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Resident continuity of care experience: a casualty of ambulatory surgery and current patient admission practices
The American Journal of Surgery 193 (2007) 243–247
Association for Surgical Education
Resident continuity of care experience: a casualty of ambulatory surgery and current patient admission practices Adrienne L. Melck, M.D., Eric M. Weber, M.D., F.R.C.S.(C.), Ravi S. Sidhu, M.D., M.Ed., F.R.C.S.(C.)* Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, C318-1-91 Burrard Street, Vancouver, British Columbia, Canada V6Z 1Y6 Manuscript received March 31, 2006; revised manuscript November 1, 2006
Abstract Background: The purpose of this study was to define and assess the impact of changes in health care delivery on the current continuity of care experience of surgical residents. Methods: This 4-week, prospective cohort study included all patients who underwent a general surgical procedure at the University of British Columbia if a resident was present at the operation. The residents’ perioperative involvement in each patient’s care was recorded. Results: Of the 592 eligible cases, 74.8% were elective same-day admissions, 5.4% elective previously admitted patients, and 19.8% emergencies. The overall rate of assessment was 27% preoperatively, 84% postoperatively on the ward, and ⬍1% in oupatient clinic postdischarge. Elective cases were associated with significantly lower rates of preoperative assessment compared with emergency cases (15% versus 74%, P ⬍ .001). Conclusions: Changes in health care delivery have outpaced changes in the structure of surgical education, resulting in suboptimal continuity of care experiences for trainees. Residency programs must adapt their curricula to include adequate ambulatory experience. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Continuity of care; General surgery; Postgraduate training; Residency
In the current paradigm of surgical training, residents acquire progressively increased responsibility as they advance through their residency program under the guidance and supervision of attending surgeons. Despite dramatic changes to the delivery of health care over the last few decades, the fundamental structure of surgical training programs has undergone little change since Dr William Halsted introduced North America to the concept of graded responsibility within residency training in the early 1900s [1]. More and more, elective surgical patients are admitted the morning of their procedure and, in many instances, discharged the same day. Thus, preoperative consultation and detection of postoperative complications increasingly occurs in ambulatory clinics, a setting that residents often do not access. The inclusion of continuity of care in the training requirements outlined by various surgical accreditation boards * Corresponding author. Tel.: ⫹1-604-806-8698; fax: ⫹1-604-8068666. E-mail address: [email protected]
highlights the central importance of this concept. The American Board of Surgery requires surgical trainees to have “actively participated in making or confirming the diagnosis, selecting the appropriate operative plan, and administering preoperative and post-operative care [2].” Similarly, the Royal College of Physicians and Surgeons of Canada requires that its trainees “have recognition of responsibility for the overall care of the surgical patient [3].” A welltrained surgeon has not only mastered the technical aspects of surgery but meticulously prepares his/her patient for the operating room and astutely detects and manages all complications related to the procedure performed. This art can only be imparted to surgical trainees if they have the opportunity to realize the impact of their preoperative and intraoperative decisions on postoperative outcomes. Furthermore, continuity of care has been shown to lead to more knowledgeable patients, better patient satisfaction, and improved compliance with selected treatment regimens [4]. The numerous recent advances in medical technology that have added to the diagnostic and therapeutic tools
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available to today’s general surgeon further emphasizes the need for surgical training paradigms to keep pace. With the advent of interventional radiology, minimally invasive surgery, and newer endoscopic techniques, the options for our surgical patients have multiplied, making the choice of a treatment plan more complex. Surgical trainees are often excluded from this decision-making process by virtue of their absence from preoperative and postoperative outpatient clinics. There have been several reports implicating work-hour restrictions in poor continuity of care among surgical trainees, which have mainly been retrospective [5–7]. One prospective study evaluated continuity of care in a Canadian general surgery training program, including an analysis of the effect of an emergency procedure [8]. However, this study did not look at rates of outpatient follow-up or the effect of hospital setting (academic versus community) on continuity of care experiences. Given that there exists a void in the published continuity of care experiences in the current era of work-hour restrictions, the aim of this study was, first, to prospectively ascertain the current experience of general surgery residents within a Canadian general surgery training program with regard to the continuity of care they are able to provide for patients and, second, to delineate the various resident, patient, and hospital factors influencing this experience. In particular, we examine how issues unique to the way health care is currently delivered (eg. same-day admission for elective surgery and ambulatory surgery) impact on the continuity of care experience. Methods This study was conducted within the University of British Columbia (UBC) 6-year general surgery training program, which is accredited by the Royal College of Physicians and Surgeons of Canada. Although the majority of clinical rotations take place at the university’s 3 main teaching hospitals in Vancouver, residents are required to do at least 2 community general surgery rotations in various regions of the province of British Columbia. Thus, portions of this study were conducted at some of these community teaching sites. At the UBC’s 3 main teaching hospitals, there are a total of 20 attending general surgeons and 4 pediatric general surgeons. The general surgery services are entirely run by residents and fellows in the traditional hierarchical fashion, as defined by Halsted. There are no physician extenders on the service. The house staff members are responsible for in-hospital patient care under the supervision of attending surgeons and are required to attend all scheduled operative procedures, as well as emergency procedures when on call. At 2 of the main training sites (St. Paul’s Hospital and British Columbia Children’s Hospital), the inpatient wards, operating rooms, and physicians’ clinics are all contained within the same facility, and on-service residents are required to attend at least 2 outpatient clinic half days during their rotation. At the other main training site (Vancouver General Hospital), the physicians’ clinics are located in outside, private offices, and on-service residents are not mandated to attend these clinics.
