Correspondence

Proceduralists — Leading Patient-Safety Initiatives

N Engl J Med 2007; 356:1789-1790April 26, 2007

Article

To the Editor:

We have enjoyed watching the Journal's new procedural videos and applaud their emphasis on proper procedural techniques. This new approach to procedural training complements a trend at a few institutions that are taking patient safety to the next level by supporting a new group of doctors known as “proceduralists,” physicians who specialize in procedural activities.1 While busy interventional radiologists and vascular surgeons continue to shift their focus toward technically more challenging cases, which also have higher reimbursement, surveys show that internists are performing fewer procedures than ever before.2 Proceduralists may therefore help to bridge the growing chasm between the surgical and nonsurgical specialties. They focus their activities on a diverse repertoire of medical procedures that can be time-consuming, have inherent risks for patients, and are essential both for diagnostic and therapeutic purposes but are relatively poorly reimbursed.

Proceduralist practices are evolving, with the size and scope varying largely according to the economic and political environment in a given hospital. However, reports on the work of proceduralists are scarce. Beth Israel Deaconess Medical Center in Boston recently reported on its experience using a medical procedural service with an emphasis on residency training for procedures. After implementation of the service and the associated training program, complication rates were reduced as compared with community standards.3 The University of Chicago Pulmonary–Critical Care Division implemented a procedural service to help residents comply with work-hour rules.4

At our institution, Cedars–Sinai Medical Center, the Procedure Center has steadily grown in both volume and scope over the past 10 years. In 2005, each of four proceduralists performed more than 2000 procedures and received extra certification in fluoroscopy, conscious sedation, upper airway endoscopy, percutaneous tracheostomy, ventilator management, and ultrasonography.1 At Cedars–Sinai, all procedures are tracked through personal digital assistants, and pooled complication rates are less than 1% (much lower than published complication rates). Cedars–Sinai proceduralists also coordinate annual training sessions for incoming interns to practice procedural techniques on nonhuman tissue models and to learn the proper use of ultrasonography and wide sterile barriers.5 In addition, proceduralists provide a convenient service for the private medical staff and improve the efficiency of care (owing to their ready availability), which aligns procedural activities with the institution's emphasis on optimizing resource use and reducing the length of hospital stays.

In today's health care environment, where safety and standardization have become paramount, proceduralists may be raising the performance bar to new levels. Just as the use of hospitalists has become an accepted model for delivering inpatient care, the use of proceduralists may become the new standard for procedural services.

Mark J. Ault, M.D.
Bradley T. Rosen, M.D., M.B.A.
Cedars–Sinai Medical Center, Los Angeles, CA 90048
mark.ault@cshs.org

5 References

1. 1

   Rosen BT, Ault MJ, Ng PK. The proceduralist: an emerging specialty for general internists. J Gen Intern Med 2005;20:Suppl 1:25-25
   Medline

2. 2

   Wigton RS, Alguire PC. Procedural skills of the general internist 18 years later: a resurvey of ACP members. Ann Intern Med 2007;144:355-360
   

3. 3

   Smith CC, Gordon CE, Feller-Kopman D, et al. Creation of an innovative inpatient medical procedure service and a method to evaluate house staff competency. J Gen Intern Med 2004;19:510-513
   CrossRef | Web of Science | Medline

4. 4

   Kelly CK. Tips for saving time in the era of new work hour rules. ACP Observer. September 2004. (Accessed April 5, 2007, at http://www.acponline.org/journals/news/sep04/time.htm.)
   

5. 5

   Ault MJ, Rosen BT, Ault B. The use of tissue models for vascular access training: phase I of the Procedural Patient Safety Initiative. J Gen Intern Med 2006;21:514-517
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Mark J. Ault, Bradley T. Rosen. (2010) Portable ultrasound: the next generation arrives. Critical Ultrasound Journal 2:1, 39-42
   CrossRef

2. 2

   Mark J. Ault, Bradley T. Rosen. (2010) The Magic Wand of the Ultrasound?. Annals of Emergency Medicine 55:1, 130
   CrossRef

3. 3

   Bradley T. Rosen, Poulina Q. Uddin, Annie R. Harrington, Brian W. Ault, Mark J. Ault. (2009) Does personalized vascular access training on a nonhuman tissue model allow for learning and retention of central line placement skills? Phase II of the procedural patient safety initiative (PPSI-II). Journal of Hospital Medicine 4:7, 423-429
   CrossRef