Special Feature
THE ART AND SCIENCE OF MEDICAL EDUCATION
Training Using Simulation in Internal Medicine Residencies:
An Educational Perspective
Authors
Michael T. Flannery, MD and Kara F. Villarreal, AA
Editor
Jeffrey G. Wong, MD, FACP
Abstract: Background: The American Board of Internal Medicine has
defined through the min-CEX (Clinical Examination booklet) that a resident
would need to perform anywhere from 3 to 5 procedures to be competent
in a given procedure. Many faculty and residents believe that this number
is too low to achieve competency. Methods: Although simulation has been
required as part of medical training, we have reviewed a number of articles
addressing competence and potentially fewer complications with improved
patient safety. Results: The Accreditation Council for Graduate Medical
Education has simply stated that simulation should be part of residency
training. However, this has resulted in a disorganized approach among
the nearly 385 internal medicine programs in the United States.
Conclusions: This article suggests a model of simulation that addresses
procedures, medical codes and major medical problems that each resident
achieve competence in before graduating residency. This would
require minimally a doubling of the number of procedures to define
competency and will do so in a far more scientific method.
Key Indexing Terms: ABIM; ACGME; Milestones; NAS; GME; Med-
ical procedures; Simulation. [Am J Med Sci 2015;349(3):276–278.]
PERSPECTIVE
A t one time in internal medicine residencies, procedural com-
pliance was determined by the “see one, do one, teach one
process.” If anyone was having difficulty, it was either handled
internally by the senior residents or if refractory referred to
program management. When the American Board of Internal
Medicine (ABIM) came up with the Mini-CEX and procedure
logbooks, it was suggested that the following procedures be
performed from a numerical standpoint; paracentesis (3), arte-
rial blood gas analysis (5), arthrocentesis (3), central venous
line placement (triple lumen catheter [TLC]) (5), lumbar punc-
ture (LP) (5), nasal gastric tube (3), thoracentesis (5), breast
From the Department of Internal Medicine, University of South Florida
Morsani College of Medicine, Tampa, Florida.
Submitted February 26, 2014; accepted in revised form May 12, 2014.
The authors have no financial or other conflicts of interest to disclose.
Correspondence: Michael T. Flannery, MD, Department of Internal
Medicine, University of South Florida Morsani College of Medicine, 12901
Bruce B Downs Boulevard, MDC Box 19 Room L1041, Tampa, Fl 33612
(E-mail: mflann5555@aol.com).
276 The American Journal of the Medical Sciences
examinations (5), rectal examinations (5), pelvic examination
with pap smear and wet mount (5). These were static numbers
that came from the resident’s logbook. Our program took the
approach that if at least 3 of these procedures had not been
performed in the 1st year then we would not credential that
resident. The delinquent resident would be referred to the grad-
uate medical office to identify them and do any delinquent
procedures until they were competent. They could not do them
unsupervised as a postgraduate year 2 (PGY-2) resident. In my
first 10 years as the Associate Program Director, it was an
exceptionally rare process to report anyone as the residents
had a multitude of procedures. Then, in the early years after
2000, when I became the Program Director (PD), several influ-
ences on procedures began to take place. The main issue was
the availability of diagnostic radiology to do ultrasound-guided
paracentesis, thoracentesis, LP and TLCs. Also, the develop-
ment of a specialized nursing service to place midlines and
peripherally inserted central catheter lines took away other res-
ident opportunities. A focus on less administrative work meant
that residents were uncomfortable with electrocardiogram
(ECG) lead placement, drawing venous and arterial blood and
placement of peripheral venous line access. With residents put-
ting less focus on a career in ambulatory medicine, ambulatory
procedures such as breast examinations, prostate examinations
and pelvic examinations with pap smears diminished as well.
Simulation and video procedures offered new opportunities to
assess residents on common ABIM procedures. In the January
2013 the ABIM policies and procedures for certification, those
procedures noted to perform safely and competently included;
Advanced Cardiac Life Support (ACLS), drawing of arterial/
venous blood, placing a peripheral venous line, pap smears and
endocervical culture. For all other procedures, the indications,
contraindications, management of complications, pain manage-
ment and sterile techniques must be known.
