident self-assessment (of satisfaction of training, comfort/confidence, subjective knowledge and skill)5, 8, 10 to knowledge assessments via written tests7 and assessment of procedural volume.4, 9, 10 Notably, several of these studies investigated patient outcome measures, including successful procedure rates,4, 6 use of best practice safety measures,6 and complication rates,5, 6, 10

Overall, self-assessment measures generally improved with implementation of the MPS, including resident comfort/confidence8, 10 and perceived improvement in knowledge.8, 10 Objective improvement in medical knowledge and skills using observation with checklists was also reported.7 Studies that examined rates of procedures performed by residents after implementation of an MPS showed increased numbers of procedures and ability to “credential” residents to perform invasive procedures.4, 9 Although one group found improvement in complication rates as compared to the literature,5 another showed similar rates of major complications.6 However, studies that investigated rates of “successful” procedures found more successful procedures in MPS groups when compared to procedures performed by primary services.6

Challenges to the implementation of MPS include a lack of standardized published curriculum and limited hospital and residency program resources. Although there have been guides published for individual procedures (for example: lumbar puncture and paracentesis on MedEd Portal), there is no published literature or “handbook” on how to create an MPS. As such, each institution creates a unique service—which can be advantageous as it enables rotation directs to not only create services that are adaptable to their institutions but also the risk of inconsistency in degree of competency among graduating residents. Carving out dedicated resident time from already packed schedules and funding full-time supervisors present additional challenges.

Implementation of an MPS appears to be a promising approach for providing self-selected trainees with the procedural competency they need for their future careers. Outcome data regarding MPS electives, while limited, show an increase in resident-performed procedures,4,9 improved objective procedural knowledge and observed skill level,7 and improved patient safety outcome measures with either stable or improved complication rates.5, 6 As such, an elective rotation for residents to hone their procedural skills is an effective mechanism to improve both resident competency and shows promise for improving patient safety outcome measures.


  1. Wigton RS, Alguire P. The declining number and variety of procedures done by general internists: a resurvey of members of the American College of Physicians. Ann Intern Med. 2007 Marc 6;146(5):355-60.
  2. American Board of Internal Medicine. Policies and procedures for certification. Published March 2020. Accessed May 15, 2020.
  3. Brydges R et al. Core competencies or a competent core? A scoping review and realist synthesis of invasive bedside procedural skills training in internal medicine. Acad Med. 2017 Nov;92(11):1632-1643.
  4. Montuno A, Hunt BR, Lee MM. Potential impact of a bedside procedure service on training procedurally competent hospitalists in a community-based residency program. J Community Hosp Intern Med Perspect. 2016 Jul 6;6(3):31054.
  5. Smith CC, et al. Creation of an innovative inpatient medical procedure service and a method to evaluate house staff competency. J Gen Intern Med. 2004 May;19(5 Pt 2):510-3.
  6. Tukey MH, Wiener RS. The impact of a medical procedure service on patient safety, procedure quality and resident training opportunities. J Gen Intern Med. 2014 Mar;29(3):485-90.
  7. Lenchus JD. End of the “see one, do one, teach one” era: The next generation of invasive bedside procedural instruction. J Am Osteopath Assoc. 2010 Jun;110(6):340-6.
  8. Lenhard A, et al. An intervention to improve procedure education for internal medicine residents. J Gen Intern Med. 2008 Mar;23(3):288-293.
  9. Gorgone M, et al. The procedure coordinator: A resident-driven initiative to increase opportunity for inpatient procedures. J Grad Med Educ. 2018 Oct;10(5);583-596.
  10. Mourad M, Ranji S, Sliwka D. A randomized controlled trial of the impact of a teaching procedure service on the training of internal medicine residents. J Grad Med Educ. 2012 Jun;4(2):170-5.


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