The new proceduralists: Have they found their niche?

Financial and quality pressures have some large hospitals designating a specialized cadre of physicians to perform procedures. But is the trend ready to take off?

By John McCormack, amednews correspondent — Posted Sept. 17, 2007

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First came the hospitalists, who managed hospitalized patients' care in the stead of the patients' usual physicians. Now come the proceduralists, who are performing procedures in the stead of the patients' usual physicians, or emergency physicians.

The term "proceduralist" is evolving, in some places, from referring to a physician who performs procedures to meaning a physician who performs nothing but procedures. Typically, proceduralists are hospitalists or critical care physicians who spend most of their time performing procedures such as intubation, paracentesis and thoracentesis. They work in designed procedure centers, popping up in academic medical centers nationwide.

Those behind the rise say proceduralists are filling a need. Many internists are concentrating on cognitive work and performing fewer procedures -- 50% fewer today than 18 years ago, according to a University of Nebraska Medical Center study published in the March 6 Annals of Internal Medicine. Meanwhile, specialists such as interventional radiologists and vascular surgeons have begun to focus on more technically challenging cases.

In all specialties, declining reimbursement and rising liability insurance rates have provided a disincentive to doctors for taking on risky procedures, particularly if they are ones a physician does not perform frequently. Plus, quality initiatives and studies have focused on data showing that the more often a physician does a procedure, the better he or she is at it.

"The major rationale here is that if you have someone who does something a lot, they will be better at it," says Eric Holmboe, MD, senior vice president for evaluation and quality research at the American Board of Internal Medicine, Philadelphia.

But while hospitalists have gone from unknown to ubiquitous during the last 10 years, it's not certain if proceduralists will follow the same pattern of growth.

"Proceduralists and procedural centers are popping up here and there, but it is still in its infancy," says Bradley T. Rosen, MD, assistant director of the Procedure Center at Cedars-Sinai Medical Center, Los Angeles. "The movement is where the hospitalist movement was about 10 years ago. People are gravitating toward doing it, and some physicians are actually performing the service without calling themselves 'proceduralists' yet."

How a procedure center works

The Cedars-Sinai center has four proceduralists, one nurse practitioner and 14 nurses to handle 24 specific procedures. Staff members schedule all inpatient and outpatient procedures. The department maintains mobile carts, containing all of the required supplies for typical procedures. In addition, the proceduralists have access to a procedure room and colonoscopy suite. Center staff also can be requested to come to the emergency department.

"We do all of this to increase efficiency. Otherwise, it would not be worth it for the doctors to run around doing procedures," Dr. Rosen says.

By increasing efficiency, Cedars' proceduralists say they increase volume, thereby increasing income. At the same time, other physicians and hospitalists can see patients more efficiently, without schedule disruptions.

At Cedars, the proceduralists receive voluntary referrals from house staff and private medical staff. Any physician can, however, choose to perform procedures.

The hospital bills separately for almost all of the procedures performed, as they are not part of a bundled surgical code.

In addition, the hospital pays a subsidy to the proceduralists, who are salaried, in exchange for the added value it believes the service brings to the institution.

From the hospital perspective, the subsidy is justified due to the improvements in quality, as well as efficiency. For example, with the proceduralist service, Cedars-Sinai is able to improve patient throughput and decrease lengths of stay, Dr. Rosen says.

"Overall, our complication rates are less than 1%, compared to the published data for similar procedures where complication rates are 3-5%," Dr. Rosen says. In addition, the service has helped to minimize infections and inappropriate line removal while also ensuring compliance with regulatory guidelines, he says.

Plus, the proceduralists are an integral part of the hospital's quality efforts and have helped to develop and implement quality improvement initiatives, Dr. Rosen says.

The procedure center has been so successful, Cedars-Sinai is putting a $1 million addition on the center to double its size and allow the addition of another proceduralist.

Questions on central model

Whether this model can work in all hospitals, however, remains to be seen.

"It's more likely that a larger hospital would be able to gain the efficiencies offered by a procedure center, while smaller hospitals might be able to get by using interventional radiology or vascular surgery for procedures," Dr. Rosen says.

