Medical service insurance and surgical training

The American VOLUME

PRESIDENTIAL

108

Journal

NOVEMBER

1964

of Surgery NUMBER

ADDRESS

Medical

Service Insurance and

Surgical -1 raining ’ ’ I

at the Sixteenth

Annual Meeting

*

difficult to maintain due to inadequate beds and patients for training at senior level. The growth of hospitalization and medical service insurance has contributed to this deficiency. Before getting involved in this subject, it seems that a little frankness on the basic reason for having a training program in a nonuniversity private hospital is in order. Several reasons can be given: the standards of patient care will be raised ; records will be improved ; the attending staff will be stimulated and will benefit from having teaching responsibilities. All of these things are true, but the basic reason for having a training program is to attract house officers who will provide service to the hospital and attending staff in the care of the patient load. To claim any other motive would be hypocrisy. The “training” part of the program is the means to an end-not an end in itself. In this regard the nonuniversity private hospital differs to a degree from the university hospital which has a dual responsibility, but which still is not without need of trainees for service functions. There is nothing inherently wrong in using trainees for service, but it is wrong to use them without adequate material and educational compensation. Only in recent years has the demand for interns and residents been so great that something simulating reasonable compensation has become the general practice. Only in recent years have training programs had to provide an acceptable organization of their “training” function in order to retain approval and thus remain in competition for trainees. How great is the need for hospital training

been known that most presidential addresses will either extol the past, view the present with alarm, or crusade for the future. There is another rather rare category that might be called the “intellectual debut” in which the honored speaker seizes the opportunity and the captive audience to display some intellectual gem he has been unsuspected of possessing. Unfortunately, I am not blessed with an intellectual gem so the debut is ruled out. Extolling the past is a harmless procedure, but the research required for accuracy is a deterring factor. Since I am not a professor and cannot assign a resident to research my address, I must leave extolling the past to others, though I am much in favor of it. Viewing the present with alarm comes fairly easy for me and crusading not too difficult, although I must admit my crusades have not been overwhelmingly successful. I am one of those people who believes the world will probably never again be as it was twenty years ago and even unlikely to remain as it is today. This philosophy is enough to brand me as a liberal by some of my friends, although I still am permitted to contribute to the Republican party. My address is actually a mild crusade for the future combined with a slight dissatisfaction with the current state of affairs. In selecting my subject I was also aware that it might be of particular interest to members of the Southwestern Surgical Congress whose membership includes many surgeons who work chiefly at nonuniversity connected hospitals. Approved residency training programs in such hospitals are T HAS LONG

* Presented

I’IVE

of the Southwestern April 27-30, 1964.

597

American

Surgical

Congress,

San Antonio,

Journal

of Surgery,

Volume

108,

Texas,

i-v-ovembru 1964

Presidential services in medicine and surgery? To be specific, how much actual need is there for training services in general surgery? Are we training enough general surgeons, too many or too few? No one can answer this question exactly. However, it is fairly obvious that there are more hospitals that would like to have house officers to train-and, incidently, to give service-than there are candidates to apply for the training. The number of hospitals desiring training programs is not determined by the number of young physicians seeking training, but by the desire of hospitals for trainees to perform a service function. This distortion of the law of supply and demand has resulted in a sizeable group of hospitals with training programs, or a desire for training programs, for which there is really no demand and which in many instances are kept solvent by the use of foreign graduates. Perhaps it is time to concentrate more on quality of training services and to discourage many of the fringe programs that are applying for approval. This is a problem for the Conference Committee on Graduate Training in Surgery and applies only indirectly to the subject of my address. Any training service worthy of the approval which will place it on the market for trainees has a responsibility to be as good as possible, not just good enough to win borderline approval. There are many factors that will determine the quality of a training service including: the interest and participation of the attending staff; the organization and quality of conferences, ward rounds, etc.; the types of patients and diversity of disease admitted to the institution ; and, the number of beds available for the “service” patients which form the backbone of a graduated residency system. It is with this latter factor, the “service” patient, that I am chiefly concerned and subsequent remarks will be confined to this area. For the past fifteen years it has been increasingly evident that insurance for hospitalization and medical care is responsible for a decrease in the “service” category patient. It is true that some programs have been unaffected, such as those of the Military Hospitals, Veterans Administration and many municipal hospitals. The programs that have felt the change most include those of many of the large hospitals affiliated with medical schools as well as the nonaffiliated private hospitals. It is ironic that a socioeconomic change as highly desirable as

