Anticipation or avoidance: internal medicine resident experiences performing invasive bedside procedures




Background: Internal Medicine (IM) residents are required to perform bedside procedures for diagnostic and therapeutic purposes. Residents’ experiences with procedures vary widely, for unclear reasons.

Objective: To explore IM residents’ experiences with performing bedside procedures and to identify barriers and facilitators to obtaining sufficient experience.

Methods: Using an inductive, thematic approach, we conducted five individual semi-structured interviews and one focus group with seven IM residents (12 residents in total) during the 2017-2018 academic year at a Canadian tertiary care centre. We used iterative, open-ended questions to elicit residents’ experiences, and barriers and facilitators, to performing bedside procedures. Transcripts were analyzed for themes using Braun and Clarke’s method. 

Results: We identified four themes 1) Patient-specific factors such as body habitus and procedure urgency; 2) Systems factors such as time constraints and accessibility of materials; 3) Faculty factors including availability to supervise, comfort level, and referral preferences, and 4) Resident-specific factors including preparation, prior experiences, and confidence. Some residents expressed procedure-related anxiety and avoidance.

Conclusion: Educational interventions aimed to improve procedural efficiency and ensure availability of supervisors may help facilitate residents to perform procedures, yet may not address procedure-related anxiety. Further study is required to understand better how procedure-averse residents can gain confidence to seek out procedures.


Metrics Loading ...

Author Biographies

Christie Lee, University of Toronto

Assistant Professor, International Fellowship Director Critical Care Medicine University Health Network/Sinai Health System, Education Director Mount Sinai Hospital

Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto

Andrea V Page, University of Toronto

Associate Professor of Medicine, Division of Infectious Diseases, Department of Medicine, Sinai Health System

Wightman-Berris Academy Director, Temerty Faculty of Medicine, University of Toronto  

Shiphra Ginsburg, University of Toronto

Professor of Medicine, Department of Medicine, Faculty of Medicine, University
of Toronto; Scientist, Wilson Centre for Research in Education, University Health Network,
University of Toronto, Toronto, Ontario, Canada; and Canada Research Chair in Health
Professions Education.


Royal College of Physicians and Surgeons of Canada. Objectives of training in the specialty of internal medicine. 2017.

Pugh D, Cavalcanti RB, Halman S, et al. Using the Entrustable professional activities framework in the assessment of procedural skills. J Grad Med Educ. 2017;

Lenchus JD. End of the "see one, do one, teach one" era: The next generation of invasive bedside procedural instruction. J Am Osteopath Assoc. 2010;

Huang GC, McSparron JI, Balk EM, et al. Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches. BMJ Qual Saf. 2016;25(4):281-94.

Wickstrom GC, Kelley DK, Keyserling TC, et al. Confidence of academic general internists and family physicians to teach ambulatory procedures. J Gen Intern Med. 2000;

Promes SB, Chudgar SM, Grochowski COC, et al. Gaps in procedural experience and competency in medical school graduates. Acad Emerg Med. 2009;

Mourad M, Kohlwes J, Maselli J, Auerbach AD. Supervising the supervisors-procedural training and supervision in internal medicine residency. J Gen Intern Med. 2010;

Wigton RS, Alguire P. The declining number and variety of procedures done by general internists. Ann Intern Med. 2007;

Barsuk JH, Cohen ER, Williams M V., , et al. The effect of simulation-based mastery learning on thoracentesis referral patterns. J Hosp Med. 2016;

Hicks CM, Gonzales R, Morton MT, Gibbons R V, Wigton RS, Anderson RJ. Procedural experience and comfort level in internal medicine trainees. J Gen Intern Med. 2000;

Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Residents' procedural experience does not ensure competence: a research synthesis. J Grad Med Educ. 2017;

Gottlieb M, Chan TM, Zaver F, Ellaway R. Confidence-competence alignment and the role of self-confidence in medical education: a conceptual review. Med Educ. 2022;56(1):37-47.

Boots RJ, Egerton W, McKeering H, Winter H. They just don?t get enough! Variable intern experience in bedside procedural skills. Intern Med J. 2009;39(4):222-7.

Lambert SD, Loiselle CG. Combining individual interviews and focus groups to enhance data richness. J Adv Nurs. 2008 Apr 1;62(2):228-37.

LaDonna KA, Artino AR, Balmer DF. Beyond the guise of saturation: rigor and qualitative interview data. J Grad Med Educ. 2021;13(5):607-11.

Low J. A pragmatic definition of the concept of theoretical saturation. Sociol focus. 2019;52(2):131-9.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;

Berger R. Now I see it, now I don't: researcher's position and reflexivity in qualitative research. Qual Res. 2015;15(2):219-34.

Touchie C, Humphrey-Murto S, Varpio L. Teaching and assessing procedural skills: a qualitative study. BMC Med Educ. 2013;

Kay C, Szabo A, Jackson J. Factors influencing resident performance of invasive bedside procedures. J Contemp Med Educ. 2015;3(2):82.

Huang GC, Smith CC, Gordon CE, et al. Beyond the comfort zone: residents assess their comfort performing inpatient medical procedures. Am J Med. 2006;

Lovibond P. Fear and avoidance: an integrated expectancy model. In: Fear and learning: from basic processes to clinical implications. Washington, DC, US: American Psychological Association; 2006. p. 117-32.

Kay C, Wozniak EM, Szabo A, Jackson JL. Examining invasive bedside procedure performance at an academic medical center. South Med J. 2016;

Girdler SJ, Girdler JE, Tarpada SP, Morris MT. Nonmaleficence in medical training: balancing patient care and efficient education. Indian J Med Ethics. 2019;4(2):129-33.

McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Med Educ. 2010.

Aggarwal R. Just-in-time simulation-based training. BMJ Qual Saf. 2017;26(11):866-8.

Frost DW, Quan S, Villalobos D, Morra D, Cavalcanti RB. Design and implementation of a low-cost multimodal procedure cart for an internal medicine ward. Hosp Pract (1995). 2011;

Shelton CL, Mort MM, Smith AF. 'It's learned on the job and it depends who you're with.' An observational qualitative study of how internal jugular cannulation is taught and learned. J Intensive Care Soc. 2018;

Iobst WF, Sherbino J, Cate O Ten, et al. Competency-based medical education in postgraduate medical education. Med Teach. 2010;




How to Cite

Louis AS, Lee C, Page AV, Ginsburg S. Anticipation or avoidance: internal medicine resident experiences performing invasive bedside procedures. Can. Med. Ed. J [Internet]. 2023 Jun. 12 [cited 2023 Dec. 8];14(5):5-13. Available from:



Original Research

Most read articles by the same author(s)