At each of the community teaching sites, there are anywhere from 3 to 6 general surgeons on staff. In general, residents rotating through these sites are responsible for the care of patients in whose operations they were involved, as well as patients seen in consultation through the emergency department or the medical wards. There is no requirement to attend outpatient clinics at these sites. The study was a prospective cohort investigation conducted over an 8-month period from May 1 to December 31, 2005. All general surgery residents on either a general surgery or pediatric general surgery rotation during the study period were asked to participate. Each potential participant was given a detailed description of the study design in written form, with opportunities to ask questions of the principal investigator. Once a resident gave his/her consent to participate in the study, each for a 4-week period, all patients who underwent a general surgical procedure at the institution in which the resident was stationed were included in the study if the resident was present at the time of operation. All participants were oriented to the study during a 20-minute session. The definitions of all terms used were clarified, and questions were answered. Residents completed a questionnaire for each patient encounter during this period (Appendix 1). The information recorded included the following: 1. Procedure-related demographic data: date, hospital, procedure, surgeon, and nature of procedure (emergent operation versus elective and same-day admission versus elective, previously admitted) 2. Resident demographic data: postgraduate (PGY) level and operative role (primary operator versus teaching assistant versus first assistant versus second assistant) 3. Resident continuity of care data A. Preoperative: participation in preoperative assessment (either in the emergency room, preoperative assessment room on the day of surgery, or outpatient clinic) and in the decision to operate B. Intraoperative: involvement in any intraoperative decisions C. Postoperative: participation in daily ward assessment, discharge planning, and postoperative outpatient clinic assessment All data obtained were collected and then transferred into a database by a single investigator (ALM). A review of the completed data-acquisition forms at the end of the study determined the continuity of care. Any missing data identified after reviewing the data-acquisition forms were completed through interviews with the appropriate residents. The chi-square test was used to analyze the data for statistical significance. The methodology of this study was deemed valid based on a previously published study by 1 of the authors, which determined that self-reported data were accurate in the resident population [8]. In addition, a pilot study was conducted several months before the present study at 2 of the UBC’s main teaching hospitals, using residents on the vascular surgery service [9]. The purpose of the pilot study was to ensure the feasibility of our planned data-collection meth-
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considered third and fourth in line, respectively, for operative participation. Teaching assistant is when a senior resident supervises/guides a procedure being performed by a more junior trainee.)
Fig. 1. Number of cases included in this study by type of procedure. HPB ⫽ hepatopancreaticobiliary; SP ⫽ spleen; ST ⫽ stomach; SB ⫽ small bowel; C ⫽ colon; R ⫽ rectum; A ⫽ anus; TH ⫽ thyroid; PT ⫽ parathyroid; AD ⫽ adrenal; BR ⫽ breast; VH ⫽ ventral hernia; IH ⫽ inguinal hernia; MISC ⫽ miscellaneous including trauma, skin/muscle/nerve biopsies, tracheostomy, salivary gland excision, vasectomy, hydrocelectomy, circumcision, and lysis of adhesions.
ods. This served as further validation for the methods used in this study protocol. In British Columbia, residents are restricted to 1 in 4 in-house calls and 1 in 3 home calls. The frequency of calls varies at the community teaching sites. These conditions remained constant during this study. This study was conducted with approval from the Behavioral Research Ethics Board of the UBC. Results Patients and residents A total of 596 surgical procedures were included in this study; because of to in-hospital mortality, 4 cases were excluded from the statistical analysis. Of the remaining 592 cases, 19.8% were emergencies, 74.8% were elective cases admitted on the same day of surgery, and the remaining 5.4% were elective cases admitted before the day of surgery. The resident cohort included 5 junior residents (PGY I-II) and 7 senior residents (PGY III-VI), for a total of 12 general surgery residents. During the time period of this study, there were 20 eligible residents (residents on an operative general surgery service) out of the 35 total surgical residents. As participation is voluntary, 8 eligible residents did not participate. During the study period, these residents were stationed at 9 different hospitals including the University of British Columbia’s 3 main teaching hospitals (Vancouver General Hospital, St. Paul’s Hospital, and British Columbia Children’s Hospital) as well as 6 community hospitals, including facilities in Greater Vancouver, Vancouver Island, and southeastern British Columbia. The majority of data were prospectively collected with incomplete information collected by follow-up resident interviews. The types of general surgery procedures performed are outlined in Figure 1. At the time of surgery, the resident’s role in the operation was recorded as primary operator 60.3% of the time, first assistant 29.9% of the time, second assistant 9.1% of the time, and third assistant or teaching assistant 0.7% of the time. (Second assistant and third assistant refers to being scrubbed in on a case but being
Continuity of care experience Of the 592 eligible patients, 27% were assessed by the resident preoperatively, whereas 84% were assessed daily on the ward by the resident postoperatively in the 242 cases in which the patient was admitted to hospital. Complete in-hospital continuity of care (assessing the same patient preoperatively and postoperatively) was achieved in 29% of the cases. Patient follow-up in outpatient clinics occurred in only 5 patients (1%). The residents were involved in the decision to operate in 13% of cases, and they were involved in intraoperative decision making 74% of the time. Type of admission Compared with elective cases, the rate of preoperative assessment, involvement in the decision to operate, and complete continuity of care were all significantly higher for emergency cases (74% versus 15%, P ⬍ .001; 60% versus 2%, P ⬍ .001; and 63% versus 14%, P ⬍ .001, respectively) (Fig. 2). For elective cases admitted before the day of surgery compared with elective cases admitted the same day, there were also significantly higher rates of preoperative assessment (44% versus 13%, P ⬍ .001), involvement in the decision to operate (13% versus 1%, P ⬍ .001), and complete continuity of care (45% versus 9%, P ⬍ .001) (Fig. 3). Junior versus senior residents Junior residents (PGY I-II) were involved in 31.8% of the cases, and the remaining 68.2% were reported by senior residents. As anticipated, senior residents had a significantly higher rate of intraoperative decision making compared with juniors (92% versus 36%, P ⬍ .001). Training site There were significantly higher rates of preoperative assessment (35% versus 22%, P ⫽ .001) and involvement in the decision to operate (23% versus 8%, P ⬍ .001) in the main teaching hospitals compared with the community hospitals. In contrast, rates of intraoperative decision making (85% versus 52%, P ⬍ .001) and postoperative assessment (92% versus 73%, P ⬍ .001) were higher in the community
Fig. 2. Percent of cases associated with resident continuity of care for each phase of patient contact for emergency versus elective cases. *P ⬍ .05.