To confirm fewer procedures are performed today in
practice, 1 study did a 20-year follow-up survey of general
internists and the number of procedures performed in practice
dropped from 16 in 1986 to 7 in 2004. Physicians who
practiced in smaller rural areas and those who had greater time
spent in patient care tend to do twice as many procedures as
those in larger centers with less practice time. Of the 6

Volume 349, Number 3, March 2015

procedures required by the ABIM in 2006, only 1 was
performed by most internists (joint aspiration/injection, 20
median procedures in the past year). Although numbers may
vary from residency to residency and geographically, there
seems to be a general concern that fewer procedures are being
performed and in no way are we judging the competence of the
individual except indirectly from those that observe the pro-
cedure. Of the 22 new milestones for internal medicine,
released by an expert committee in 2013, 2 have to do with
procedures; (PC4) skill in performing procedures and (MK2)
knowledge of diagnostic testing and procedures. Skill and
knowledge in performing procedures will require a different
approach in teaching internal medicine residents the basics
during training, whether they intend to use such procedures in
their future practice or not. Our program and many others have
approached this in different ways with little guidance from the
Accreditation Council for Graduate Medical Education
(ACGME). This is especially true from their statement that
simulation be part of the training process. Of course, a program
may simulate major medical problems and medical codes with
an occasional ethical dilemma added to the mix. This need has
already been determined in that it has been shown that most
PDs believe that their residents are not prepared for practice
from a procedural standpoint.2 In addition, it has been demon-
strated that, regarding complications, 70% occur before a resi-
dent became certified in a procedure.3
Programs have taken different initiatives to train resi-
dents through some form of simulation; standardized patients,
simulation models, supervised and debriefed, and video re-
views. Of course, direct observation from senior residents and
faculty continues to be a mainstay in teaching procedural
knowledge and competence. Some programs have used pre-
and posttesting after a teaching event to confirm the knowledge
learned. Procedural competence is not suddenly a new thought
as it has been in development over the past 15 years.4–6 Regard-
ing the numbers of procedures for a particular competency, 1
study found that the ABIM procedure numbers were within 1
standard deviation to achieve competence. A number of various
procedures have demonstrated increased confidence and com-
petence in procedures with simulation.8–10 Competence would
be defined as determined to be ready for the procedure without
direct supervision. One set back is ambulatory procedures such
as pap smears and arthrocentesis. Residents in 1 study found
that the ambulatory clinic was not helpful in learning these
procedures and others.11
As most PDs realize, it is not just competency during the
resident’s overall training period, but a particular emphasis on
the 1st year acquisition of competency so that they may super-
vise such procedures as a PGY-2 resident without direct super-
vision and monitor the education of the postgraduate year 1
(PGY-1) residents. Therefore, our program always sent a total
procedure list, based on the ABIM numbers mentioned previ-
ously, to our GME office so that the designated institutional
official could allow those with appropriate numbers to move
forward, whereas others (usually 1–2 of 25 PGY-1 residents)
needed to remain supervised in areas where they had not
achieved sufficient numbers. Of course, this is a number-
based system and has little to do with resident confidence and
competence. For the past 2 years, all residents had to go through
the simulation center and pass a direct observation checklist for
TLCs to be deemed ready for residency training. Pre-/
posttesting was completed as well. Although data are being
reviewed, residents informally confirmed increased confidence.
Other prior simulation studies have also reported improved
patient outcomes with fewer complications.12–17 Such testing
Copyright © 2015 by the Southern Society for Clinical Investigation.
Simulation in Internal Medicine: An Educational Perspective
is planned on being repeated to compare results. Certainly, if
beneficial results are obtained that improve patient safety, then
expansion of this process to other commonly required proce-
dures should be undertaken. Rheumatology now teaches artho-
centesis, and there has been increased emphasis through the
women’s health center to improve resident skills on pap smear
and cultures. Anesthesia faculty at our Veteran’s Administra-
tion hospital teach an intubation course for all residents who
rotate through the medical intensive care unit. Every model for
each residency was developed and approved by the GME
office. A simulation center was built that has educational floors
for students and residents. Cooperation with the hospital is
critical; for instance, to run a code, you need pharmacy, nursing
and anesthesia. Because they need accreditation, as well, we
have worked out a symbiotic relationship with our hospital and
its staff. This is critical in the time of the New Accreditation
System where increased communication between stakeholders
for resident education and patient safety is essential during
a Clinical Learning and Environment Review (CLER) visit.
