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THE INFLUENCE OF SURGICAL TRAINING ON THE PRACTICE OF SURGERY
COST EFFECTIVENESS IN SURGERY
0039-6109/96 $0.00
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THE INFLUENCE OF SURGICAL TRAINING ON THE PRACTICE OF SURGERY Are Changes Necessary? Michael D. Stone, MD, and Jennifer Doyle, MA
Surgical education and practice are inextricably linked: Each is essential to the other's existence, and what happens in one arena inevitably affects the other. Both are subject to the governmental and market forces that are revolutionizing the delivery of health care in the United States today. Public debate over national health care reform has focused on the issues of access and cost, but while much lip service has been given to the issue of access, most attention has centered not on health care delivery but its financingz3h the absence of governmental reform, economic market forces predominate as the agent of change. Increasing consolidation of the nation's health care resources in the hands of forprofit companies has led to the promotion and adoption of managed care plans. Enrollment in managed care plans (HMOs and PPOs) is growing at more than 11%a year,' totaling 50,000,000 by the end of 1994,"jor roughly one out of four insured Americans. In today's market, relatively few, large corporations dominate health care and do so in the primary interest of profits, not the health of the nation's people.', 29 The basic tenet of managed care, and the mechanism for increasing profits, is cost reduction achieved through a shift of financial risk to physicians and hospital organizations, with capitation as the mature market m0de1.~ Efforts to reduce costs are having a profound impact on surgical practice, including decreased utilization of services and changing prac-
From the Department of Surgery, Harvard Medical School; and New England Deaconess Hospital, Boston, Massachusetts
SURGICAL CLINICS OF NORTH AMERICA VOLUME 76 * NUMBER 1 * FEBRUARY 1996
1
2
STONE & DOYLE
tice patterns (Figs. 1 and 2). Some changes have had a positive effect on surgical practice: Increased emphasis on efficiency, for example, forces practitioners to cast off diagnostic and treatment routines based on tradition rather than scientific thinking. These changes will have significant impact on surgical education because much of it takes place within surgical practice. In the managed care schema, education is no longer a priority but a cost center. Surgical educators need to adapt to many changes in surgical practice while opposing some potential changes that may be harmful to the learning process. A balance must be struck Whereas government, business and hospital administrators will need to recognize that "the quality of American medicine is dependent on the quality of medical education,"" surgical faculty need to recognize that "unless we train students to provide demonstrably effective care at a competitive cost, we will train them for obsolescence."22 We will suggest changes in medical education beginning in the preclinical years and continuing through clinical surgical training during and after medical school. We will describe the effects of the changing health care environment on surgical practice, and consequently on surgical education, at both the medical school and residency levels. Specifically, we will suggest changes in curriculum and educational methods necessary for surgical training to adapt to changes in health care financing, educational venue, and availability of resources (faculty and patients). PRE-CLINICAL EDUCATION
During medical school and residency, the principles of managed care must be integrated into the surgical curric~lum.~ Medical students
Figure 1. Inpatient and outpatient hospital-based operations (in thousands). Note: These data pertain to American Hospital Association (AHA)-registered hospitals in the United States. Black bar = inpatient operations; shaded bar = outpatient operations. (Data from American Hospital Association: Unpublished data from the AHA Annual Survey Files. Chicago, AHA.)
THE INFLUENCE OF SURGICAL TRAINING O N THE PRACTICE OF SURGERY
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Figure 2. Summary of growth of free-standing ambulatory surgical centers. Free-standing ambulatory surgical centers are facilities at which outpatient surgical procedures are performed. The centers are physically separate from hospitals and vary in terms of ownership and sponsorship, governance structure, comprehensiveness of services, and affiliations with hospitals. Shaded bar = number of facilities; black bar = number of procedures. (Data from SMG Marketing Group: Freestanding Outpatient Surgery Centers’ Directory and Report. Chicago, SMG Marketing Group, 1994.)
must be introduced to the new economics of health care early in the preclinical years to provide a fundamental understanding of the rationale for cost efficiency. They must learn the new language of managed care, the concept of financial risk with capitation, and the ”alphabet soup” of new types of health care organizations. Business principles such as costing, margin, and others should be introduced. Familiarity with these basics allows students to better understand practice restrictions, which are inevitable in the absence of voluntary cost reduction. Students must see themselves as future members of a health care organization rather than the independent practitioner of the past. Students need to learn team leadership and group dynamics to effectively head the health care force. They must learn to approach problems in a multidisciplinary fashion, marshalling the efforts of multiple departments rather than limiting themselves to a monolithic, unidepartmental approach. The development and use of algorithms and clinical pathways to streamline patient care must be grasped early on and reinforced by their use in subsequent preclinical and clinical courses. Standardization of diagnostic and therapeutic interventions in the form of algorithms, while aimed at increasing efficiency and cost effectiveness, also restricts autonomy in patient care. Trainees have less opportunity to exercise their own judgment. Critical thinking and clinical reasoning need to be emphasized as never before. The use of defined algorithms runs the risk of a
4
STONE&DOYLE
"cookbook" approach to care, and trainees need to learn the rationale for these decision trees, perhaps by participating in development of new algorithms and in updating older algorithms. New methods of research and evaluation of outcomes must accompany these changes. Therefore, students must be introduced to the concepts of quality and outcome measurement, as well as methods of quality improvement. The patient-doctor relationship will change as a result of the changes in health care financing. Students must be made aware of the new concepts of patient satisfaction and physician report cards and how these relate to their practice security and referrals.6,* Attitudes and communication skills that enhance this relationship must be taught and modeled.21Throughout this new curriculum, ethical issues related to the dual role of the physician as care-giver and risk taker must be emphasized. Physicians must not lose sight of their special role of patient advocate. New courses in cost-effective diagnostic medicine must be developed. These should be multidisciplinary and problem based. Limiting diagnostic tests to those that will change the management of the patient must be repeatedly emphasized. The cost of diagnostic tests and therapeutic modalities should be emphasized at all levels of training. Appropriate, cost-effective strategies for follow-up of patients with chronic diseases, such as cancer, must be introduced during the preclinical years and reinforced during clinical training.
