How Far Should I Take That Procedure?
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 fairly simple case. You have done this procedure numerous times with this same attending. So, you go ahead and do it again. No complications. No issues. When you are done with procedure, 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 work up a different patient and start the next 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 site of the biopsy. 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 be sent 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!
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 very capable. So what to do? I am going to 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?
This should be the first question that you need to ask as a radiology resident. If you do not think you have done enough of a procedure independently from start to finish, you certainly have no business doing any procedure or a portion of a procedure alone. Comfort level is also just as important. Even if you have the numbers of procedures behind you, 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?
Prior to performing any procedure, interventional or noninterventional, 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 inconsequential a procedure is, you always need to think about if it is necessary first!!!
Level of Difficulty of Procedure/ Potential For Complications
Some procedures such as a fluoroscopic upper GI series have a much lower complication rate than a complex oncological liver embolization. So, it is important to assess the difficulty and potential complications of any given procedure before deciding whether you should tackle it on you own. Most liver embolizations, stent placements, and angioplasties, should probably be under the direct supervision of an attending, unless perhaps you are about to graduate from an interventional fellowship in a few days. On the other hand, a paracentesis, although with the potential for some complications, can certainly 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 extremely important to listen to the guidance of your attending prior to beginning or ending any procedure. Because you are not the physician that signs off on everything, you really need to abide by the rules of the person that is in charge. Always make sure to get the OK from the supervising physician prior to performing any procedure!
Many patients have an expectation for 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. This is the realm of lawsuits and legal issues!!!
The difficulty of residency can be more about self assessment/awareness and working with colleagues than it is about the actual day to day mechanics of performing cases. You as a resident, need to always be aware of your own 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 perform any procedures, and are expected to complete a procedure. Only then should you consider doing a procedure independently.