Measuring Procedural Skills

Surgical residency programs have long required trainees to record their experience with surgical procedures, but internal medicine has only recently required residents to document their experience with medical procedures. In the late 1980s, the American College of Physicians responded to the need for guidelines by appointing committees and beginning a series of national surveys to make recommendations about credentialing standards [1]. During this same period, physicians in several specialty areas, notably gastroenterology and cardiology, developed recommendations about specific procedures. In 1991, the American Board of Internal Medicine required documentation of applicants' training experience in seven core procedures [2].

Although basing credentialing on completion of a minimum number of procedures is a convenient and widely used practice, some problems are associated with this approach. Learners progress at different rates, and the number of procedures done is no guarantee of proficiency. Different credentialing bodies may require different numbers for the same procedure. Once a minimum number is specified, it often becomes the de facto standard for training: In effect, the floor becomes the ceiling. In addition, the requisite number has not been established for most procedures.

In the absence of objective data, such recommendations have relied on expert consensus. The few studies that have assessed the amount of training needed have found that the number of procedures that must be done for the trainee to attain competence in the procedure independently is higher than the minimum levels recommended by expert panels. Hawes and colleagues [3] graded the performance of 25 residents as they learned flexible sigmoidoscopy. The investigators found that …