Resident Continuity of Care Experience:
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Resident Continuity of Care Experience: A Casualty of Current Healthcare Delivery, Not Work Hour Restrictions. Dr. A. Melck, Dr. E. Webber, Dr. R. Sidhu Association for Surgical Education March 25, 2006 – Tucson, AZ. Background.

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Dr. A. Melck, Dr. E. Webber, Dr. R. Sidhu Association for Surgical Education

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Resident Continuity of Care Experience:A Casualty of Current Healthcare Delivery, Not Work Hour Restrictions

Dr. A. Melck, Dr. E. Webber, Dr. R. Sidhu

Association for Surgical Education

March 25, 2006 – Tucson, AZ


Background

  • The importance of continuity of care in medical education has been well-documented.

  • Continuity of care leads to more knowledgeable patients, better patient satisfaction, and improved compliance with selected treatment regimens.*

    *(Rogers J et al. Am J Public Health 1980)


Decision-making

Compassion

Technical Skill

Communication


Background

  • Exemplary surgical care requires astute pre-, intra- and post-operative decision-making skills.

  • Surgical residents must gain this expertise by experiencing the impact of their decisions.


Background

“…have recognition of responsibility for the overall care of the surgical patient.”


Background

“…actively participated in making or confirming the diagnosis, selecting the appropriate operative plan, and administering preoperative and post-operative care”

THE AMERICAN BOARD OF SURGERY


BackgroundWilliam S. Halsted

  • introduced German model of residency training in the early 1900s

  • emphasis on graded responsibility and inpatients

    (Hamdorf JM et al. Br J Surg 2000)


Background

  • Over the past century:

    • Little change in the fundamental structure of training programs, BUT

    • Substantial change to healthcare delivery


Background: Changes in Healthcare Delivery

  • same day admission for surgery

  • ambulatory surgery

  • limitations on resident work hours

  • limited operating room resources


Background

“…leaders of academic medicine must bebetter prepared to address an array of very serious challenges...I find that very few (journals) publish articlesthat address those challenges…”

Michael E. Whitcomb, MD, Editor

June, 2005


Objectives

  • To define the current continuity of care experience of general surgery residents in a Canadian training program.

  • To delineate the patient, resident, and hospital factors influencing this experience.


Methods

  • REB-approved, prospective cohort study conducted at UBC

  • Inclusion Criteria: all patients who underwent a general surgery procedure if a resident was present at the time of operation.

  • Residents completed a questionnaire for each patient encounter.


Patient

Resident

Methods: Data Collected

  • date

  • hospital

  • procedure

  • surgeon

  • nature of

    procedure

  • PGY level

  • operative role


Preoperative

Intraoperative

Postoperative

Methods: Data Collected

  • involvement in

    intraoperative

    decisions

  • outpatient clinic

  • emergency room

  • preoperative

    assessment room

  • decision to

    operate

  • outpatient clinic

  • daily ward rounds


Methods

  • Missing data was identified and completed through interviews with residents.

  • Methodology validated through previously performed pilot study with vascular surgery residents and fellows.


Results

  • 592 encounters

  • 3 academic hospitals–

  • 6 community hospitals–

  • 12 participating residents:

    • 5 juniors (PGY I-II)

    • 7 seniors (PGY III-VI)

VGH, SPH, BCCH

RCH, SMH, LGH, MSJ, EKRH, NRGH


Results

  • Resident Role:

    • Primary operator – 60.3%

    • 1st assistant – 29.9%

    • 2nd assistant – 9.1%

    • 3rd assistant – 0.2%

    • Teaching assistant – 0.5%


Operative Cases by Type of Admission


Results: Procedures Performed


Results: Overall Continuity of Care


Factors Affecting Continuity of Care: Electivevs. Emergency

* P<.001


Factors Affecting Continuity of Care: Same-day vs. Previously Admitted Elective Surgery

*P<0.001


Factors Affecting Continuity Of Care: Academic vs. Community Hospital

*P<.001


Results: Level of Training

  • Senior residents had a significantly higher rate of intraoperative decision-making (92% vs. 36%, p<0.001)


Summary

  • 80% cases are elective, majority of these are same-day admissions

  • Poor overall COC rate a result of poor preop assessment rate (27%)

  • Poor preop assessment rate most negatively affected by elective surgery (especially same-day admissions)


Summary

  • Preoperative assessment and overall COC rates respectable for emergency (>70%) and previously-admitted elective cases (50%)

  • Dismal rate of outpatient post-discharge assessment (<1%)


Discussion

  • Current training paradigms have not kept pace with changing realities of healthcare.

  • Training does not reflect actual practice patterns:

    • Majority of surgical decision-making occurs

      in ambulatory settings

    • Majority of training occurs in high acuity inpatient settings


Discussion

  • Despite work hour restrictions, COC rates are respectable for inpatients.

  • The continuum is lost when outpatient contact is required.

  • Changes in healthcare delivery have had the most negative impact on trainee COC experience.


Discussion

  • Must consider altering training structure:

    • mandated clinic experience

    • longer rotations

    • increased emphasis on preop assessment on day of surgery

    • resident-run ambulatory clinic

    • preceptor-based rotations


Conclusions

  • COC experiences of general surgery trainees are suboptimal, especially for preop and postop outpatient assessment.

  • Type of surgery impacts significantly on COC experiences.

  • Changes in healthcare delivery must be met with changes in the structure of training programs.


Thank-You

Thank-you


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