Matching physician skill to patient needs is vital to the success of any hospitalist program. Physicians who enter Hospital Medicine, typically from residency training in Internal Medicine, are different now than 20 or even 10 years ago due to more emphasis in residency training on ambulatory care and relatively recent resident work hour restrictions.
This, coupled with more specialized residency and fellowship training at many of the larger or mid-sized training programs, physicians completing a typical three year Internal Medicine residency today have mastered more clinical and didactic information than their predecessors, gained countless hours of CPOE training and expertise and even participated in numerous research and quality improvement activities. However, they have little formal training in many previously commonly taught bedside procedures and unfortunately even less actual hands on experience performing such procedures. The once lauded Senior/Chief IM resident who could perform a bevy of complex invasive procedures is now an unfortunate rarity. Residents are relegated to spectators often at our most prestigious programs while Fellows learn and perform procedures such as
- Central venous access
- Lumbar punctures.
Many of the iconic clinical “truths” of the work up of such diseases as a pleural effusion with Oslerian Directives of “never let the sun set on a non-diagnosed pleural effusion” are now merely relegated to a CPOE order for IR (interventional radiology) to perform an ultrasound guided thoracentesis.
Hospitalists should be concerned. For some it is possible to remain in larger, academic training programs flush with Fellows and Specialists to perform procedures the patients need. However, many Hospitalists find themselves in the unfamiliar and sometimes frightening “wilderness” of the community hospital or it’s close cousin, the Critical Access Hospital; These environs are places where lost skills are brought glaringly to the forefront. In such locations, a Hospitalist may find themselves as the only physician on duty, save for the ED physician, and woefully out of their procedural depth, placing themselves and ultimately the patient under their care at risk.
While IM Residency Programs remove procedural training requirements for residents, and more of these same residents pursue Hospitalist Medicine as their desired career paths, the problem grows. Even the Society of Hospital Medicine has within it’s “Core Curriculum for Hospital Medicine Fellowships” recommendations for significant procedural training in the aforementioned procedural skills. And, while Ultrasound Guidance has made many of these procedures more precise and safer, the skills necessary to actually perform the procedure may still be lacking. Worse yet, such US guidance may create a false sense of confidence in a novice attempting the procedure, placing the patient at increased risk.
Finally, our customers/clients, our hospitals expect, even require, Hospitalists to be both proficient and competent to perform many, if not all of these procedures. Furthermore, many of our smaller community and rural hospitals utilize or require Hospitalists to serve as quasi-intensive care physicians, providing care to the sickest patients while simultaneously providing procedural expertise in the ICU, the wards and even back up / assistance to the Emergency Department. In short, the Hospitalist may easily find themselves under trained, under pressure to perform and the last line of hope for a critical patient.
In order to provide our Hospitalists with the ability to learn new procedural skills, practice or retrain previously learned skills or even maintain and prevent atrophy of procedural skill sets, simulation laboratories and training sessions are a critical element for Hospitalist Programs to invest both time and money, the ROI is potentially great.
First, assess the client’s needs. If the hospitals are robust enough to have 24/7 Intensivists, Anesthesiologists, Interventional Radiologists and active Fellowship Specialty Physicians onsite, the need maybe little to none. Conversely, hospitals without such services and robust staffing, may not realize their needs or the potential savings in Cost per Case, Improved Patient Throughput and Reduced ALOS which can be realized with procedurally competent Hospitalists. Such discussions are an initial key step in creation of a program.
Second, assess of the interest and motivation of the Hospitalists to learn new procedural skills and to use these skills. Additionally, a needs assessment as to the skills sets individual hospitalists, hospitalist teams and special circumstance Hospitalists (Nocturnists, House Physicians, ICU coverage, Trauma or Surgical Hospitalists, OB Hospitalists) should be performed. Clearly, the skill sets will vary and the needs assessment will vary on circumstances. Leadership must be obtained both administratively and from within the physician Hospitalists. Ideally, physician champions should be found and empowered with the necessary protected time and financial investment in training and equipment.
Third, use the skills assessment and needs assessment to develop the equipment needs assessment. Restraint is required, to avoid some pitfalls, such as outdated or inferior equipment, consideration of cost/benefit of purchase or rental; Some consideration as to the mobility of the equipment if multi-sited procedure labs will be offered versus and “central” training lab, ease of access to the Central lab, use/re-use of equipment, effective lifespan of the equipment and durability of the equipment are important. Additionally, frequency and timing of training labs, open lab options for trainees and consideration for certificates of training or CME credits should be addressed.
Finally, real patient procedural experience and proctoring is a must. While simulation lab training is important, the ability to provide real patient procedural experiences and proctoring by currently competent and trained procedural physicians is the most crucial step, especially when learning a new skill or training a novice to gain real world procedural competency. Use of physician champions at site hospitals or even collaborative training with departments of surgery, anesthesia or radiology may be options to ensure closure of this training circle.
Michael Menolasino, III, DO, FACOI, FHM
Dr. Menolasino serves as the Director of Quality and Education for Community Hospitalists. He was instrumental in the development of the CH Portable Simulation Lab and provides monthly procedure education at our multiple locations.
Dr. Menolasino is a graduate of Benedictine University and the Des Moines University Osteopathic Medical School. He did his residency training at Metropolitan Hospital in Grand Rapids, Michigan and went on to complete a Faculty Development Fellowship at Michigan State’s University College of Osteopathic Medicine. He has served as a Clinical Associate Professor for Ohio University, Lake Erie College, and Michigan State University, making him the ideal education leader for our clinical team.