CLINICAL TRAINING
Clinical education in surgery during medical school and during residency differs in the focus of the learners but is similarly affected by practice changes in health care and the need for cost reductions. Attempts to restructure the nation's physician work force by producing more primary care physicians and fewer specialists are succeeding in reducing the number of students entering surgical residencies. In March of 1995, for the first time in 7 years, more than 50% of United States medical school seniors chose to pursue training in one of the "generalist disciplines."26 As one might expect, there has been a corresponding decrease in the number of students entering general surgery residenc i e ~Additionally, .~~ medical students spend less time in surgery than they have previously: In the past 5 years, the majority of US medical schools required students to spend an average of 12% less time in surgery, from an average of 10.8 weeks in 1989 to 9.5 weeks in 1994.25 During the surgical clerkship, teachers must focus on the "undifferentiated" student who needs to gain a core set of knowledge, skills, and attitudes. This may be the only exposure to a specialty for many who will be expected to serve as "gatekeepers." Surgical clerkship educational goals, however, should not be restricted to teaching primary care issues. Surgical teaching should focus on those problems that are
THE INFLUENCE OF SURGICAL TRAINING ON THE PRACTICE OF SURGERY
5
common, those that are critical to evaluate properly, and those for which surgeons are the best teachers. Students should be introduced to the basics of evaluation, the role of surgery, and when to refer. This set of goals should be further pursued with surgical instructors during residency training in primary care areas.31 Because patient care is the medium through which all surgical trainees are taught, reduced utilization of hospital care, including reductions in length of stay and the shift to outpatient care, result in the same stress on medical student and surgical resident education. These are reviewed below.
DECREASEDLENGTHOFSTAY
Managed care plans reduce costs by emphasizing outpatient care and reducing hospital utilization. Surgical length-of-stay (LOS) has decreased dramatically over the last 5 years, and an increasing number of surgical procedures are performed on an outpatient basis or in freestanding ambulatory surgery centers. Between 1980 and 1992, the average LOS for a patient undergoing cholecystectomy, for example, decreased from 10.914to 4.9 days.27Similarly, patients undergoing appendectomies in 1980 stayed in hospital an average of 5.6 days, but only 4.7 in 1992.l4zz7 Length of stay has been shortened by eliminating the preoperative night stay in the hospital and reducing postoperative days. For students and residents, these changes mean less exposure to, and therefore diminished understanding of, surgical diseases and patients. Students and residents observe less of the progression of surgical diseases from onset to postoperative healing. Without preoperative admissions, surgical clerks and residents have fewer opportunities to take a history and perform complete physical examinations, diminishing their skills in these areas. The loss of clinical skills results in the costly overutilization of imaging and other tests in their stead. This deficiency is only partially compensated for by the necessary and important office experience, where students and residents perform focused histories and examinations, and by experience in preadmission testing units. A brief visit with the patient in the preoperative holding area is similarly inadequate, even when teaching faculty are present and the case is discussed with the learner. Faculty no longer can assume the development and honing of clinical skills from extensive experience, as in the past. Beginning in medical school and continuing through residency, greater emphasis must be placed on developing and honing clinical examination and other clinical assessment skills, and faculty must carefully monitor the learner’s progress in these areas. To accomplish this, surgical faculty must allow trainees to see and assess office patients alone rather than utilizing the “shadow” method of observing the attending-patient interaction. The former method requires more office time and is less cost effective. Efficiency of time in the office
6
STONE & DOYLE
must be taught. Similarly, assessment of fitness for surgery, involving interpretation of laboratory and other tests, as well as observing or participating in the informed consent process, must take place in the office or elsewhere. Shorter postoperative stays result in diminished experience and understanding of wound care, pain management, complications, and the patient’s psychological response to surgery, their diagnosis, and outcome. These topics must, therefore, be actively covered in formal didactic sessions and in the trainee’s office experiences. Additionally, shorter postoperative LOS requires that the care of more seriously ill patients (only those with more acute illnesses are allowed to stay in the hospital) be compressed within a shorter period of time, resulting in intensification of trainee workload. Because additional caregivers, such as physician’s assistants, may be necessary but unavailable because of cost, surgical programs must monitor trainee work volume to guarantee that their work retains its educational value. Surgical training must emphasize the importance of reducing LOS. Trainees must learn how and when to prepare outpatients for surgery. Communication skills, including assessment of patient understanding of and ability to follow instructions, must be emphasized, beginning in medical school. Preparation for early discharge requires skill in patient education, interaction with hospital case management teams, and knowledge of available community options for posthospital care. Faculty must discuss issues related to time of discharge on daily rounds and play a substantive role in this decision process until adequate trainee experience and judgment are
CHANGE IN VENUE