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Fig. 3. Percent of cases associated with resident continuity of care for each phase of patient contact for elective previously admitted patients versus elective same-day admission patients. *P ⬍ .05.
setting (Fig. 4). There was no significant difference in complete continuity of care (26% community versus 34% academic, P ⫽ .1). Demographic data Patient age, sex, and the hospital where the procedure was performed were not associated with significant differences in continuity of care rates. Comments The health care system has changed dramatically over the last several decades, which has affected current surgical practice in unique ways. Furthermore, in 2003, the Accreditation Council for Graduate Medical Education issued regulations restricting residents’ work hours in the United States [10], with similar restrictions enforced in Australia and throughout Europe. These work hour restrictions have been shown to negatively impact resident continuity of care experiences in general surgery.5-7 In a 2-year retrospective review, Feanny et al. compared senior general surgery residents trained before and after the implementation of work hour restrictions by the ACGME. They found that with the advent of the restrictions, operative continuity of care has decreased from 60% to 26% of cases.6 However, studies examining the impact of changes in healthcare delivery on continuity of care have been limited. This prospective study defines the current continuity of care experience of general surgery residents within a Canadian residency program, and outlines a variety of factors that affect this experience. Our study revealed that the rate of complete in-hospital continuity of care, which is defined as participation in both the preoperative and in-hospital postoperative assessment of a surgical patient by the same resident, was 29%, with an especially low rate of postdischarge assessment (1%). This low complete in-hospital continuity of care was mainly influenced by a low preoperative assessment rate (27%), which reflects the large proportion of patients that arrive in hospital on the morning of their surgery. All 5 instances wherein a patient was seen in an outpatient clinic postdischarge occurred on surgical rotations in which residents are mandated to attend outpatient clinics as part of the rotation. Although speculative, the poor rate of attendance at outpatient clinics may be explained by residents’ daily responsibility to manage inpatient wards, do emergency consultations and attend the operating room, the lack of proximity to
these clinics, and resident preference for time in the operating room over time spent in clinic. Several authors have reported similar findings. Anderson et al [11] undertook a retrospective review of 21 general surgery residents who collectively participated in 114 surgical procedures over a 2-year period at 3 hospitals. The rate of preoperative assessment in this study was 70.2%; however, in over 25% of those cases, the only evidence that the resident was involved preoperatively was the fact that they had written preoperative orders. The operating resident provided some component of postoperative in-hospital care and postdischarge follow-up care in 86.8% and 37.7% of cases, respectively. The rate of postdischarge follow-up was significantly higher than in the present study; however, the authors state that their residency program is specifically structured to allow residents the opportunity to examine their patients at the first postdischarge visit. The overall rate of complete continuity of care in Anderson’s study was 23.7%. Compared with the pilot study [9], the general surgery services in this study had poor overall continuity of care rates (57% versus 29%). This difference requires further study; however, it may be caused by the fact that the general surgery services tend to have more patients relative to the number of house staff. Hence, residents may not have as much time for clinic attendance or immediate preoperative patient assessment. Various strategies have been used to improve continuity of care. Chung and colleagues [12] investigated the effect of 1-on-1 mentor-resident rotations on continuity of care and found that there was a significantly greater percentage of continuity of care achieved when compared with typical in-hospital surgical rotations (98% versus 42%). A Michigan group established a resident-run ambulatory clinic to improve surgical resident continuity of care, which was defined as involvement by the same resident in each of 6 phases of the same patient’s care: confirmation of diagnosis, provision of preoperative care, discussion with attending physician, selection and provision of intervention, direction of postoperative care, and postdischarge follow-up. In doing so, they achieved a dramatic improvement in continuity of care provided by the senior surgical residents [13]. In the present study, training outside of an academic center was associated with lower rates of preoperative assessment but higher rates of intraoperative and in-hospital postoperative assessment. The likely explanation for these
Fig. 4. Percent of cases associated with resident continuity of care for each phase of patient contact for teaching hospitals versus community hospitals. *P ⬍ .05.
