Procedure Training Policy, Internal Medicine Residency Program, Mount Auburn
Hospital, Cambridge, MA
Summary statement: This document pertains mostly to categorical Internal Medicine interns
and residents at Mount Auburn Hospital. In order to be certified by the American Board of
Internal Medicine (ABIM), you must complete the Mount Auburn Hospital procedure
curriculum. You cannot graduate from the residency program without completing these requirements. You
cannot take the Internal Medicine board exam without finishing these requirements. A copy of the
ABIM requirements from their website is pasted in the addendum at the end of this
document. For preliminary interns: you must review the educational material and complete the
quizzes for central and arterial lines prior to your first ICU rotation. For any house officer
(intern, resident, categorical, or preliminary): you must review the relevant educational material and
submit the associated quiz prior to performing any procedure. Record all procedures in
New Innovations.
Procedure Training Policy: During your rotations through the intensive care unit (ICU),
cardiology service, wards service, clinics, emergency room, and electives you will encounter a
number of commonly performed procedures in both inpatient and outpatient settings.
Although technical proficiency for most procedures is not required by the ABIM for
certification in Internal Medicine, you are required by the ABIM to develop (1) competence
in understanding the indications, contraindications, risks and benefits, and (2) proficiency in
handling specimens, interpreting results, and conducting informed consent for the following
procedures:
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Paracentesis
ACLS
Arterial Line
Arthrocentesis
Central Line
Venous Blood Draw
Arterial Blood Draw
Incision and Drainage of Abscess
Lumbar Puncture
Nasogastric Tube
Pap Smear and Endocervical Culture
Peripheral Venous Line
Pulmonary Artery Catheter
Thoracentesis
You will be given the opportunity to perform procedures once you have completed the
background work necessary to approach them (described below).
For a subset of the above procedures, the ABIM requires technical proficiency for ABIM
certification (i.e., you must perform these):
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ACLS: you must maintain up-to-date certification throughout residency training
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Venous Blood Draw: this is included with intern orientation (satisfies the
requirement)
Arterial Blood Draw: you must complete 5
Peripheral Venous Line: this is included with intern orientation (satisfies the
requirement)
Pap Smear and Endocervical Culture: you must complete 5 or submit a completed
technical proficiency form (most house staff ask the gynecology attending to sign
this after their ambulatory elective)
Prior to participating in any procedure, we require that you follow the below outlined 4-step
process. Dr. Gordan will verify that you have completed the background work and quiz for
all procedures. Please submit all quizzes to Margie McGlone in the Department of
Medicine. Log all procedures onto New Innovations.
In addition, prior to your first ICU rotation, all house staff must complete the central and
arterial line background material and self-assessment quizzes, even if you are not planning to
perform these procedures. Given that these lines are common in the ICU, and we require all
residents to be familiar with them.
The success of your experience and competency in acquiring these skills depends on your
preparation with the required videos, readings, self-assessment quizzes, simulation, and
hands-on preparation. The required four step process is as follows:
Step 1: Background Preparation
The background reading and quiz for each item is loaded on New Innovations  House
officer Handbook  Procedure Training
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Review relevant literature for each procedure
View the New England Journal of Medicine video for each listed procedure (except
for pulmonary artery catheterization which does not have an associated video)
Review the Mount Auburn Hospital procedure consent form in its entirety
Step 2: Self-Assessment Quiz
After completing the background preparation, you then take the self-assessment quiz and
hand it to Margie McGlone in the Department of Medicine. A tracking system of quiz
completion is maintained and posted in Meditech. If you answer more than 2 questions
incorrectly, you will not receive credit for the quiz and will have to resubmit prior to
participating in the procedure.
Step 3: Procedure Training Session
Prior to placing a central line, you must practice on the simulator, and work with the
ultrasound. An ICU attending must supervise your simulation, and complete a checklist
(found on New Innovations) certifying that you can participate in central line placement.
Step 4: Procedure Participation And Technical Skill Acquisition
Once you have completed steps 1-3, you can then participate in performing the associated
procedure. When you have done at least five of any procedure and you feel that you are able
to perform the procedure independently, you need to ask for a procedure to be supervised
by an attending. If the attending agrees that you can perform the procedure independently,
you will ask them to sign a technical proficiency form (found on New Innovations). Even
when you are technically proficient, you cannot perform a procedure without an attending’s
knowledge. In the ICU, all procedures must be supervised by an attending. Simply
performing 5 of any given procedure does not equate to technical proficiency.