Increasing numbers of operations are being performed on an ambulatory basis, that is, with no overnight hospital stay, or in nonhospital settings. The number of all surgical procedures performed in the outpatient setting has nearly doubled from 8 million in 1985 to 15.7 million in 1992. Nearly 3 million of the latter procedures were performed in freestanding ambulatory Most major surgical procedures continue to be performed in hospitals, but many cases appropriate for junior level trainees such as plastic surgery and common biopsy procedures are being performed outside of the hospital setting, the traditional leaming place for residents and students. These changes require that students and residents see patients in surgical offices prior to and after such procedures, and that the trainees’ schedules be adjusted for them to participate in outpatient procedures within the hospital and at ambulatory centers, where they may enhance their suturing technique and other basic surgical skills. Initial teaching and learning of basic techniques can be accomplished more cost effectively outside of the expensive operating room arena. Greater emphasis on simulators and clinical skills labora-
THE INFLUENCE OF SURGICAL TRAINING ON THE PRACTICE OF SURGERY
7
tories will be necessary to ensure appropriate technical development without increased costs. Because many ambulatory procedures are performed on awake patients, additional operative management skills, including patient selection, techniques of local anesthesia, and patient communication, must be taught and modeled.30 As academic medical centers develop networks with community hospitals, one can expect a shift of routine, high-volume cases such as herniorrhaphy, cholecystectomy, and breast surgery from the more expensive teaching hospital to the less expensive community site. Teaching hospital physician staffs will be downsized, increasing the pool and training level of community surgeons. More complex surgeries may then shift to community sites as well. Surgical programs will need to develop student and resident rotations at network hospitals to allow trainees to go where the patients are being treated. The direct and indirect financial costs of this training will not be readily acceptable to these surgeons and institutions. Given expected decrements in governmental graduate medical education funding and hospital revenues, there will be little in the way of financial reward to offer these new teacher^.^, 11-13* 15, 17, l8 Traditional educational structures, such as resident teams, will need to be abandoned in favor of more cost-effective approaches. It may be necessary to send only one or a few trainees to a variety of sites to ”apprentice” with community surgeons, diffusing the educational “burden” and minimizing the institutional loss of efficiency while exposing the resident to the ”real” surgical world. Surgical educators will need to develop the teaching skills of these new, less experienced faculty, who must be familiar with the principles of adult education, be able to communicate effectively, perform evaluations, and provide feedback. Educators must help these teachers develop appropriate didactic conferences, including the use of telemedicine. Control of the quality of education and resident experience may become more difficult. Technical training in the operating room, obtained by performing procedures with appropriate supervision, must not be subjugated to cost considerations. The emphasis placed by managed care plans on ambulatory care and the concomitant decrease in hospital length of stay has resulted in the downsizing, privatization, and closure of many of the nation’s municipal hospital^.^, 33 These hospitals have traditionally been the bastion of “ward” services, with maximum resident autonomy. Resident decision making is a necessary part of the adult education and resident training process but is less cost effective. For these institutions to be competitive in today’s market, greater faculty supervision of day-to-day decision making is necessary. The challenge for surgical educators will be to strike a new, cost-effectivebalance between supervision and autonomy. A return to the apprenticeship model may be the optimal answer, allowing close supervision and appropriate modeling of cost-conscious care. Increased privatization of medical practice and hospitals will have other potential effects on medical and surgical education: For-profit
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HMOs and hospitals are interested in efficiency and economies of scale; they are less interested in medical education, which they perceive as a threat to both?, lo As downsizing of nonphysician hospital personnel occurs, there will be the temptation to “dump” noneducational work on resident staff. Surgical educators and regulatory agencies will need to carefully evaluate resident workload.
FEASIBILITY OF PROPOSED CHANGES
The evolution of surgical education to a ”cost center” will add to the overall stress on physicians and hospital organizations. As payments diminish, revenue-generating use of physician time will become more important, and teaching, which is often unremunerated at present, will be assigned a lower priority. At the same time, medical schools and the Residency Review Committee for Surgery are seeking greater faculty time for outpatient experience and supervision of trainees. Reduction in revenues and graduate medical education funding will stimulate hospitals to reduce costs in all areas while attempting to maximize work output from faculty and residents alike. As Malcolm Knowles,2O the premier theorist of adult education, has acknowledged, educational goals in the real world must be filtered through the needs of the institution and society as a whole. Health care institutions, therefore, must define their mission, particularly the strength of their commitment to education. The level of this commitment must be agreed to by physicians, hospital administrators, residents, and student and medical school representatives. Undoubtedly, some institutions will discontinue training programs for monetary reasons, and the number of surgery training programs will continue to decrease. Cost of medical care is the driving force behind the current changes in surgical practice, and is, in turn, driven by an excess of physicians overall and specialist physicians in particular. Surgical resident education and career counseling must emphasize general surgery career paths rather than surgical subspecialties. Fewer surgical residents will be trained in fewer training programs (Residency Review Committee for Surgery, Unpublished data, 1995).2,11, 32 Medical schools and surgery programs must develop regional approaches to care and training to reduce redundancy of effort and spending. It is time to begin reducing the number of physicians entering the job market by reducing the number of international medical graduates and the number of graduates from US medical Reliable manpower data and projections are necessary to make future judgments.31Finally, surgical educators must work to help society recognize that the quality of American health care is a dividend of investment in quality medical education.