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findings relates to the structure of training in the community versus academic sites. At the community sites, faculty surgeons generally round on their own patients and do not rely on residents in the ward or clinic settings. Hence, residents tend to follow only those patients they have operated on leading to good postoperative in-hospital continuity of care. In academic centers, the residents form the backbone of the ward service and see more patients preoperatively (likely emergency and preadmitted patients). During the study period, the majority of surgery (80.2%) was elective; thus, in the context of modern surgical practice and current surgical training models, the majority of general surgery patients are not accessible to residents before the day of their operation. Clearly, trainees are not being exposed to complete surgical care. This is the case for both junior and senior residents. Although our study did not address the impact of workhour restrictions on continuity of care, it is likely that the structure of the training program is responsible for the poor continuity of care rates (ie, with the current system, continuity of care is respectable for patients admitted before their elective surgery or patients admitted emergently). Similarly, postoperative continuity of care is respectable for inpatients. The continuum is lost when outpatient contact is required. The present surgical training system does not reflect this reality of practice. Certainly, there needs to be significant improvement in the continuity of care experience of general surgery residents. As proposed by Chung et al [12], preceptor-based rotations do improve continuity of care, but this comes at the cost of restricting a trainee to one person’s biases, techniques, and opinions. There is no question that mandating ambulatory clinic experiences improves continuity of care, especially in the realm of postdischarge patient assessment. Ideally, this would involve a resident-run clinic as outlined in the Michigan study [13]; alternatively, it would take considerable effort and coordination on the part of both residents and their attending surgeons to ascertain when patients are to be seen postoperatively at the attending’s office, with permission of the involved resident to be excused from in-hospital duties in order to attend. In the current study, the issue of faculty as well as residents having a low priority for clinic attendance did arise from the qualitative comments of the participants. As can be expected from the traditional surgical training paradigm, residents and faculty believed operating room attendance, emergency room coverage, and inpatient care took priority over ambulatory clinic attendance. Perhaps the direst situation to be addressed is the unacceptably low rates of preoperative assessment. Not only does this impact poorly on a trainee’s understanding of the complete care of a surgical patient, it is also likely disconcerting for patients that the main physician directing their postoperative care is an individual whom they never met before surgery. Same-day admission surgery is here to stay, so, to accommodate for this, there must be more emphasis on residents to preoperatively assess their patients. Perhaps staff should insist that their residents at least meet and examine a patient before being allowed to scrub in on that case. It should be stressed that residents incorporate a visit to the preoperative holding area as part of their morning
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rounds. Adequate space for preoperative assessment should be insisted on by attending surgeons for this purpose. One of the main limitations of this study is that data were self-reported by residents; this may have led residents to overestimate the actual experience they obtained and/or to change their behavior as a result of being studied. However, both of these biases would lead to a potential overestimation of experiences so it is possible that continuity of care experiences were, in fact, even worse than reported. Although unlikely, underestimation of experiences may have also been possible. Further research is required to validate the findings of this study in other general surgery training programs and to assess the impact of making changes as suggested earlier. In conclusion, continuity of patient care is one of the most fundamental principles in medical education and must be a part of surgical training as required by surgical accreditation bodies. In this study of a general surgery training program, complete in-hospital continuity of care was poor (29%) and most negatively influenced by elective surgery. In the current climate of ambulatory surgery, we can no longer adhere to the same model of surgical education as it was conceived by Halsted over a century ago and still expect to teach our trainees exemplary and complete care of surgical patients. Appendix Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.amjsurg.2006.11.002. References [1] Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg 2000;87: 28 –37. [2] Booklet of information, July 2004 –June 2005. Philadelphia, PA: American Board of Surgery; 2004. [3] The Royal College of Physicians and Surgeons of Canada. Objectives of training and specialty training requirements in general surgery. Available at: http://rcpsc.medical.org. Accessed October 31, 2006. [4] Rogers J, Curtis P. The achievement of continuity of care in a primary care training program. Am J Public Health 1980;70:528 –30. [5] Fischer JE. Continuity of care: a casualty of the 80 hour work week. Acad Med 2004;79:381–3. [6] Feanny MA, Scott BG, Mattox KL, et al. Impact of the 80-hour work week on resident emergency operative experience. Am J Surg 2005; 190:947–9. [7] Irani JL, Mello MM, Ashley SW, et al. Surgical residents’ perceptions of the effects of the ACGME duty hour requirements 1 year after implementation. Surgery 2005;138:246 –53. [8] Sidhu RS, Walker GR. Resident continuity of care experience in a Canadian general surgery training program. Can J Surg 1999;42:353–7. [9] Gagnon J, Melck A, Kamal D, et al. Continuity of care experience of residents in an academic vascular department: are trainees learning complete surgical care? J Vasc Surg 2006;43:999 –1003. [10] Accreditation Council for Graduate Medical Education. Report of the ACGME Work Group on Resident Duty Hours. Available at: http// www.acgme.org. Accessed October 31, 2006. [11] Anderson CI, Albrecht RR, Anderson KD, Dean RE. Can continuity-of-care requirements for surgery residents be demonstrated in the current teaching environment? Arch Surg 1996;131:915–21. [12] Chung RS, Verghese J, Diaz J, Eisenstat M. One-on-one mentorresident rotation for improving continuity of care in a surgical training program. J Surg Res 1997;69:359 – 61. [13] Mittal V, David W, Young S, et al. Improved continuity of care in a community teaching hospital model. Arch Surg 1999;134:555– 8.