Additional thoughts: You are expected to consider the risks and benefits of each procedure.
Prior to calling an attending or moonlighter for supervision, the following must be
accomplished:
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Successful completion of the above training and verification
Identify the procedure indication
Obtain consent
Recognize risk factors (e.g., full anticoagulation) and address these risks prior to
performing any procedure.
Ensure that the patient’s nurse is available at the procedure time
Perform a timeout with the patient’s nurse
Gather and prepare all procedure materials for yourself and the attending.
Alert the attending physician. At this point, the attending should be able to walk into
the room and supervise the procedure without significant delay. If the attending
determines that you are not prepared to perform the procedure, or if the attending
feels that the procedure should not be performed by a house officer, you will be
asked to step aside for safety
When the procedure is completed, you will document a note in the patient record.
For central lines, you will use the hospital-approved procedure form (found in the
ICU)
You will take care of the procedure samples, and any necessary post-procedure tests
Record the procedure immediately in New Innovations
Addendum: For your records, and to reinforce the above policy, included below is a copy of
the complete ABIM procedure training requirements for Internal Medicine Residents
http://www.abim.org/certification/policies/imss/im.aspx#procedures
Procedures Required for Internal Medicine
Safety is the highest priority when performing any procedure on a patient. ABIM recognizes that there is
variability in the types and numbers of procedures performed by internists in practice. Internists who perform
any procedure must obtain the appropriate training to safely and competently perform that procedure. It is
also expected that the internist be thoroughly evaluated and credentialed as competent in performing a
procedure before he or she can perform a procedure unsupervised.
For Certification in internal medicine, ABIM has identified a limited set of procedures for which it expects all
candidates to be competent with regard to their knowledge and understanding. This includes (1)
demonstration of competence in medical knowledge relevant to procedures through the candidate's ability to
explain indications, contraindications, patient preparation methods, sterile techniques, pain management,
proper techniques for handling specimens and fluids obtained, and test results (2) ability to recognize and
manage complications and (3) ability to clearly explain to a patient all facets of the procedure necessary to
obtain informed consent.
For a subset of procedures, ABIM requires all candidates to demonstrate competence and safe performance
by means of evaluations performed during residency training. The set of procedures and associated
competencies required for each are listed below.
To help residents acquire both knowledge and performance competence, ABIM believes that residents
should be active participants in performing procedures. Active participation is defined as serving as the
primary operator or assisting another primary operator. ABIM encourages program directors to provide each
resident with sufficient opportunity to be observed as an active participant in the performance of required
procedures. In addition, ABIM strongly recommends that procedural training be conducted initially through
simulations. At the end of training, as part of the evaluation required for admission to the Certification
Examination in Internal Medicine, program directors must attest to each resident's knowledge and
competency to perform the procedures. ABIM does not specify a minimum number of procedures to
demonstrate competency; however, to assure adequate knowledge and understanding of the common
procedures in internal medicine, each resident should be an active participant for each procedure five or
more times.
Competency is required in the following procedures:
Perform
Safely and
Competently
Know, Understand and Explain
Indications;
Contraindications;
Recognition &
Management of
Complications;
Pain
Management;
Sterile
Techniques
Requirements
& Knowledge
Specimen Interpretation
to Obtain
Handling of Results
Informed
Consent
Abdominal paracentesis
X
X
X
X
Advanced cardiac life support
X
N/A
N/A
N/A
Arterial line placement
X
N/A
X
X
Arthrocentesis
X
X
X
X
Central venous line placement
X
X
N/A
X
Drawing venous blood
X
X
X
N/A
X
Drawing arterial blood
X
X
X
X
X
Electrocardiogram
X
N/A
X
N/A
Incision and drainage of an
abscess
X
X
X
X
Lumbar puncture
X
X
X
X
Nasogastric intubation
X
X
X
X
Pap smear and endocervical
culture
X
X
X
X
X
Placing a peripheral venous
line
X
N/A
N/A
N/A
X
Pulmonary artery catheter
placement
X
N/A
X
X
Thoracentesis
X
X
X
X
X