Supervising the supervisors--procedural training and supervision in internal medicine residency

Abstract

Background: At teaching hospitals, bedside procedures (paracentesis, thoracentesis, lumbar puncture, arthrocentesis and central venous catheter insertion) are performed by junior residents and supervised by senior peers. Residents' perceptions about supervision or how often peer supervision produces unsafe clinical situations are unknown.

Objective: To examine the experience and practice patterns of residents performing bedside procedures.

Design and participants: Cross-sectional e-mail survey of 653 internal medicine (IM) residents at seven California teaching hospitals.

Measurements: Surveys asked questions in three areas: (1) resident experience performing procedures: numbers of procedures performed and whether they received other (e.g., simulator) training; (2) resident comfort performing and supervising procedures; (3) resident reports of their current level of supervision doing procedures, experience with complications as well as perceptions of factors that may have contributed to complications.

Results: Three hundred sixty-seven (56%) of the residents responded. Most PGY1 residents had performed fewer than five of any of the procedures, but most PGY-3 residents had performed at least ten by the end of their training. Resident comfort for each procedure increased with the number of procedures performed (p < 0.001). Although residents reported that peer supervision happened often, they also reported high rates of supervising a procedure before feeling comfortable with proper technique. The majority of residents (64%) reported at least one complication and did not feel supervision would have prevented complications, even though many reported complications represented technique- or preparation-related problems.

Conclusions: Residents report low levels of comfort and experience with procedures, and frequently report supervising prior to feeling comfortable. Our findings suggest a need to examine best practices for procedural supervision of trainees.

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 reporting being “comfortable” or “very comfortable” performing each procedure by resident year.

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 reporting being “comfortable” or “very comfortable” supervising each procedure by resident year.