At this point and time, what procedures should internal
medicine residents be doing?18 The ABIM bases their decision
on manual skills and cognitive competence. Those requiring
manual skills include ACLS, drawing arterial/venous blood,
placing a peripheral venous access, pap smear and endocervical
culture. If ACLS is included, then defibrillation, central venous
access and emergency intubation should be included. Other
procedures that require cognitive skill but less manual skills
include arterial line placement, arthrocentesis, ECG, incision
and drainage of an abscess, LP, nasogastric tube placement,
pulmonary artery catheter placement and thoracentesis. After
over 20 years as an Associate Program Director and PD of
a moderately large internal medicine residency program (80–
90 residents), I believe that the process needs to change. For
one thing, hospitals were no longer asking globally whether
a resident was credentialed for a specific procedure; they are
now asking for the total counts for all procedures.
Drawing arterial and venous blood and doing pelvic
examinations, I & D (incision and drainage) of abscesses and
ECGs can be performed by a PGY-1 in their emergency room
rotation. Other rotations such as cardiac care units or medical
intensive care units should include plenty of opportunities for
central line placement, paracentesis, thoracentesis, LP and
emergency endotracheal intubation. Outpatient clinics, both
general and subspecialty, will give opportunities for arthrocent-
esis, pap smears and endocervical culture. The procedures are
there and should not be given away to peripherally inserted
central catheter nurses or interventional radiology until several
attempts have been made. The simulation center gives a wonder-
ful opportunity to fine-tune skills before approaching the bed-
side. Increasing competence, decreasing errors and improving
efficiency will make residents and their patients happier with
better outcomes and fewer complications.
In a report by the Association of American Medical
Colleges (AAMC), of 90 participating medical schools, 83
indicated some use of simulation across a 5-year span of
residency education. The bulk of this education occurred in
years 1 and 2, which makes sense in internal medicine since the
3rd year is predominately elective. The most common clerk-
ships for medical students to use simulation as part of their
training were internal medicine, emergency medicine and
pediatrics.19 Of course, everyone in undergraduate education
and GME agree that there should be a continuum of competen-
cies across medical school into residency. In our program, 3rd
and 4th year students get some clinical procedural time on
simulation. It is somewhat unplanned compared with the
277
Flannery and Villarreal
resident except with teaching ACLS and making sure that
everyone entering any program has a checklist approval of their
competence before they enter the wards and intensive
care units.
Several other concepts would make sense moving
forward from an ACGME standpoint. Define which proce-
dures and how many, for core internal medicine residency,
that an individual resident must achieve before being
allowed to graduate similar to our other competencies. This
would occur over 3 areas: (1) procedures common to
internal medicine, (2) codes especially unstable supraven-
tricular tachycardia, ventricular tachycardia/fibrillation,
asystole and symptomatic bradycardia and (3) major med-
ical conditions, congestive heart failure, acute pulmonary
embolus and acute sepsis (or others substituted). Some
procedures may need to be repeated before the PGY-2 to
ensure appropriate supervision. The majority of this simu-
lation teaching would occur in the first 2 years. In all
likelihood, this would require a minimum of 10 simulations
across the 3 areas described. Quality improvement studies
may be undertaken at institutions that have defined where
their greatest needs are to better train residents and improve
patient safety.
The simulation center at our institution has equipment to
experience all of the various fields of medical and surgical
practice/procedures. Teams can practice initial management of
any procedure and then review the taped version for discussion.
The attending is present, and hospital personnel necessary for
some procedures such as codes are present in agreement with
our large urban level 1 trauma center. Students, residents and
fellows can schedule time at the center for any procedure or
medical condition to simulate not only the triage but also the
management of conditions.
It is unlikely that other services that currently do
procedures will complain of a decrease in volume with such
a small number of increased procedures needed by residents.