THE INFLUENCE OF SURGICAL TRAINING O N THE PRACTICE OF SURGERY
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References 1. Anders G: Money Machines: HMOs Pile Up Billions In Cash, Try to Decide What to Do With It. The Wall Street Journal, December 21, 1994, p 1 2. Boston Globe: MGH, Brigham Reduce Number of Medical Residents. July 16,1995, p 1 3. Boston Globe: Private firm eyed to run BCH-BU: Critics say public hospital needed; officials cite savings. May 9, 1995, p 1 4. Cantor JC, Baker LC, Hughes RG: Preparedness for practice: Young physicians’ view of their professional education. JAMA 270:1035-1040, 1993 5. Cohen JJ: The Importance of the Medicare Program in Supporting Academic Medicine. Statement to the Committee on Finance, US Senate, July 26, 1995 6. Commonwealth Fund: Patient Experiences with Managed Care: A Survey. New York, July, 1995 7. Congressional Budget Office: The Effects of Managed Care and Managed Competition. CBO Memorandum, February, 1995 8. Consumer Reports: How is Your Doctor Treating You? February, 1995, pp 81-88 9. Cooper RA: Critical workforce questions dominate CAS discussions. AAMC Reporter, April, 1995, pp 1-3 10. Corrigan JM, Thompson LM: Involvement of health maintenance organizations in graduate medical education. Acad Med 66:656-661, 1991 11. Council of Graduate Medical Education: Recommendations to Congress, April 27,1995 12. Flint L, Flint CB: Academic surgical group practices at the dawn of health reform. Ann Surg 220374-381,1994 13. Foreman S, Kerr WB, Mullins CB, et al: Academic medical centers, proposed Medicare cuts, and the emerging price-competitive environment. Acad Med 70:510-511,1995 14. Haug JN, Seeger R (eds): Socio-Economic Factbook for Surgery 1982. Chicago, American College of Surgeons, 1982 15. Howell RE: The Role of the Medicare Program in Supporting Academic Medicine: Statement to the Committee on Commerce, Subcommittee on Health and Environment, US House of Representatives, June 28, 1995 16. Iglehart J K Conference summary: Duke University conference on the private sector. Health Aff 14304-311, 1995 17. Iglehart J K The American Health Care System: Private insurance. N Engl J Med 326:1715-1720, 1992 18. Iglehart JK: The American Health Care System: Teaching hospitals. N Engl J Med 329:1052-1056, 1993 19. Kindig DA, Libby D How will graduate medical education reform affect specialties and geographic areas? JAMA 2723742, 1994 20. Knowles MS: The Modern Practice of Adult Education: From Pedagogy to Andragogy. rev ed. New York, Cambridge, 1980 21. Levinson W Physician-patient communication: A key to malpractice prevention. JAMA 272:1619-1620, 1994 22. McFall RM. The Future of Mental-Health Care. Chronicle of Higher Education, July 21, 1995, B pp 1-3 23. Mongan JJ: Anatomy and physiology of health reform’s failure. Health Aff 1499-101, 1995 24. Nager N, Saadatmand F The status of medical education for black Americans. J Natl Med Assoc 83:787-792, 1991 25. Neumayer L: Survey of US Clerkship Directors in Surgery: Presented at the Association for Surgical Education Annual Meeting; Tucson, AZ, May, 1995 26. Randlett RlC Results of the National Resident Matching Program for 1995. Acad Med 70:547-549, 1995 27. Rogers CM (ed): Socio-Economic Factbook for Surgery, 1995. Chicago, American College of Surgeons, 1995 28. Shine KI: Freeze the number of Medicare-subsidized graduate medical education positions. JAMA 273:1057-1058, 1995 29. Starr P: The Social Transformation of American Medicine. New York, Basic Books, 1982, pp 394417
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30. Stone MD, Doyle J, Patselas TN, et al: Management of ambulatory surgery and outpatient care. In Cox SS, Pories WJ, Foil MB, et a1 (eds): Surgical Resident Curriculum, ed 2. Arlington, VA, Association of Program Directors in Surgery, 1995, pp 151155 31. Stone MD, Steele G Jr, Doyle J: The push toward generalism: A view from surgery. World J Surg 18:738-744, 1994 32. Weiner JP: Forecasting the effects of health reform on US physician work force requirement: Evidence from HMO staffing patterns. JAMA 272:222-230, 1994 33. Whiteis DG: Hospital and community characteristics in closures of urban hospitals, 1980-87. Public Health Rep 107409416, 1992
Address reprint requests to Michael D. Stone, MD Department of Surgery Harvard Medical School Deaconess Hospital 110 Francis Street Suite 2H Boston, MA 02215
0039-6109/96 $0.00
+ .20
THE INFLUENCE OF SURGICAL TRAINING ON THE PRACTICE OF SURGERY Are Changes Necessary? Michael D. Stone, MD, and Jennifer Doyle, MA
Surgical education and practice are inextricably linked: Each is essential to the other's existence, and what happens in one arena inevitably affects the other. Both are subject to the governmental and market forces that are revolutionizing the delivery of health care in the United States today. Public debate over national health care reform has focused on the issues of access and cost, but while much lip service has been given to the issue of access, most attention has centered not on health care delivery but its financingz3h the absence of governmental reform, economic market forces predominate as the agent of change. Increasing consolidation of the nation's health care resources in the hands of forprofit companies has led to the promotion and adoption of managed care plans. Enrollment in managed care plans (HMOs and PPOs) is growing at more than 11%a year,' totaling 50,000,000 by the end of 1994,"jor roughly one out of four insured Americans. In today's market, relatively few, large corporations dominate health care and do so in the primary interest of profits, not the health of the nation's people.', 29 The basic tenet of managed care, and the mechanism for increasing profits, is cost reduction achieved through a shift of financial risk to physicians and hospital organizations, with capitation as the mature market m0de1.~ Efforts to reduce costs are having a profound impact on surgical practice, including decreased utilization of services and changing prac-
