344

A SURGICAL PROGRAM DIRECTOR'S VIEW* FRANK C. SPENCER, M.D. Professor and Chairman, Department of Surgery George David Stewart Professor of Surgery New York University School of Medicine New York, New York President American College of Surgeons

IMUCH APPRECIATE THE OPPORTUNITY to participate in this important

symposium, for it provides an opportunity for all of us to review about 18 months of experience with the new 405 regulations. Initially, certain key characteristics of surgical residency programs should be emphasized (Table I). Six basic ones are shown on this table. Resident education. It is almost a truism to say that the primary purpose of house staff training is resident education, but this has important economic connotations. A serious abuse currently exists in utilizing house staff to perform a large amount of paramedical work that could be done by salaried ancillary personnel. Continuity of care. This concept is absolutely crucial. It requires an unpredictable commitment of time, depending upon the clinical status of the patient. For more than 20 years, the major weekly surgical conference at Bellevue Hospital has been the Thursday Mortality-Morbidity Conference. A frequent cause of serious problems is ignorance of data, often resulting from lack of cross-communication between different members of the surgical team. Lack of continuity of care is the major cause of this fundamental ignorance of important data. Continuity of care is not only essential to stay fully familiar with the multiple events that may change rapidly with a seriously ill patient, but also merges with the basic ethical theme of commitment to the patient. This strong sense of personal commitment to an ill patient that overrides conflicting considerations is the prime ethic of medicine. Hence, a flexible time schedule is clearly essential. By contrast, a rigid time schedule can quickly develop into "legitimately abandoning the patient." Throughout *Presented as part of a Conference on Regulation of Residency Training: An Appraisal of Recent Changes held by the Associated Medical Schools of New York, the Committee on Medical Education of the New York Academy of Medicine, and the United Hospital Fund of New York November 28, 1990.

Bull. N.Y. Acad. Med.

SURGICAL DIRECTOR'S DIRECTOR'S SURGICAL

VIEW

345

TABLE I. SIX BASIC CHARACTERISTICS OF SURGICAL RESIDENCY PROGRAMS 1) The primary purpose is resident education. 2) Continuity of care is the most important component, overriding other considerations. a) Familiarity with data increases the quality of decisions. b) Embodies the basic medical ethic, commitment to the patient. 3) Supervision at all levels a) Chain of command: graded responsibility and authority b) Attending surgeon ultimately responsible 4) "On-call time" is not "working time," a key consideration. a) "House staff" are staff who "live in the hospital" to care for patients, not to perform hospital chores. b) This concept has greatly enhanced both patient care and resident education. 5) Protect resident from inappropriate duties. These may occupy over 80% of working time at night, and this evolved from increasing technology and tertiary care. 6) Essentials of a residency program are best defined by a Residency Review Committee. The need for more than 20 committees indicates the wide variation in content of different training programs.

the lifetime of a physician recurrent decisions must be made about how to balance effective care of an ill patient and yet avoid excessive fatigue. Supervision. Supervision at all levels of care is a fundamental requirement of surgical residency programs, clearly defined in the "Essentials" published by the Residency Review Committee for Surgery. There must be an appropriate chain of command with graded responsibility and authority; the attending surgeon is ultimately responsible. "On-call time is not working time. " This concept of on-call time is crucial. Residency training is graduate medical education; it is not a salaried job. This is the fundamental reason that hospitals are reimbursed for the expenses of residency training programs by the federal government with Medicare funds. Residency training is not employment; it is graduate education that benefits society. The concept of a house staff was a great advance in both medical education and patient care. As the phrase states, residents live in a hospital. They are not working constantly, like an air controller at an airport, but are periodically observing their patients, alternating with periods of rest when necessary. They are not in the hospital to perform hospital chores. Protecting a resident from inappropriate duties. Failure of this guideline has led to the current problems. This is discussed in detail in subsequent paragraphs. Residency review committees. These residency review committees define the essential characteristics for quality graduate training in a specialty. These Vol. 67, No. 4, July-August 1991