Cedars-Sinai's Procedure Center had its beginnings in the early 1990s, and has doctors on hand to step into the emergency department, the operating room, or anywhere else in the hospital where a certain procedure needs to be done.

Few other hospitals have created a full-service center, but a number are developing procedural services expressly for resident training purposes.

"The standard model of 'see one, do one, teach one' is not adequately training residents," says Jeffrey Barsuk, MD, assistant professor of medicine at Northwestern University Feinberg School of Medicine, Chicago. As a matter of fact, according to a study recently published in Chest, Barsuk and a research team found that third-year residents who were trained using this method did not meet American Heart Assn. guidelines for thoracentesis. (See correction)

At Northwestern, proceduralists work with residents in simulation labs and during actual procedures in an effort to provide better training on complicated procedures.

Similarly, the University of Chicago uses proceduralists both to train residents and to do procedures, says Vineet Arora, MD, associate program director of internal medicine residency at the Pritzker School of Medicine.

"It's nice to have access to an experienced supervisor who can come in and teach the resident how to do the procedure, instead of having the knowledge handed down from senior residents to junior residents," Dr. Arora says.

In part because of the shift away from procedures, the American Board of Internal Medicine has changed its requirements for certification. In 2005, the ABIM required physicians to demonstrate safe and competent performance for nine procedures, while in 2006, physicians were required to safely perform only five procedures but know, understand and be able to explain 14 additional ones.

But Dr. Barsuk says that in super-sized institutions, it would be difficult for a procedure center to keep up with the work load, so it's important other physicians continue to be trained.

"In a really big institution, it's probably more efficient for physicians to do their own procedures in many instances," he says. "It's important for residents to know how to do the procedures, know the complications and contraindications. Even if a hospital does have a procedure center, if something happens in the procedure center and a patient comes to the floor, they need to be able to recognize the complications."

No single specialty

While many physicians are making a living as hospitalists, many observers say it is difficult to make a living as a proceduralist now, unless a physician has the structure of a Cedars-Sinai procedure center.

Although procedures are reimbursed at a higher rate than are cognitive services, the rates are not high enough to lure a great number of physicians, observers say.

"For a physician who is good at seeing patients and rounding, economically it makes more sense for them to continue to focus on doing the cognitive work and not disrupting their workday to do the occasional procedure," Dr. Rosen says.

Russell Holman, MD, president of the of Society of Hospital Medicine, Philadelphia, an organization whose members are mostly hospitalists, said he believes physicians would be drawn to becoming proceduralists by the work, not the money. He said he sees the start of a movement.

"Physicians who want the practice variation and enjoy doing this type of work will be drawn to being a proceduralist. There is a potential for enhanced income because of the higher rates of reimbursement, but I don't see that as a main reason why physicians would gravitate to this work," he says.

"It is safe to say that general internists, family [doctors] and even some hospitalists have been performing fewer procedures in many locations," Dr. Holman says, "but it is early in the evolution of proceduralists, and it is difficult to say where things will land."

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One hospital's lineup

Procedures and services offered by the procedure center at Cedars-Sinai Medical Center, in Los Angeles:

Insertions and removals

PICC lines
Central lines
Difficult IVs
PAS-port catheters
Tunneled catheters
NG, G, J tubes
Mahurkar catheters
Arterial lines
Swan-Ganz catheters

Additional procedures

Lumbar puncture
Soft tissue FNA
Trach change
Perc tracheostomy
Chest tube insertion
Flexible sigmoidoscopy
I&D abscess
Skin biopsy
Conscious sedation

Consultative services

CVC repair/declots
Line infections
Fluoroscopic consultations for line complications
Emergency airway management
Pleurex drainage

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This story incorrectly misstated the purpose and results of a study published in Chest. The study found that second-year residents using simulation training showed significantly higher adherence to American Heart Assn. standards for response to advanced cardiac life support events than did third-year residents who did not receive such training. The study concluded that "there is a growing body of evidence that simulation can be a useful adjunct to traditional methods of procedural training." The story misstated the nature of the training in the study, and misstated in saying that the study focused on thoracentesis. American Medical News regrets the error.

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