From the Department of Surgery, Harvard Medical School; and New England Deaconess Hospital, Boston, Massachusetts
SURGICAL CLINICS OF NORTH AMERICA VOLUME 76 * NUMBER 1 * FEBRUARY 1996
1
2
STONE & DOYLE
tice patterns (Figs. 1 and 2). Some changes have had a positive effect on surgical practice: Increased emphasis on efficiency, for example, forces practitioners to cast off diagnostic and treatment routines based on tradition rather than scientific thinking. These changes will have significant impact on surgical education because much of it takes place within surgical practice. In the managed care schema, education is no longer a priority but a cost center. Surgical educators need to adapt to many changes in surgical practice while opposing some potential changes that may be harmful to the learning process. A balance must be struck Whereas government, business and hospital administrators will need to recognize that "the quality of American medicine is dependent on the quality of medical education,"" surgical faculty need to recognize that "unless we train students to provide demonstrably effective care at a competitive cost, we will train them for obsolescence."22 We will suggest changes in medical education beginning in the preclinical years and continuing through clinical surgical training during and after medical school. We will describe the effects of the changing health care environment on surgical practice, and consequently on surgical education, at both the medical school and residency levels. Specifically, we will suggest changes in curriculum and educational methods necessary for surgical training to adapt to changes in health care financing, educational venue, and availability of resources (faculty and patients). PRE-CLINICAL EDUCATION
During medical school and residency, the principles of managed care must be integrated into the surgical curric~lum.~ Medical students
Figure 1. Inpatient and outpatient hospital-based operations (in thousands). Note: These data pertain to American Hospital Association (AHA)-registered hospitals in the United States. Black bar = inpatient operations; shaded bar = outpatient operations. (Data from American Hospital Association: Unpublished data from the AHA Annual Survey Files. Chicago, AHA.)
THE INFLUENCE OF SURGICAL TRAINING O N THE PRACTICE OF SURGERY
3
Figure 2. Summary of growth of free-standing ambulatory surgical centers. Free-standing ambulatory surgical centers are facilities at which outpatient surgical procedures are performed. The centers are physically separate from hospitals and vary in terms of ownership and sponsorship, governance structure, comprehensiveness of services, and affiliations with hospitals. Shaded bar = number of facilities; black bar = number of procedures. (Data from SMG Marketing Group: Freestanding Outpatient Surgery Centers’ Directory and Report. Chicago, SMG Marketing Group, 1994.)
must be introduced to the new economics of health care early in the preclinical years to provide a fundamental understanding of the rationale for cost efficiency. They must learn the new language of managed care, the concept of financial risk with capitation, and the ”alphabet soup” of new types of health care organizations. Business principles such as costing, margin, and others should be introduced. Familiarity with these basics allows students to better understand practice restrictions, which are inevitable in the absence of voluntary cost reduction. Students must see themselves as future members of a health care organization rather than the independent practitioner of the past. Students need to learn team leadership and group dynamics to effectively head the health care force. They must learn to approach problems in a multidisciplinary fashion, marshalling the efforts of multiple departments rather than limiting themselves to a monolithic, unidepartmental approach. The development and use of algorithms and clinical pathways to streamline patient care must be grasped early on and reinforced by their use in subsequent preclinical and clinical courses. Standardization of diagnostic and therapeutic interventions in the form of algorithms, while aimed at increasing efficiency and cost effectiveness, also restricts autonomy in patient care. Trainees have less opportunity to exercise their own judgment. Critical thinking and clinical reasoning need to be emphasized as never before. The use of defined algorithms runs the risk of a
4
STONE&DOYLE
"cookbook" approach to care, and trainees need to learn the rationale for these decision trees, perhaps by participating in development of new algorithms and in updating older algorithms. New methods of research and evaluation of outcomes must accompany these changes. Therefore, students must be introduced to the concepts of quality and outcome measurement, as well as methods of quality improvement. The patient-doctor relationship will change as a result of the changes in health care financing. Students must be made aware of the new concepts of patient satisfaction and physician report cards and how these relate to their practice security and referrals.6,* Attitudes and communication skills that enhance this relationship must be taught and modeled.21Throughout this new curriculum, ethical issues related to the dual role of the physician as care-giver and risk taker must be emphasized. Physicians must not lose sight of their special role of patient advocate. New courses in cost-effective diagnostic medicine must be developed. These should be multidisciplinary and problem based. Limiting diagnostic tests to those that will change the management of the patient must be repeatedly emphasized. The cost of diagnostic tests and therapeutic modalities should be emphasized at all levels of training. Appropriate, cost-effective strategies for follow-up of patients with chronic diseases, such as cancer, must be introduced during the preclinical years and reinforced during clinical training.