Association for Surgical Education
Resident continuity of care experience: a casualty of ambulatory surgery and current patient admission practices Adrienne L. Melck, M.D., Eric M. Weber, M.D., F.R.C.S.(C.), Ravi S. Sidhu, M.D., M.Ed., F.R.C.S.(C.)* Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, C318-1-91 Burrard Street, Vancouver, British Columbia, Canada V6Z 1Y6 Manuscript received March 31, 2006; revised manuscript November 1, 2006
Abstract Background: The purpose of this study was to define and assess the impact of changes in health care delivery on the current continuity of care experience of surgical residents. Methods: This 4-week, prospective cohort study included all patients who underwent a general surgical procedure at the University of British Columbia if a resident was present at the operation. The residents’ perioperative involvement in each patient’s care was recorded. Results: Of the 592 eligible cases, 74.8% were elective same-day admissions, 5.4% elective previously admitted patients, and 19.8% emergencies. The overall rate of assessment was 27% preoperatively, 84% postoperatively on the ward, and ⬍1% in oupatient clinic postdischarge. Elective cases were associated with significantly lower rates of preoperative assessment compared with emergency cases (15% versus 74%, P ⬍ .001). Conclusions: Changes in health care delivery have outpaced changes in the structure of surgical education, resulting in suboptimal continuity of care experiences for trainees. Residency programs must adapt their curricula to include adequate ambulatory experience. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Continuity of care; General surgery; Postgraduate training; Residency
In the current paradigm of surgical training, residents acquire progressively increased responsibility as they advance through their residency program under the guidance and supervision of attending surgeons. Despite dramatic changes to the delivery of health care over the last few decades, the fundamental structure of surgical training programs has undergone little change since Dr William Halsted introduced North America to the concept of graded responsibility within residency training in the early 1900s [1]. More and more, elective surgical patients are admitted the morning of their procedure and, in many instances, discharged the same day. Thus, preoperative consultation and detection of postoperative complications increasingly occurs in ambulatory clinics, a setting that residents often do not access. The inclusion of continuity of care in the training requirements outlined by various surgical accreditation boards * Corresponding author. Tel.: ⫹1-604-806-8698; fax: ⫹1-604-8068666. E-mail address: [email protected]
highlights the central importance of this concept. The American Board of Surgery requires surgical trainees to have “actively participated in making or confirming the diagnosis, selecting the appropriate operative plan, and administering preoperative and post-operative care [2].” Similarly, the Royal College of Physicians and Surgeons of Canada requires that its trainees “have recognition of responsibility for the overall care of the surgical patient [3].” A welltrained surgeon has not only mastered the technical aspects of surgery but meticulously prepares his/her patient for the operating room and astutely detects and manages all complications related to the procedure performed. This art can only be imparted to surgical trainees if they have the opportunity to realize the impact of their preoperative and intraoperative decisions on postoperative outcomes. Furthermore, continuity of care has been shown to lead to more knowledgeable patients, better patient satisfaction, and improved compliance with selected treatment regimens [4]. The numerous recent advances in medical technology that have added to the diagnostic and therapeutic tools
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available to today’s general surgeon further emphasizes the need for surgical training paradigms to keep pace. With the advent of interventional radiology, minimally invasive surgery, and newer endoscopic techniques, the options for our surgical patients have multiplied, making the choice of a treatment plan more complex. Surgical trainees are often excluded from this decision-making process by virtue of their absence from preoperative and postoperative outpatient clinics. There have been several reports implicating work-hour restrictions in poor continuity of care among surgical trainees, which have mainly been retrospective [5–7]. One prospective study evaluated continuity of care in a Canadian general surgery training program, including an analysis of the effect of an emergency procedure [8]. However, this study did not look at rates of outpatient follow-up or the effect of hospital setting (academic versus community) on continuity of care experiences. Given that there exists a void in the published continuity of care experiences in the current era of work-hour restrictions, the aim of this study was, first, to prospectively ascertain the current experience of general surgery residents within a Canadian general surgery training program with regard to the continuity of care they are able to provide for patients and, second, to delineate the various resident, patient, and hospital factors influencing this experience. In particular, we examine how issues unique to the way health care is currently delivered (eg. same-day admission for elective surgery and ambulatory surgery) impact on the continuity of care experience. Methods This study was conducted within the University of British Columbia (UBC) 6-year general surgery training program, which is accredited by the Royal College of Physicians and Surgeons of Canada. Although the majority of clinical rotations take place at the university’s 3 main teaching hospitals in Vancouver, residents are required to do at least 2 community general surgery rotations in various regions of the province of British Columbia. Thus, portions of this study were conducted at some of these community teaching sites. At the UBC’s 3 main teaching hospitals, there are a total of 20 attending general surgeons and 4 pediatric general surgeons. The general surgery services are entirely run by residents and fellows in the traditional hierarchical fashion, as defined by Halsted. There are no physician extenders on the service. The house staff members are responsible for in-hospital patient care under the supervision of attending surgeons and are required to attend all scheduled operative procedures, as well as emergency procedures when on call. At 2 of the main training sites (St. Paul’s Hospital and British Columbia Children’s Hospital), the inpatient wards, operating rooms, and physicians’ clinics are all contained within the same facility, and on-service residents are required to attend at least 2 outpatient clinic half days during their rotation. At the other main training site (Vancouver General Hospital), the physicians’ clinics are located in outside, private offices, and on-service residents are not mandated to attend these clinics.
