Wednesday, March 07, 2007

Internists doing fewer traditonal internist procedures

The results of a survey sent to 2500 general internist members of the American College of Physicians and replied to by 1389 indicate that internists are doing fewer of the procedures that traditionally had been done by that speciality.This report was published in a recent issue of The Annals of Internal Medicine.

The authors compared the results with those of a survey done in 1986. Here are some of the data.

In 1986, 66% did thoracentesis versus 23 % in 2004, for abdominal paracentesis-60% dropped to 23%, bone marrow aspiration from 27% to 8 %, flex sig dropped from 42% to 20%, insertion of central line 39% to 16%.Interestingly skin biopsies increased as did cryosurgery for skin lesions . Gram stain of the sputum decreased from 50% to 5%.

The increased numbers of IM sub-specialists,tighter credentialing procedures at hospitals,the advent and proliferation of hospitalists were some of the reasons suggested by the authors behind the changes.

Of interest to me was the companion article-an editorial from the American Board of Internal Medicine (ABIM)- regarding what procedures should be taught to physicians in training to become internists.The authors distinguished between the types of procedures residents would be taught to do versus those that they would be taught about.In regard to the latter, we are told that for certain procedures, only what the ABIM refers to as "cognitive competence" will be required. This interesting pedagogic, linguistic construct apparently means that the resident must be shown to be competent in discussing the indications,contraindications, complications etc related to the procedure and be able to obtain an informed consent for the procedure-apparently that someone else will do. Included in the set of procedures are several that many of us older internists consider basic internist activities: thoracentesis, abdominal paracentesis, naso gastric intubation and lumbar puncture.

Internists in training will be required to actually learn how to do ( as opposed to learn how to talk about) the following: venous and arterial access,pap test, endocervical culture and the basic elements of ACLS including intubation.

As best, I could determine from web sources, family practice residency programs continue to teach a wide variety of procedures including those that internists now only have to be able to talk about including thoracentesis, lumbar puncture and abdominal paracentesis.

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