346

F.C. SPENCER

committees were a remarkable American invention in the first half of this century; they are admired and emulated throughout the world. The vast difference among requirements for training different specialties has gradually led to the creation of more than 20 separate residency review committees, one for each specialty. A key principle is that decisions for a specialty are made by the residency review committee for that specialty, not by anyone else. The current organizational structure has the Accreditation Council for Graduate Medical Education (ACGME) coordinating the overall function of different residency review committees, but a specific specialty decision is made only by the committee for that specialty. ORIGIN OF CURRENT PROBLEMS The evolution of the current problems is listed in Table II. With the remarkable technical advances in medicine, critically ill patients may now be effectively treated who simply did not survive in past years. Hence, hospitals are increasingly crowded with critically ill patients requiring a large number of diagnostic studies and a corresponding increase in "paper work." These events have naturally evolved from the remarkable progress in medicine over the past 50 years. They have resulted, however, in a large increase in the work performed by a house officer; in some published studies more than 80% of the time of junior house staff was consumed with performing such ancillary work. This large amount of ancillary work is not only fatiguing but actually harms the patient because the house officer is often away from the patient and is no longer familiar with essential data. Continuity of care has been seriously impaired. This is a key concept, for the solution is principally economic, finding sufficient funds to employ paramedical personnel to do the large amount of ancillary work. The best solution is inclusion in the hospital budget of salaries for such personnel. Unless such personnel are budgeted, by default the work that such personnel would have done is usually performed by the house staff. TABLE II. CURRENT PROBLEMS 1) Arise from 3 factors: a) Increasing complexity of illness b) Increased technology c) Increase in "paper-work" 2) Result in increase in work load, fatigue, and taking house officer away from patient 3) Solutions are principally economic: paramedical staff to do nonclinical work Bull. N.Y. Acad. Med.

SURGICAL DIRECTOR'S DIRECTOR'S VIEW VIEW

SURGICAL

347

I strongly applaud Dr. Axelrod's leadership in providing the funds to employ such personnel, for he clearly recognized that the changes would be expensive. He initiated a careful analysis of the economic requirements by a consultant team from Harvard University in Boston. The decision was made that about two hundred million dollars were needed annually effectively to institute appropriate changes throughout New York State. ACCOMPLISHMENTS AT NYU MEDICAL CENTER

Basic accomplishments at NYU are shown in Table III. With monies supplied by the regulations, additional surgical faculty members have been employed to be in the operating room daily, and to conduct daily attending rounds. Finding qualified staff has been difficult. We have been fortunate to find three surgeons who have recently finished their training and are available for one to two years before entering additional specialty training. This additional staff have been a valuable supplement to the participation by the regular surgical faculty. A separate important point is that on-call time is not working time, an exception granted to the surgical specialties. This has been absolutely crucial. What the resident does when he is "on-call" is his decision. He may wish to stay with his patients, sleep, or go to the library, part of his graduate medical education. Four periodic time surveys have been done over the past year and a half, coordinated by Dr. Thomas Gouge of our faculty. A lot of progress has been made though the problems are certainly not completely solved. The primary difficulty has been with the recruitment of qualified paramedical staff. The TABLE III. ACCOMPLISHMENTS: NYU MEDICAL CENTER (BELLEVUE AND TISCH HOSPITALS) 1) Attending always in operating room; daily attending rounds a) 3 new faculty employed full-time at Bellevue b) Continuing participation by regular faculty 2) House staff hours: a) 8 and 16 hour blocks-80 hour week b) 1 day off per week; 1 week-end off per month 3) Four periodic time surveys 4) Paramedical recruitment: a) Bellevue Hospital: 2 data managers Goal: 5 b) Tisch Hospital: 10 nurse clinicians Goal: 4 physician assistants Vol. 67, No. 4, July-August 1991

348

348

SPENCER---SPENCER F.C. F.C.~~~~~~~

ideal type of staff person has been termed a "data manager," combining the abilities of both a nurse and an administrative assistant familiar with the paperwork involved, different regulations, teaching, and other requirements. Two are currently employed at Bellevue. Ten could clearly be used, but such unique staff are hard to find. The house staff have found them invaluable. In Tisch Hospital a total of 10 nurse clinicians have been employed. They have been a valuable asset to both patient care and house staff teaching. Physician assistants, however, are difficult to find and very expensive. Accomplishments in ancillary hospital care staffing are shown in Table IV. The basic three are teams for intravenous therapy, transport, and phlebotomy. As illustrated, the problem is partly solved but not completely, partly from difficulties in recruiting, partly from lack of funds. BASIC PROBLEMS