At each of the community teaching sites, there are anywhere from 3 to 6 general surgeons on staff. In general, residents rotating through these sites are responsible for the care of patients in whose operations they were involved, as well as patients seen in consultation through the emergency department or the medical wards. There is no requirement to attend outpatient clinics at these sites. The study was a prospective cohort investigation conducted over an 8-month period from May 1 to December 31, 2005. All general surgery residents on either a general surgery or pediatric general surgery rotation during the study period were asked to participate. Each potential participant was given a detailed description of the study design in written form, with opportunities to ask questions of the principal investigator. Once a resident gave his/her consent to participate in the study, each for a 4-week period, all patients who underwent a general surgical procedure at the institution in which the resident was stationed were included in the study if the resident was present at the time of operation. All participants were oriented to the study during a 20-minute session. The definitions of all terms used were clarified, and questions were answered. Residents completed a questionnaire for each patient encounter during this period (Appendix 1). The information recorded included the following: 1. Procedure-related demographic data: date, hospital, procedure, surgeon, and nature of procedure (emergent operation versus elective and same-day admission versus elective, previously admitted) 2. Resident demographic data: postgraduate (PGY) level and operative role (primary operator versus teaching assistant versus first assistant versus second assistant) 3. Resident continuity of care data A. Preoperative: participation in preoperative assessment (either in the emergency room, preoperative assessment room on the day of surgery, or outpatient clinic) and in the decision to operate B. Intraoperative: involvement in any intraoperative decisions C. Postoperative: participation in daily ward assessment, discharge planning, and postoperative outpatient clinic assessment All data obtained were collected and then transferred into a database by a single investigator (ALM). A review of the completed data-acquisition forms at the end of the study determined the continuity of care. Any missing data identified after reviewing the data-acquisition forms were completed through interviews with the appropriate residents. The chi-square test was used to analyze the data for statistical significance. The methodology of this study was deemed valid based on a previously published study by 1 of the authors, which determined that self-reported data were accurate in the resident population [8]. In addition, a pilot study was conducted several months before the present study at 2 of the UBC’s main teaching hospitals, using residents on the vascular surgery service [9]. The purpose of the pilot study was to ensure the feasibility of our planned data-collection meth-
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considered third and fourth in line, respectively, for operative participation. Teaching assistant is when a senior resident supervises/guides a procedure being performed by a more junior trainee.)
Fig. 1. Number of cases included in this study by type of procedure. HPB ⫽ hepatopancreaticobiliary; SP ⫽ spleen; ST ⫽ stomach; SB ⫽ small bowel; C ⫽ colon; R ⫽ rectum; A ⫽ anus; TH ⫽ thyroid; PT ⫽ parathyroid; AD ⫽ adrenal; BR ⫽ breast; VH ⫽ ventral hernia; IH ⫽ inguinal hernia; MISC ⫽ miscellaneous including trauma, skin/muscle/nerve biopsies, tracheostomy, salivary gland excision, vasectomy, hydrocelectomy, circumcision, and lysis of adhesions.
ods. This served as further validation for the methods used in this study protocol. In British Columbia, residents are restricted to 1 in 4 in-house calls and 1 in 3 home calls. The frequency of calls varies at the community teaching sites. These conditions remained constant during this study. This study was conducted with approval from the Behavioral Research Ethics Board of the UBC. Results Patients and residents A total of 596 surgical procedures were included in this study; because of to in-hospital mortality, 4 cases were excluded from the statistical analysis. Of the remaining 592 cases, 19.8% were emergencies, 74.8% were elective cases admitted on the same day of surgery, and the remaining 5.4% were elective cases admitted before the day of surgery. The resident cohort included 5 junior residents (PGY I-II) and 7 senior residents (PGY III-VI), for a total of 12 general surgery residents. During the time period of this study, there were 20 eligible residents (residents on an operative general surgery service) out of the 35 total surgical residents. As participation is voluntary, 8 eligible residents did not participate. During the study period, these residents were stationed at 9 different hospitals including the University of British Columbia’s 3 main teaching hospitals (Vancouver General Hospital, St. Paul’s Hospital, and British Columbia Children’s Hospital) as well as 6 community hospitals, including facilities in Greater Vancouver, Vancouver Island, and southeastern British Columbia. The majority of data were prospectively collected with incomplete information collected by follow-up resident interviews. The types of general surgery procedures performed are outlined in Figure 1. At the time of surgery, the resident’s role in the operation was recorded as primary operator 60.3% of the time, first assistant 29.9% of the time, second assistant 9.1% of the time, and third assistant or teaching assistant 0.7% of the time. (Second assistant and third assistant refers to being scrubbed in on a case but being
Continuity of care experience Of the 592 eligible patients, 27% were assessed by the resident preoperatively, whereas 84% were assessed daily on the ward by the resident postoperatively in the 242 cases in which the patient was admitted to hospital. Complete in-hospital continuity of care (assessing the same patient preoperatively and postoperatively) was achieved in 29% of the cases. Patient follow-up in outpatient clinics occurred in only 5 patients (1%). The residents were involved in the decision to operate in 13% of cases, and they were involved in intraoperative decision making 74% of the time. Type of admission Compared with elective cases, the rate of preoperative assessment, involvement in the decision to operate, and complete continuity of care were all significantly higher for emergency cases (74% versus 15%, P ⬍ .001; 60% versus 2%, P ⬍ .001; and 63% versus 14%, P ⬍ .001, respectively) (Fig. 2). For elective cases admitted before the day of surgery compared with elective cases admitted the same day, there were also significantly higher rates of preoperative assessment (44% versus 13%, P ⬍ .001), involvement in the decision to operate (13% versus 1%, P ⬍ .001), and complete continuity of care (45% versus 9%, P ⬍ .001) (Fig. 3). Junior versus senior residents Junior residents (PGY I-II) were involved in 31.8% of the cases, and the remaining 68.2% were reported by senior residents. As anticipated, senior residents had a significantly higher rate of intraoperative decision making compared with juniors (92% versus 36%, P ⬍ .001). Training site There were significantly higher rates of preoperative assessment (35% versus 22%, P ⫽ .001) and involvement in the decision to operate (23% versus 8%, P ⬍ .001) in the main teaching hospitals compared with the community hospitals. In contrast, rates of intraoperative decision making (85% versus 52%, P ⬍ .001) and postoperative assessment (92% versus 73%, P ⬍ .001) were higher in the community
Fig. 2. Percent of cases associated with resident continuity of care for each phase of patient contact for emergency versus elective cases. *P ⬍ .05.