Address the widespread use of health insurance should present us with such a dilemma. In the field of surgical training it is important that adjustments to this socioeconomic change be made if we are to continue to train surgeons in the manner that time has proved to be the most effective, i.e., through a graduated system leading to a senior position of responsibility for patients, with the consultation and supervision of a responsible attending staff. Time will not allow me to defend the claim that this-the Halstedian system of surgical training-is so much the superior of other methods of training that we should accept no alternative. However, this is the assumption on which is based the argument for the maintenance of ward beds and service patients or their equivalent. Whereas for many years there was no problem in filling service beds from the indigent or semi-indigent population, this is no longer true. In most areas, and particularly in those areas supporting a population large enough to require a hospital which might support a training program, the indigent population has decreased in number or has become insured to such an extent that they have passed into the category of private patients. I do not wish to imply that private patients are of no value in a training program because the opposite is true. However, especially in surgery, it is mandatory that patients be available for the resident to complete his training by independent operating and assumption of responsibility, again under careful attending staff supervision. How can we continue to provide acceptable senior training under the impact of today’s socioeconomic advances, remembering that voluntary health insurance is going to continue to increase and that those segments of the population not covered by voluntary insurance will, in all probability, eventually be covered by some type of state or federal insurance? First, I would like to comment briefly on how I think it should not be done. Although preceptorship training played an important role in the past and is still used to a very limited extent, we should not try to solve present difficulties by reverting to preceptorships with their many undesirable features. This would be retrogression. Neither should we resort to extending the role of the private patient in surgical training which cannot be done without some degree of subterfuge and duplicity, characteristics undesirable in the training program of young men. Further-

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Presidential

Address the maintenance of adequate training services. In my opinion the various methods of solving this problem up to the present time are inadequate. They are inadequate not because they may not have been to a degree successful but because they are devious, tenuous and evasive. They are devious because adjustments are made to altered conditions by superficial changes that are not changes at all, such as the change in attire and title of a senior resident. They are tenuous because the solutions are so contrived, so stop-gap. They are evasive because they really do not take into account the future which almost certainly will see the problems of today greatly multiplied. What, then, would be the ingredients of an adequate solution? The chief one would be recognition by the medical profession as a whole that training of younger men must proceed and that adjustments in the admission policies of insured patients to training services must be made. Another would be the recognition of this same fact by the insurance companies and by Blue Shield in particular. This recognition should extend to the point of permitting payment of the scheduled fee for surgery done by a resident in training. Of course, Blue Shield policies are a direct reflection of the desires of the medical profession. At the present time these policies reflect the prejudices of the practicing segment of the profession against the “competition” that would result from insured patients being cared for on training services. In the past fifteen years there has been no real evidence that these prejudices and fears are justified. Many institutions have managed to keep their training services solvent by using insured patients through one device or another. Most of the commercial carriers have presented no problem since their clients have free choice and can be treated on a training service if they so desire. However, Blue Shield restricts its payments to surgeons in practice and withholds the surgical fee if the patient is cared for by a resident in training regardless of the degree of maturity of the resident and regardless of the quality of the training service and the quality of its supervision by an attending staff. This situation has led to inconsistencies that have been remarked upon too frequently and are too obvious to require comment at this time. In any philosophic discussion of this dilemma it is admitted that to plead the cause of the training services it must be assumed that the