The most difficult problems are tabulated in Table V. In surgery the number of house staff employed are sharply defined by the Residency Review Committee for Surgery. For example, we have seven third year residents; we cannot have eight. The availability of nurse clinicians is limited by the nursing shortage. Physician assistants are even more scarce. Currently we do not have a single one employed at Bellevue or Tisch Hospitals, despite a long period of searching. This is partly due to the lack of available funds. Current salary requirements are nearly $70,000 a year. TABLE IV. ACCOMPLISHMENTS: ANCILLARY HOSPITAL CARE Tisch Bellevue (% coverage) (% coverage) 50 0 IV Teams 100 50 Transport teams 80 100 Phlebotomy teams

TABLE V. PROBLEMS

1) Recruitment: a) Can't increase surgical house staff b) Nurse clinicians limited by nursing shortage c) Physician assistants not available, and expensive ($60,000-75,000 per year) d) Data managers scarce 2) Cardiac and trauma services: intensity of illness and frequency of emergency problems Bull. N.Y. Acad. Med.

SURGICAL DIRECTOR'S DIRECTOR'S VIEW VIEW

SURGICAL

349

The most difficult problems have been on the cardiac and trauma services because of the intensity of illness and frequency of emergency problems. A house officer away for 12 hours from a critically ill patient may quickly lose track of basic data and become an observer, not a participant. Nurse clinicians have been an invaluable resource in partly solving this problem, but it is not completely solved. SUMMARY

In summary, the two major facts that have emerged from a year and a half of experience with 405 regulations are shown in Table VI. The increased staffing with the monies made available has greatly enhanced patient care and decreased the resident workload. I want to again compliment Dr. Axelrod for the foresight to make these funds available despite adverse criticism. He clearly understood that the changes needed were quite expensive because the problems are primarily economic in origin. What type of paramedical personnel are needed is yet uncertain. I mentioned briefly earlier that the "data manager" combines an excellent administrative secretary and a nurse. The simple institution of electronic data processing can, surprisingly enough, worsen the problem rather than help. For example, institution of a beeper system, making it possible for anyone to "beep" a house officer at any time, resulted in an astonishing increase in "beeper frequency," a house officer receiving seven or eight such messages per hour, 24 hours a day, rather than communicating by other methods. Such "instant" communication can become a serious hazard rather than a help. Second, as repeatedly mentioned, the on-call time concept is crucial, permitting flexibility that avoids fatigue and yet maintains continuity of care. Otherwise there is a real danger with a rigid time-on/time-off schedule. RECOMMENDATIONS

Four recommendations from current experiences are shown in Table VII. As repeatedly emphasized, there is a serious shortage of both physician assistants and nurse clinicians. A valuable contribution from this conference would be a strong recommendation that more such programs will be developed for training such important personnel. Extension of the on-call concept, so crucial with surgical patients, to all medical specialties is strongly recommended. Continued fiscal support is obviously crucial. Attempting to restrict hours without provision of monies for the personnel needed not only harms patient care but will impair resident education with little benefit to anyone. Vol. 67, No. 4, July-August 1991

350

F.C. SPENCER

TABLE VI. KEY FEATURES 1) Increased staffing with monies available has greatly enhanced patient care and decreased resident workload. 2) "On-call time is not working time:" a key feature

1)

2) 3) 4)

TABLE VII. RECOMMENDATIONS Increase training programs for ancillary staff: physicians assistants etc. Extend on-call time concept to all house staff Continued fiscal support is crucial to the continuing success of these programs. Flexibility in hours: focus on paramedical staff, not hours (Scandinavian and Australian examples)

Finally, flexibility in the hour requirements is clearly crucial. In solving the current problems over a period of time, a strong focus should be on developing what kinds of paramedical personnel are needed and finding the funds for such staff. Obsessive focus on the number of hours worked a week not only does not solve the basic problem but can do serious harm. This has already occurred in some parts of the world, especially Scandinavia and Australia. Through a variety of events with labor legislation and union contracts, the number of hours worked a week have gradually decreased to where it is now a felony for a house officer to work more than 40 hours a week, regardless of the severity of the illness of his patient. The time decisions are no longer under the control of the medical profession. Hence, in reaching our goal of both effective patient care and effective medical education, flexibility is required with a continuing reassessment, as provided by this symposium, on both our progress and our remaining problems.

Bull. N.Y. Acad. Med.

A surgical program. Director's view.

In summary, the two major facts that have emerged from a year and a half of experience with 405 regulations are shown in Table VI. The increased staff...
636KB Sizes 0 Downloads 0 Views