Internists perform a wide range of medical procedures, although practices vary widely among institutions and by specialty. Internists, nurses, or other ancillary health care professionals perform venipuncture for blood testing, arterial puncture for blood gases, endotracheal intubation, and flexible sigmoidoscopy, and insert IV lines, nasogastric (NG) tubes, and urinary catheters. These procedures are not covered here, but require skill and practice to minimize pt discomfort and potential complications. Here, we review more invasive diagnostic and therapeutic procedures performed by internists—thoracentesis, lumbar puncture, and paracentesis. Many additional procedures are performed by specialists and require additional training and credentialing, including the following:

• Allergy: skin testing, rhinoscopy
• Cardiology: stress testing, echocardiograms, coronary catheterization, angioplasty, stent insertion, pacemakers, electrophysiology testing and ablation, implantable defibrillators, cardioversion
• Endocrinology: thyroid biopsy, dynamic hormone testing, bone densitometry
• Gastroenterology: upper and lower endoscopy, esophageal manometry, endoscopic retrograde cholangiopancreatography, stent insertion, endoscopic ultrasound, liver biopsy
• Hematology/oncology: bone marrow biopsy, stem cell transplant, lymph node biopsy, plasmapheresis
• Pulmonary: intubation and ventilator management, bronchoscopy
• Renal: kidney biopsy, dialysis
• Rheumatology: joint aspiration

Increasingly, ultrasound, CT, and MRI are being used to guide invasive procedures, and flexible fiberoptic instruments are extending the reach into the body. For most invasive medical procedures, including those reviewed below, informed consent should be obtained in writing before beginning the procedure.