CLINICAL TRAINING
Clinical education in surgery during medical school and during residency differs in the focus of the learners but is similarly affected by practice changes in health care and the need for cost reductions. Attempts to restructure the nation's physician work force by producing more primary care physicians and fewer specialists are succeeding in reducing the number of students entering surgical residencies. In March of 1995, for the first time in 7 years, more than 50% of United States medical school seniors chose to pursue training in one of the "generalist disciplines."26 As one might expect, there has been a corresponding decrease in the number of students entering general surgery residenc i e ~Additionally, .~~ medical students spend less time in surgery than they have previously: In the past 5 years, the majority of US medical schools required students to spend an average of 12% less time in surgery, from an average of 10.8 weeks in 1989 to 9.5 weeks in 1994.25 During the surgical clerkship, teachers must focus on the "undifferentiated" student who needs to gain a core set of knowledge, skills, and attitudes. This may be the only exposure to a specialty for many who will be expected to serve as "gatekeepers." Surgical clerkship educational goals, however, should not be restricted to teaching primary care issues. Surgical teaching should focus on those problems that are
THE INFLUENCE OF SURGICAL TRAINING ON THE PRACTICE OF SURGERY
5
common, those that are critical to evaluate properly, and those for which surgeons are the best teachers. Students should be introduced to the basics of evaluation, the role of surgery, and when to refer. This set of goals should be further pursued with surgical instructors during residency training in primary care areas.31 Because patient care is the medium through which all surgical trainees are taught, reduced utilization of hospital care, including reductions in length of stay and the shift to outpatient care, result in the same stress on medical student and surgical resident education. These are reviewed below.
DECREASEDLENGTHOFSTAY
Managed care plans reduce costs by emphasizing outpatient care and reducing hospital utilization. Surgical length-of-stay (LOS) has decreased dramatically over the last 5 years, and an increasing number of surgical procedures are performed on an outpatient basis or in freestanding ambulatory surgery centers. Between 1980 and 1992, the average LOS for a patient undergoing cholecystectomy, for example, decreased from 10.914to 4.9 days.27Similarly, patients undergoing appendectomies in 1980 stayed in hospital an average of 5.6 days, but only 4.7 in 1992.l4zz7 Length of stay has been shortened by eliminating the preoperative night stay in the hospital and reducing postoperative days. For students and residents, these changes mean less exposure to, and therefore diminished understanding of, surgical diseases and patients. Students and residents observe less of the progression of surgical diseases from onset to postoperative healing. Without preoperative admissions, surgical clerks and residents have fewer opportunities to take a history and perform complete physical examinations, diminishing their skills in these areas. The loss of clinical skills results in the costly overutilization of imaging and other tests in their stead. This deficiency is only partially compensated for by the necessary and important office experience, where students and residents perform focused histories and examinations, and by experience in preadmission testing units. A brief visit with the patient in the preoperative holding area is similarly inadequate, even when teaching faculty are present and the case is discussed with the learner. Faculty no longer can assume the development and honing of clinical skills from extensive experience, as in the past. Beginning in medical school and continuing through residency, greater emphasis must be placed on developing and honing clinical examination and other clinical assessment skills, and faculty must carefully monitor the learner’s progress in these areas. To accomplish this, surgical faculty must allow trainees to see and assess office patients alone rather than utilizing the “shadow” method of observing the attending-patient interaction. The former method requires more office time and is less cost effective. Efficiency of time in the office
6
STONE & DOYLE
must be taught. Similarly, assessment of fitness for surgery, involving interpretation of laboratory and other tests, as well as observing or participating in the informed consent process, must take place in the office or elsewhere. Shorter postoperative stays result in diminished experience and understanding of wound care, pain management, complications, and the patient’s psychological response to surgery, their diagnosis, and outcome. These topics must, therefore, be actively covered in formal didactic sessions and in the trainee’s office experiences. Additionally, shorter postoperative LOS requires that the care of more seriously ill patients (only those with more acute illnesses are allowed to stay in the hospital) be compressed within a shorter period of time, resulting in intensification of trainee workload. Because additional caregivers, such as physician’s assistants, may be necessary but unavailable because of cost, surgical programs must monitor trainee work volume to guarantee that their work retains its educational value. Surgical training must emphasize the importance of reducing LOS. Trainees must learn how and when to prepare outpatients for surgery. Communication skills, including assessment of patient understanding of and ability to follow instructions, must be emphasized, beginning in medical school. Preparation for early discharge requires skill in patient education, interaction with hospital case management teams, and knowledge of available community options for posthospital care. Faculty must discuss issues related to time of discharge on daily rounds and play a substantive role in this decision process until adequate trainee experience and judgment are
CHANGE IN VENUE
