Wednesday, May 6, 2015

Problems with surgical residents and continuity of care

How are we doing with residency training and continuity of care? Not too well if you believe a recent paper called "Continuity of Care in General Surgery Resident Education" appearing online in the American Journal of Surgery.

A group from Rush University in Chicago looked at the records of 228 patients who underwent commonly performed operations during the year 2012. They found that in only 21/228 (9.2%) of cases had the operating resident seen the patient preoperatively, and in 20/223 (9.0%) had the operating resident seen the patient in postoperative follow-up. In no case, did the operating resident see the same patient both pre- and postoperatively.

The table lists the type of cases and the frequency of resident participation in preoperative care or postoperative follow-up.

This is important because on page 18 of the Residency Review Committee (RRC) for Surgery Program Requirements for Graduate Medical Education in General Surgery, the following is stated:

A resident may be considered the surgeon only when he or she can document a significant role in the following aspects of management: determination or confirmation of the diagnosis, provision of preoperative care, selection, and accomplishment of the appropriate operative procedure, and direction of the postoperative care.

If you interpret this literally, in not one of the 228 cases that were done was the resident who performed the procedure entitled to consider herself the surgeon for purposes of taking credit in the eyes of the RRC.

Continuity of patient care is also part of the professionalism core competency.

This is not the first paper describing this problem, nor is it the first paper to find that no residents followed a single patient all the way through the process.

What is the cause of this problem? It's not the length of the rotations because the shortest rotation for a senior resident was six weeks which should have afforded the residents ample time to have established complete continuity in at least a few cases.

The authors should be commended for their candor in reporting these findings. Had their paper been published 20 or 25 years ago, their program would have been cited by the RRC for a deficiency in continuity of care.

It’s an even bigger concern in community hospital surgical programs where the majority of elective patients come from private practice offices.

What's the solution? The easiest fix would be to change the RRC requirement. What is the point of having a rule that can't be followed?

The residents are not learning about making the diagnosis, deciding whether to operate, the informed consent discussion, and evaluating the patient after discharge from the hospital.

The real issue is that there is much more to surgery than simply doing the operation.


RobertL39 said...

Does this mean that 'rounds' are dead? You round on the patients that your team is taking care of. How could the surgeon NOT see the patient post-op? Not seeing them pre-op is a *little* easier to understand, particularly if they came from private offices. How many of these were outpatient surgeries, which would skew the results substantially? These figures make it difficult at best for surgeons to complain about lack of continuity between internists and hospitalists.

Anonymous said...

Anonymous Europe: As a trainee, I know what you are talking about. I usually try to see the patients preoperatively and during the post.op follow up I get to operate on. But, it is hard, very-very hard.

In my opinion the problem is burocracy. It sounds weird and we have heard this many times but consider this: As a trainee you are responsible for a ward. You are tasked (besides performing and assisting operations) to manage an overwhelming amount of paperwork which should be done by a nurse/coding assistant/whatever you want to call her. The nurses on the ward nag you constantly because of usually some minor stuff which they could do from themselves but won't because of actual legislation. This hampers you mightily through the day. You barely make it on time to the OR and glad that you made it this far. Unfortunately the day is so packed that you just do not get to see those patients who undergone an operation by you if they are on a different ward where you are. And all this because of meaningless, senseless medical documentation... If a resident had to do less paperwork it would be way easier. Additionally I would consider on of the two following options: 1. Trainees operate only those patients who lie on their ward. 2. Trainees are assigned to patients, and they should only care about those patients and no-one else.

Anonymous said...

Am I correct that residents can't sign off on the operating report due to insurance billing regulations? If so where is it documented so they can receive credit for having performed the operation.

Skeptical Scalpel said...

Robert, these were all day surgery or short-stay cases. Rounds are still made on inpatients.

Anon Europe, I agree the paperwork is killing everyone. There are studies documenting the huge amounts of time residents spend on the computer and the little time they spend with patients.

Anon, you are correct. The residents can't be named as surgeon on the hospital chart. Residents take credit for the case on the honor system. To be honest, whether a resident actually did a case or not can be a matter of perspective. It can be and has been debatable.

Anonymous said...

WOW! How does the resident know what procedure to do, and to which patient? Even if these were Out Patient procedures, I feel that it is extremely poor patient care to be just a technician. No wonder medicine is getting such a bad name. Personally I would never put a scalpel to a patient whom I had not seen, examined, explained the procedure to them, and then after the procedure made sure that things are going well. It doesn't take that much time. Oh, I forgot, residents are only allowed to spend 80 hrs/wk. This from an Old Surgeon who trained in the 1980's.

Anonymous said...

I am "merely" a patient (albeit a well-educated and well-informed one), but I couldn't agree more that it is ESSENTIAL to see the patient AT LEAST post-op, and preferably pre-op as well. I would feel helpless in the face of such disjointed care.

PGYx said...

Not a surgeon here, but I am trained to perform various neuromusculoskeletal procedures. Learning to do the procedures is relatively simple (unlike more extensive surgery, I know), but even during residency selecting patients most likely to tolerate and benefit from a given procedure has always struck me as the real art of medicine. Hard to do that well if you don't get to evaluate before the procedure, perform the procedure, AND follow up to assess response to the procedure.

In my field, I believe this deficit of training in appropriate patient selection results in many procedures done for patients who have very little chance of benefitting. Some docs barely bother to take a good history (partly due to time constraints) and and many actually lack some important physical exam skills and/or knowledge base needed to make a specific diagnosis.

This is bad for the patients who don't benefit. It also leads some to draw the conclusion that a given procedure doesn't work, when really it just doesn't work for patients who were poor candidates for that procedure.

Agree with all that the paperwork burden has greatly contributed to this problem. Residents could see and learn from many more patients if they weren't so buried in documentation responsibilities.

Skeptical Scalpel said...

When I was a resident, I saw a private patient being set up for a herniorrhaphy. I examined the patient and couldn't feel the "hernia." I told the attending and he couldn't feel it either. Case canceled.

Second anon, I agree.

PGYx, who needs a history when you have a CT scan? Kidding of course. Good point that the procedure may not work well if it's done on the wrong patient.

Mark Paulsen said...

Maybe this reflects the reality of surgical practice today. I am an FP practicing in a tiny rural hospital. Most of our patients requiring surgery get transferred to a large, non-teaching Level I trauma center in a big city.What I have observed is that the initial surgery consult is done by a PA. The patient has his operation, and then is rounded on by a different surgeon or PA every day. The surgeon who did the operation may never see the patient before or after surgery. The discharge summary is often done by someone who hasn't seen the patient before the day of discharge. This seems to be the way it is done for all of the procedural specialties. Since I can remember the old days I don't like this, but discussions with my colleagues lead me to believe that this is the standard everywhere now. Even the hospitalist service tends to have a different doctor round on the inpatients each day.

Skeptical Scalpel said...

Mark, thanks for the comments. I think you are right. You may want to read a couple of other posts about this on my blog. and

artiger said...

Mark and Scalpel, that's one of the main reasons I decided on a rural area for my surgical practice.

William Reichert said...

I THOUGHT I covered this before.Surgeons don't see their patients anymore post op[. They get the hospitalists to do it. They see them for the 4 week check up. IF there is a problem before that, they get the hospitalist to admit them to reduce their 30 day readmission rate.

artiger said...

William, it's not that way everywhere.

Skeptical Scalpel said...

I agree that it's not that way everywhere, but it is fairly common.

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