What Procedures Should Internists Do?

For decades, internal medicine residency training has prepared physicians to be generalists and learning bedside procedures has been an important element of training. In this issue, Wigton and Alguire (1) ask whether practicing internists perform the bedside procedures they were trained to do. The answer is, they are not: On average, internists perform 50% fewer procedures than they did 18 years ago. When only the procedures required for certification by the American Board of Internal Medicine (ABIM) are considered, 26% of internists performed lumbar puncture in 2004 compared with 73% in 1986. The trend also held for thoracentesis (23% vs. 66%) and paracentesis (26% vs. 60%); only arthrocentesis of the knee was done by more than 50%. Even in rural towns, only 8 of the procedures were done by most respondents. Can we trust these findings? Despite a survey response rate of only 56%, the response bias more likely trends toward overrepresenting, not underrepresenting, what procedures internists do.

Why are procedure rates falling? Many diagnostic procedures, such as urinalysis or peripheral blood smears, formerly done at the bedside or in the office, are now done by Clinical Laboratory Improvement Act (CLIA)–certified laboratories. As Wigton and Alguire show, most internists refer patients who need procedures to hospital-based general internists, internal medicine subspecialists, or radiologists who use imaging techniques. This trend may reflect a deliberately conceived strategy for improving quality, because the second most frequent cause of hospital errors is complications of a medical procedure (2). Improper technique leads to infection, bleeding, pain, and other complications. Mishandling samples wastes time and resources and requires repeated procedures. Meticulous attention to technique by trained, experienced teams can …