Increasing numbers of operations are being performed on an ambulatory basis, that is, with no overnight hospital stay, or in nonhospital settings. The number of all surgical procedures performed in the outpatient setting has nearly doubled from 8 million in 1985 to 15.7 million in 1992. Nearly 3 million of the latter procedures were performed in freestanding ambulatory Most major surgical procedures continue to be performed in hospitals, but many cases appropriate for junior level trainees such as plastic surgery and common biopsy procedures are being performed outside of the hospital setting, the traditional leaming place for residents and students. These changes require that students and residents see patients in surgical offices prior to and after such procedures, and that the trainees’ schedules be adjusted for them to participate in outpatient procedures within the hospital and at ambulatory centers, where they may enhance their suturing technique and other basic surgical skills. Initial teaching and learning of basic techniques can be accomplished more cost effectively outside of the expensive operating room arena. Greater emphasis on simulators and clinical skills labora-
THE INFLUENCE OF SURGICAL TRAINING ON THE PRACTICE OF SURGERY
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tories will be necessary to ensure appropriate technical development without increased costs. Because many ambulatory procedures are performed on awake patients, additional operative management skills, including patient selection, techniques of local anesthesia, and patient communication, must be taught and modeled.30 As academic medical centers develop networks with community hospitals, one can expect a shift of routine, high-volume cases such as herniorrhaphy, cholecystectomy, and breast surgery from the more expensive teaching hospital to the less expensive community site. Teaching hospital physician staffs will be downsized, increasing the pool and training level of community surgeons. More complex surgeries may then shift to community sites as well. Surgical programs will need to develop student and resident rotations at network hospitals to allow trainees to go where the patients are being treated. The direct and indirect financial costs of this training will not be readily acceptable to these surgeons and institutions. Given expected decrements in governmental graduate medical education funding and hospital revenues, there will be little in the way of financial reward to offer these new teacher^.^, 11-13* 15, 17, l8 Traditional educational structures, such as resident teams, will need to be abandoned in favor of more cost-effective approaches. It may be necessary to send only one or a few trainees to a variety of sites to ”apprentice” with community surgeons, diffusing the educational “burden” and minimizing the institutional loss of efficiency while exposing the resident to the ”real” surgical world. Surgical educators will need to develop the teaching skills of these new, less experienced faculty, who must be familiar with the principles of adult education, be able to communicate effectively, perform evaluations, and provide feedback. Educators must help these teachers develop appropriate didactic conferences, including the use of telemedicine. Control of the quality of education and resident experience may become more difficult. Technical training in the operating room, obtained by performing procedures with appropriate supervision, must not be subjugated to cost considerations. The emphasis placed by managed care plans on ambulatory care and the concomitant decrease in hospital length of stay has resulted in the downsizing, privatization, and closure of many of the nation’s municipal hospital^.^, 33 These hospitals have traditionally been the bastion of “ward” services, with maximum resident autonomy. Resident decision making is a necessary part of the adult education and resident training process but is less cost effective. For these institutions to be competitive in today’s market, greater faculty supervision of day-to-day decision making is necessary. The challenge for surgical educators will be to strike a new, cost-effectivebalance between supervision and autonomy. A return to the apprenticeship model may be the optimal answer, allowing close supervision and appropriate modeling of cost-conscious care. Increased privatization of medical practice and hospitals will have other potential effects on medical and surgical education: For-profit
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HMOs and hospitals are interested in efficiency and economies of scale; they are less interested in medical education, which they perceive as a threat to both?, lo As downsizing of nonphysician hospital personnel occurs, there will be the temptation to “dump” noneducational work on resident staff. Surgical educators and regulatory agencies will need to carefully evaluate resident workload.
FEASIBILITY OF PROPOSED CHANGES
The evolution of surgical education to a ”cost center” will add to the overall stress on physicians and hospital organizations. As payments diminish, revenue-generating use of physician time will become more important, and teaching, which is often unremunerated at present, will be assigned a lower priority. At the same time, medical schools and the Residency Review Committee for Surgery are seeking greater faculty time for outpatient experience and supervision of trainees. Reduction in revenues and graduate medical education funding will stimulate hospitals to reduce costs in all areas while attempting to maximize work output from faculty and residents alike. As Malcolm Knowles,2O the premier theorist of adult education, has acknowledged, educational goals in the real world must be filtered through the needs of the institution and society as a whole. Health care institutions, therefore, must define their mission, particularly the strength of their commitment to education. The level of this commitment must be agreed to by physicians, hospital administrators, residents, and student and medical school representatives. Undoubtedly, some institutions will discontinue training programs for monetary reasons, and the number of surgery training programs will continue to decrease. Cost of medical care is the driving force behind the current changes in surgical practice, and is, in turn, driven by an excess of physicians overall and specialist physicians in particular. Surgical resident education and career counseling must emphasize general surgery career paths rather than surgical subspecialties. Fewer surgical residents will be trained in fewer training programs (Residency Review Committee for Surgery, Unpublished data, 1995).2,11, 32 Medical schools and surgery programs must develop regional approaches to care and training to reduce redundancy of effort and spending. It is time to begin reducing the number of physicians entering the job market by reducing the number of international medical graduates and the number of graduates from US medical Reliable manpower data and projections are necessary to make future judgments.31Finally, surgical educators must work to help society recognize that the quality of American health care is a dividend of investment in quality medical education.
