The Procedure Situation
Your radiology attending tells you to interview a patient and then complete an ultrasound-guided breast biopsy, knowing that it was a large mass and a relatively simple case. You have done this procedure numerous times with this same faculty. So, you go ahead and do it again. No complications. No issues. After you complete the biopsy, you feel immense pride in your capabilities. You show the attending the pictures from the biopsy. The attending congratulates you on a job well done.
Round 2 later that same day…
A different radiology attending wants you to work up another patient and start the subsequent breast biopsy. So, you begin to interview the patient, set up the table and the sterile field, position the patient for the procedure, and place the ultrasound probe on the biopsy site. You begin to numb the overlying skin lidocaine and make a small incision for the biopsy gun. Since the attending still has not shown up, you decide to place the needle right near the lesion, hit the targeted breast nodule, and then subsequently collect multiple samples, placing each one into a little sterile cup on the side to send to pathology. You complete the rest of the procedure without complication. All seems to be well.
You clean up everything and let the patient know that everything went just fine. And, you tell her you are going to consult with the attending before you have her leave. So, you merrily step out of the room and walk down the hallway toward the radiologist’s office to let her know about the patient’s biopsy you completed. You enter the office and state, “I completed the biopsy successfully on patient “XYZ.” The attending stares at you with a stern, angry face and says, “How dare you complete the procedure without consulting with me!!!” You are the talk of the department for the next month!
How To Assess How Much You Can Do
Unfortunately, during radiology residency, you may encounter similar situations such as this one. Different attendings have entirely varying expectations for each radiology resident. Some may expect you to start and finish all procedures. Others may be less likely to allow the resident to have independence, even though he/she may be competent. So what to do? I will go through several guidelines in assessing whether you, as a radiology resident, should complete a given procedure on your own.
Are You Competent In The Procedure?
Competency should be the first issue that you need to address as a radiology resident. Suppose you do not think you have done enough of a technique independently from start to finish. In that case, you certainly have no business doing any procedure or a portion of a procedure alone. The comfort level is also just as important. Even if you have the numbers of biopsies to back you up, if you do not feel comfortable with a procedure, you should also continue to make sure that you have your attending’s guidance at all times until you have that comfort level that you need.
Are We Doing the Procedure For The Right Reasons?
Before performing any procedure, you need to make sure that it has some clinical benefit. Nurses regularly come up to me and ask should we give intravenous contrast. The first thing I ask them is why are we doing the study/CT scan? It may not need contrast in the first place. Likewise, no matter how “minor” a procedure is, you always need to think about it if necessary first!!!
Level of Difficulty of Procedure/ Potential For Complications
Some procedures, such as an upper GI series, have a much lower complication rate than a complex liver embolization. So, it is essential to assess any given procedure’s difficulty and potential complications before deciding whether you should tackle it on your own. Most liver embolizations, stent placements, and angioplasties should probably be under the faculty’s direct supervision unless perhaps you are about to graduate from an IR fellowship in a few days. On the other hand, a paracentesis can undoubtedly be performed from start to finish by a resident.
Some attendings expect the resident to do almost everything and others feel the need to hold the resident’s hand at every step. Much of that decision may be related to the trust between the attending and resident. However, it is imperative to listen to the guidance of your attending before beginning or ending any procedure. Because you are not the physician who signs off on everything, you need to abide by the person’s rules in charge. Always make sure to get the OK from the supervising physician before performing any procedure!
Many patients expect an attending to complete a procedure. Always abide by the wishes of the patient. You never want to be caught in a situation where the patient does not want you to be performing a procedure, and you do so anyway. Not listening to the patient’s request is the realm of lawsuits and legal issues!!!
It’s All About Self-Awareness!
The difficulty of residency can be more about self-assessment/awareness and working with colleagues than about the actual day-to-day mechanics of performing cases. You, as a resident, need always to be aware of your strengths and weaknesses as well as your expectations. My advice: make sure to always know in advance that you are performing a procedure for the right reasons, have the abilities to conduct it, and your attending expects you to complete it. Only then should you consider performing a procedure independently!