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Fig. 3. Percent of cases associated with resident continuity of care for each phase of patient contact for elective previously admitted patients versus elective same-day admission patients. *P ⬍ .05.
setting (Fig. 4). There was no significant difference in complete continuity of care (26% community versus 34% academic, P ⫽ .1). Demographic data Patient age, sex, and the hospital where the procedure was performed were not associated with significant differences in continuity of care rates. Comments The health care system has changed dramatically over the last several decades, which has affected current surgical practice in unique ways. Furthermore, in 2003, the Accreditation Council for Graduate Medical Education issued regulations restricting residents’ work hours in the United States [10], with similar restrictions enforced in Australia and throughout Europe. These work hour restrictions have been shown to negatively impact resident continuity of care experiences in general surgery.5-7 In a 2-year retrospective review, Feanny et al. compared senior general surgery residents trained before and after the implementation of work hour restrictions by the ACGME. They found that with the advent of the restrictions, operative continuity of care has decreased from 60% to 26% of cases.6 However, studies examining the impact of changes in healthcare delivery on continuity of care have been limited. This prospective study defines the current continuity of care experience of general surgery residents within a Canadian residency program, and outlines a variety of factors that affect this experience. Our study revealed that the rate of complete in-hospital continuity of care, which is defined as participation in both the preoperative and in-hospital postoperative assessment of a surgical patient by the same resident, was 29%, with an especially low rate of postdischarge assessment (1%). This low complete in-hospital continuity of care was mainly influenced by a low preoperative assessment rate (27%), which reflects the large proportion of patients that arrive in hospital on the morning of their surgery. All 5 instances wherein a patient was seen in an outpatient clinic postdischarge occurred on surgical rotations in which residents are mandated to attend outpatient clinics as part of the rotation. Although speculative, the poor rate of attendance at outpatient clinics may be explained by residents’ daily responsibility to manage inpatient wards, do emergency consultations and attend the operating room, the lack of proximity to
these clinics, and resident preference for time in the operating room over time spent in clinic. Several authors have reported similar findings. Anderson et al [11] undertook a retrospective review of 21 general surgery residents who collectively participated in 114 surgical procedures over a 2-year period at 3 hospitals. The rate of preoperative assessment in this study was 70.2%; however, in over 25% of those cases, the only evidence that the resident was involved preoperatively was the fact that they had written preoperative orders. The operating resident provided some component of postoperative in-hospital care and postdischarge follow-up care in 86.8% and 37.7% of cases, respectively. The rate of postdischarge follow-up was significantly higher than in the present study; however, the authors state that their residency program is specifically structured to allow residents the opportunity to examine their patients at the first postdischarge visit. The overall rate of complete continuity of care in Anderson’s study was 23.7%. Compared with the pilot study [9], the general surgery services in this study had poor overall continuity of care rates (57% versus 29%). This difference requires further study; however, it may be caused by the fact that the general surgery services tend to have more patients relative to the number of house staff. Hence, residents may not have as much time for clinic attendance or immediate preoperative patient assessment. Various strategies have been used to improve continuity of care. Chung and colleagues [12] investigated the effect of 1-on-1 mentor-resident rotations on continuity of care and found that there was a significantly greater percentage of continuity of care achieved when compared with typical in-hospital surgical rotations (98% versus 42%). A Michigan group established a resident-run ambulatory clinic to improve surgical resident continuity of care, which was defined as involvement by the same resident in each of 6 phases of the same patient’s care: confirmation of diagnosis, provision of preoperative care, discussion with attending physician, selection and provision of intervention, direction of postoperative care, and postdischarge follow-up. In doing so, they achieved a dramatic improvement in continuity of care provided by the senior surgical residents [13]. In the present study, training outside of an academic center was associated with lower rates of preoperative assessment but higher rates of intraoperative and in-hospital postoperative assessment. The likely explanation for these
Fig. 4. Percent of cases associated with resident continuity of care for each phase of patient contact for teaching hospitals versus community hospitals. *P ⬍ .05.