THE INFLUENCE OF SURGICAL TRAINING O N THE PRACTICE OF SURGERY
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References 1. Anders G: Money Machines: HMOs Pile Up Billions In Cash, Try to Decide What to Do With It. The Wall Street Journal, December 21, 1994, p 1 2. Boston Globe: MGH, Brigham Reduce Number of Medical Residents. July 16,1995, p 1 3. Boston Globe: Private firm eyed to run BCH-BU: Critics say public hospital needed; officials cite savings. May 9, 1995, p 1 4. Cantor JC, Baker LC, Hughes RG: Preparedness for practice: Young physicians’ view of their professional education. JAMA 270:1035-1040, 1993 5. Cohen JJ: The Importance of the Medicare Program in Supporting Academic Medicine. Statement to the Committee on Finance, US Senate, July 26, 1995 6. Commonwealth Fund: Patient Experiences with Managed Care: A Survey. New York, July, 1995 7. Congressional Budget Office: The Effects of Managed Care and Managed Competition. CBO Memorandum, February, 1995 8. Consumer Reports: How is Your Doctor Treating You? February, 1995, pp 81-88 9. Cooper RA: Critical workforce questions dominate CAS discussions. AAMC Reporter, April, 1995, pp 1-3 10. Corrigan JM, Thompson LM: Involvement of health maintenance organizations in graduate medical education. Acad Med 66:656-661, 1991 11. Council of Graduate Medical Education: Recommendations to Congress, April 27,1995 12. Flint L, Flint CB: Academic surgical group practices at the dawn of health reform. Ann Surg 220374-381,1994 13. Foreman S, Kerr WB, Mullins CB, et al: Academic medical centers, proposed Medicare cuts, and the emerging price-competitive environment. Acad Med 70:510-511,1995 14. Haug JN, Seeger R (eds): Socio-Economic Factbook for Surgery 1982. Chicago, American College of Surgeons, 1982 15. Howell RE: The Role of the Medicare Program in Supporting Academic Medicine: Statement to the Committee on Commerce, Subcommittee on Health and Environment, US House of Representatives, June 28, 1995 16. Iglehart J K Conference summary: Duke University conference on the private sector. Health Aff 14304-311, 1995 17. Iglehart J K The American Health Care System: Private insurance. N Engl J Med 326:1715-1720, 1992 18. Iglehart JK: The American Health Care System: Teaching hospitals. N Engl J Med 329:1052-1056, 1993 19. Kindig DA, Libby D How will graduate medical education reform affect specialties and geographic areas? JAMA 2723742, 1994 20. Knowles MS: The Modern Practice of Adult Education: From Pedagogy to Andragogy. rev ed. New York, Cambridge, 1980 21. Levinson W Physician-patient communication: A key to malpractice prevention. JAMA 272:1619-1620, 1994 22. McFall RM. The Future of Mental-Health Care. Chronicle of Higher Education, July 21, 1995, B pp 1-3 23. Mongan JJ: Anatomy and physiology of health reform’s failure. Health Aff 1499-101, 1995 24. Nager N, Saadatmand F The status of medical education for black Americans. J Natl Med Assoc 83:787-792, 1991 25. Neumayer L: Survey of US Clerkship Directors in Surgery: Presented at the Association for Surgical Education Annual Meeting; Tucson, AZ, May, 1995 26. Randlett RlC Results of the National Resident Matching Program for 1995. Acad Med 70:547-549, 1995 27. Rogers CM (ed): Socio-Economic Factbook for Surgery, 1995. Chicago, American College of Surgeons, 1995 28. Shine KI: Freeze the number of Medicare-subsidized graduate medical education positions. JAMA 273:1057-1058, 1995 29. Starr P: The Social Transformation of American Medicine. New York, Basic Books, 1982, pp 394417
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30. Stone MD, Doyle J, Patselas TN, et al: Management of ambulatory surgery and outpatient care. In Cox SS, Pories WJ, Foil MB, et a1 (eds): Surgical Resident Curriculum, ed 2. Arlington, VA, Association of Program Directors in Surgery, 1995, pp 151155 31. Stone MD, Steele G Jr, Doyle J: The push toward generalism: A view from surgery. World J Surg 18:738-744, 1994 32. Weiner JP: Forecasting the effects of health reform on US physician work force requirement: Evidence from HMO staffing patterns. JAMA 272:222-230, 1994 33. Whiteis DG: Hospital and community characteristics in closures of urban hospitals, 1980-87. Public Health Rep 107409416, 1992
Address reprint requests to Michael D. Stone, MD Department of Surgery Harvard Medical School Deaconess Hospital 110 Francis Street Suite 2H Boston, MA 02215