more, the patient, who fits so intimately into our problem, deserves to know and to understand completely who is responsible for his care. These two expedients, preceptorships and the taking advantage of private patients to accomplish our aim, are the chief danger. They are dangerous because they are not good and because they are so expedient. Next, let us consider some of the methods that are presently being used to maintain the supply of clinical material to training service beds. One of the most effective is to license the senior trainee and elevate him to staff status, thus making him eligible to care for patients with medical service insurance and to collect the insurance fee. This is perfectly justifiable in view of the background training in surgery of this individual and the fact that he would be entirely free to take care of the same patients if he were in practice instead of training. The method is perfectly open and above board and may become the most satisfactory solution to the problem. Patients turned over to such an individual are those without a physician who present themselves to the hospital for care. The attending staff supervision would be the same as for any senior resident. Another method is for patients with minimal insurance coverage to be turned over to a resident by an attending surgeon who follows the patient’s hospital course closely enough to justify his signing the insurance form as the responsible surgeon. This method has the disadvantage that there is a split responsibility which is undesirable and there is opportunity for confusion of the patient as to just who is his surgeon. It should be realized that the number of supplemental insured patients necessary on any one service is not large. Most training services have a basic minimum of subsidized beds and will still have a supply of indigent uninsured patients. The quandary results from the fact that so many services will not have enough patients unless the number is supplemented by patients who have insurance coverage. It should also be realized that good training services will develop a reputation that will attract unattached patients who will be willing to be under the care of whomever is assigned. Therefore, in order to accomplish the end of having adequate clinical material for training purposes, it is only necessary that we not let the matter of medical service insurance become a complete obstacle to 599

Presidential service is well organized and well supervised. A service that professes to train surgeons but which does so without benefit of the best mature supervision possible is no training service at all. The trainee might as well be turned loose on the public to develop his skill through his own experience. A training service and those in charge of it have two responsibilities, one to the trainee and the other to the patients admitted to the service. It must also be assumed that the patient understands the nature of the service and the freedom of choice that is open to him. Many patients with minimal insurance and of limited income are quite willing to accept care on a training service, particularly if the service has built a reputation of providing good care. With these two basic assumptions met, it becomes easy to argue that the patient should be admitted to a training service if he so desires and that the insurance fee for professional service should be paid. A question always raised concerns the disposal of the money from such sources. Experience of the past several years has led to the general feeling that this money should not go to the support of hospitalization costs, that it should be under the control of the professional staff and should be used for a variety of purposes aimed at supporting the training aim of the service. This is a matter for local decision and control but acceptable uses of these funds would seem to include remuneration of the responsible attending staff, supplementing salaries of trainees, for library, guest speakers, travel, research, et cetera. The income from such sources should not be great. As a matter of fact, it has been rather insignificant in those hospitals where a plan of using insured patients has been in operation. The basic need of the training service is clinical material not income. If the clinical material from other sources is adequate, the use of patients with insurance coverage is unnecessary. I have presented this background discussion

Address for what purpose? After all, surgeons are being trained and the profession as a whole is much more tolerant of the “competition” of training services than it was ten or fifteen years ago. My claim is that tolerance is not enough and that makeshift solutions to maintaining adequate clinical material for training are undesirable and should be unnecessary. The medical profession should adopt policies that will actively support the training of surgeons and practices that are the least bit devious and misleading to the patient should be discarded. My proposal, therefore, is that those training programs in surgery that are of such quality as to meet the approval of the Conference Committee on Graduate Training be permitted openly to admit insured patients as necessary to provide adequate clinical material to meet the aims of the programs and that the insurance fees from these patients be collectable. This plan will require the approval and support of the medical profession to the extent that the policies of Blue Shield are changed. It will place an increased moral responsibility on those in charge of training services as well as on those with the authority to approve or disapprove them. Changes in the direction indicated by this proposal should have a good effect on the training of surgeons by increasing clinical opportunities, by removing any need for subterfuge and by demonstrating that the physician is indeed willing to take steps necessary to assure the training of his successor. Although this proposal is made with surgical training in mind, it has important implications to other specialties and to all undergraduate medical teaching. Such a plan could be given a trial in any area large enough to support a hospital or hospitals in which approved training programs in surgery are in effect. EUGENE M. BRICKER, M.D. St. Louis, Missouri

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