Indeed, many such services often complain about the number of
referred procedures, billing or not. There have not been any
studies or suggestions about how many procedures an attending
should be present for billing purposes as many procedures are
performed after hours. Obviously, attendings should bill only
for procedures that they are present. The utilization of non-
teaching services with an attending and a nurse practitioner or
physician assistant will decrease teaching services burden
allowing appropriate numbers of procedures to be completed.
There is always the question of whether the procedures we
teach will be ultimately used by residents when they get to
practice. However, we owe residents the foundational knowl-
edge of procedural competence as some will not doubt using
these skills as hospitalists, fellows and primary care physicians
in rural areas.
Despite various systems and methods of training, we find
ourselves at a unique point in resident education regarding
utilization of simulation to improve patient safety outcomes.
Our system demands such outcomes in a time of transitional
care of patients with reduced work hours. Much has been
studied, but much investigation remains necessary in a time
where resident education is correlated with improved patient
care with fewer complications. Further study is needed to
278
determine whether these recommendations hold up in resident
education and patient safety.
REFERENCES
1. Wigton RS, Alguire P. The declining number and variety of procedures
done by general internists: a resurvey of members of the American
College of Physicians. Ann Intern Med 2007;146:355–60.
2. Wigton RS, Blank LL, Nicolas JA, et al. Procedural skills training in
internal medicine residencies. Ann Intern Med 1989;111:932–8.
3. Durning SJ, Cation LJ, Jackson JL. Are commonly used resident
measurements associated with procedural skills in internal medicine
residency? J Gen Intern Med 2007;22:357–61.
4. Wigton RS. Training internists in procedural skills. Ann Intern Med
1992;116:1091–3.
5. Long DM. Competency-based residency training: the next advance in
graduate medical education. Acad Med 2000;75:1178–83.
6. Huang GC, Newman LR, Schwartztein RM, et al. Procedural com-
petence in internal medicine residents: validity of a central venous
catheter insertion assessment instrument. Acad Med 2009;84:1127–34.
7. Cation LJ, Durning SJ. Procedural skill competence and certification in
internal medicine residency training. Teach Learn Med 2003;15:175–9.
8. Fincher RE. Procedural competence of internal medicine residents:
time to address the gap. J Gen Intern Med 2000;15:432–3.
9. Augustine EM, Kahana M. Effect of procedural simulation workshops
on resident procedural confidence and competence. J Grad Med Educ
2012;479–85.
10. Lenchus JD, Carvalho CM, Ferreri K, et al. Filling the void: defining
bedside procedural competency for internal medicine residents. J Grad
Med Educ 2013;5:605–12.
11. Wickstrom GC, Kolar MM, Keyserling TC, et al. Confidence of
graduating internal medicine residents to perform ambulatory proce-
dures. J Gen Intern Med 2000;15:361–5.
12. Green ML, Aagaard EM, Caverzagie KL, et al. Charting the road to
competence: developmental milestones for internal medicine residency
training. J Grad Med Educ 2009;10:5–20.
13. Creation of a medical procedure service to improve patient safety. Available
at: http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID556. Ac-
cessed January 15, 2014.
14. Issenberg SB, Chung HS, Devine LA. Patient safety training simula-
tions based on competency criteria of the Accreditation Council for
Graduate Medical Education. Mt Sinai J Med 2011;78:842–53.
15. Improving patient safety through simulation research. Available at: http://
www.ahqr.gov/research/findings/factsheets/errors-safety/simulproj11/
index.html. Accessed January 17, 2014.
16. Savata RM. The revolution in medical education-the role of simulation.
J Grad Med Educ 2009;12:172–5.
17. Aggarwal R, Mytton OT, Derbrew M, et al. Training and simulation
for patient safety. Qual Saf Health Care 2010;19:i34–43.
18. Duffy FD. What procedures should internists do? Ann Intern Med
2007;146:392–3.
19. Medical simulation in medical education: results of an AAMMC survey.
Available at: https://members.aamc.org/eweb/upload/Medical%20Simulation
%20in%20Medical%20Education%20Results%20of%20an%20AAMC
%20Survey.pdf. Accessed January 17, 2014.
Volume 349, Number 3, March 2015