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findings relates to the structure of training in the community versus academic sites. At the community sites, faculty surgeons generally round on their own patients and do not rely on residents in the ward or clinic settings. Hence, residents tend to follow only those patients they have operated on leading to good postoperative in-hospital continuity of care. In academic centers, the residents form the backbone of the ward service and see more patients preoperatively (likely emergency and preadmitted patients). During the study period, the majority of surgery (80.2%) was elective; thus, in the context of modern surgical practice and current surgical training models, the majority of general surgery patients are not accessible to residents before the day of their operation. Clearly, trainees are not being exposed to complete surgical care. This is the case for both junior and senior residents. Although our study did not address the impact of workhour restrictions on continuity of care, it is likely that the structure of the training program is responsible for the poor continuity of care rates (ie, with the current system, continuity of care is respectable for patients admitted before their elective surgery or patients admitted emergently). Similarly, postoperative continuity of care is respectable for inpatients. The continuum is lost when outpatient contact is required. The present surgical training system does not reflect this reality of practice. Certainly, there needs to be significant improvement in the continuity of care experience of general surgery residents. As proposed by Chung et al [12], preceptor-based rotations do improve continuity of care, but this comes at the cost of restricting a trainee to one person’s biases, techniques, and opinions. There is no question that mandating ambulatory clinic experiences improves continuity of care, especially in the realm of postdischarge patient assessment. Ideally, this would involve a resident-run clinic as outlined in the Michigan study [13]; alternatively, it would take considerable effort and coordination on the part of both residents and their attending surgeons to ascertain when patients are to be seen postoperatively at the attending’s office, with permission of the involved resident to be excused from in-hospital duties in order to attend. In the current study, the issue of faculty as well as residents having a low priority for clinic attendance did arise from the qualitative comments of the participants. As can be expected from the traditional surgical training paradigm, residents and faculty believed operating room attendance, emergency room coverage, and inpatient care took priority over ambulatory clinic attendance. Perhaps the direst situation to be addressed is the unacceptably low rates of preoperative assessment. Not only does this impact poorly on a trainee’s understanding of the complete care of a surgical patient, it is also likely disconcerting for patients that the main physician directing their postoperative care is an individual whom they never met before surgery. Same-day admission surgery is here to stay, so, to accommodate for this, there must be more emphasis on residents to preoperatively assess their patients. Perhaps staff should insist that their residents at least meet and examine a patient before being allowed to scrub in on that case. It should be stressed that residents incorporate a visit to the preoperative holding area as part of their morning
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rounds. Adequate space for preoperative assessment should be insisted on by attending surgeons for this purpose. One of the main limitations of this study is that data were self-reported by residents; this may have led residents to overestimate the actual experience they obtained and/or to change their behavior as a result of being studied. However, both of these biases would lead to a potential overestimation of experiences so it is possible that continuity of care experiences were, in fact, even worse than reported. Although unlikely, underestimation of experiences may have also been possible. Further research is required to validate the findings of this study in other general surgery training programs and to assess the impact of making changes as suggested earlier. In conclusion, continuity of patient care is one of the most fundamental principles in medical education and must be a part of surgical training as required by surgical accreditation bodies. In this study of a general surgery training program, complete in-hospital continuity of care was poor (29%) and most negatively influenced by elective surgery. In the current climate of ambulatory surgery, we can no longer adhere to the same model of surgical education as it was conceived by Halsted over a century ago and still expect to teach our trainees exemplary and complete care of surgical patients. Appendix Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.amjsurg.2006.11.002. References [1] Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg 2000;87: 28 –37. [2] Booklet of information, July 2004 –June 2005. Philadelphia, PA: American Board of Surgery; 2004. [3] The Royal College of Physicians and Surgeons of Canada. Objectives of training and specialty training requirements in general surgery. Available at: http://rcpsc.medical.org. Accessed October 31, 2006. [4] Rogers J, Curtis P. The achievement of continuity of care in a primary care training program. Am J Public Health 1980;70:528 –30. [5] Fischer JE. Continuity of care: a casualty of the 80 hour work week. Acad Med 2004;79:381–3. [6] Feanny MA, Scott BG, Mattox KL, et al. Impact of the 80-hour work week on resident emergency operative experience. Am J Surg 2005; 190:947–9. [7] Irani JL, Mello MM, Ashley SW, et al. Surgical residents’ perceptions of the effects of the ACGME duty hour requirements 1 year after implementation. Surgery 2005;138:246 –53. [8] Sidhu RS, Walker GR. Resident continuity of care experience in a Canadian general surgery training program. Can J Surg 1999;42:353–7. [9] Gagnon J, Melck A, Kamal D, et al. Continuity of care experience of residents in an academic vascular department: are trainees learning complete surgical care? J Vasc Surg 2006;43:999 –1003. [10] Accreditation Council for Graduate Medical Education. Report of the ACGME Work Group on Resident Duty Hours. Available at: http// www.acgme.org. Accessed October 31, 2006. [11] Anderson CI, Albrecht RR, Anderson KD, Dean RE. Can continuity-of-care requirements for surgery residents be demonstrated in the current teaching environment? Arch Surg 1996;131:915–21. [12] Chung RS, Verghese J, Diaz J, Eisenstat M. One-on-one mentorresident rotation for improving continuity of care in a surgical training program. J Surg Res 1997;69:359 – 61. [13] Mittal V, David W, Young S, et al. Improved continuity of care in a community teaching hospital model. Arch Surg 1999;134:555– 8.