Editor’s Note: This post is one of two pieces on the topic of procedural competency. Read the other piece here.
A few days ago I was working with a new resident and she came to me for help with a procedure. She had a patient with a severe headache and fever and she wanted to do a spinal tap. We had previously discussed the differential diagnosis and the possibility of meningitis. Now it was clear the resident was not at all confident in her ability to do the procedure and that I might have to do it. I took a deep breath. Although there had been a time when I was confident about doing a spinal tap, that was long ago. I had not done one myself in over a year though I had supervised a few. I watched as the resident prepared her supplies, positioned the patient, anesthetized and cleaned the area, and inserted her needle. Unfortunately she was not able to get any spinal fluid and after two attempts, she asked if I could try. I put on sterile gloves with some trepidation and explained to the patient that I would be taking over the procedure. “My head hurts,” she said. “Please help me.”
“Yes,” I said. “I understand that this has been the most severe headache you have ever had and that the CT scan you received was normal. Now we have to make sure you don’t have an infection,” I said. “That is why you need the spinal tap.”
“Will you be able to do it?” she said. “I can’t go through this another time.”
“I have done many of these,” I said avoiding the implication of her question. “Let me feel your back.” I palpated her lumbar vertebrae and the spaces in between them where I would put my needle. Everything felt normal. “I think I should be able to get this,” I said hopefully. I looked at the needle in the tray and it did not seem that the equipment had changed from the last time I had done the procedure. I proceeded to follow all the steps I still remembered and fortunately was successful with the spinal tap, and the clear fluid flowed out into our collecting tubes. The resident seemed both relieved and embarrassed that she had not been able to do what I had apparently done easily. As we let the patient know that the procedure was over, I gave a sigh of relief because I realized what may have looked easy was probably partly a stroke of good fortune considering how infrequently I had done this procedure over the past year. I began to think about my competence to supervise and perform other procedures.
Increasingly over the past year, I had noticed myself becoming uneasy as a procedure loomed. While success on most procedures was not a question of life of death, in some cases it was, such as for patients needing intubation. If we paralyzed a patient and the resident could not successfully complete the procedure, I might be thrust into the spotlight and have twenty or thirty seconds to visualize the key structures of the throat and neck and manipulate a tube into the trachea. It was something I had done many times but the equipment had been changing and my own experience was diminishing as more and more of my time was taken up with administrative meetings, research, and educational activities, and the residents got to perform most of the procedures.
In a recent Academic Medicine article, Vaisman and Cram discuss the important question of faculty clinical abilities to supervise trainees. They describe the case of a faculty member from internal medicine supervising a thoracentesis under ultrasound guidance. This attending internist was not trained in the use of ultrasound and was in the difficult position of supervising a resident who was more familiar with the equipment and procedure than she was. They raised the question about what the attending should do in such a circumstance and the risks to patient safety and to the relationship between resident and faculty member in case of failure. I suspect the situation is far more common than we might like to believe as many faculty who used to work in the hospital have been replaced with hospitalists. In addition, for many of our procedures the techniques and equipment have changed over the past five to ten years. Ultrasound guidance for many procedures allows for direct visualization of structures that used be reached through “blind” needle placements. While residents are getting the training in ultrasound use, faculty either have not gotten trained or have not had enough experience to maintain competence.
Vaisman and Cram suggest that we need to have conversations about faculty clinical supervision for procedures and find ways to address it—either through retraining of faculty or identification of other faculty to assist with supervision. I agree. I suspect that with increasing specialization it will be very difficult for generalist faculty in many fields to maintain expertise. There may need to be a designated proceduralist—a hospitalist, critical care specialist, or other designated expert in the procedure available to teaching hospitals and clinics to supervise resident procedures, provide feedback, and intervene themselves when necessary.
I applaud Vaisman and Cram for bringing this elephant out from under the table and encouraging frank discussion about how to ensure the safety of our patients in academic institutions with appropriate supervision by faculty who have current experience and expertise to assist and educate a resident particularly when the procedure does not go smoothly. We cannot always depend upon good fortune.