“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Saturday, October 20, 2007

Tying the attendings hands ...

“Wisdom is knowing what to do next, skill is knowing how to do it, and virtue is doing it.”
~David Starr Jordan

The 80 hour work week restriction has gotten a lot of attention over the past 5 years. Many believe that these are the only changes that have significantly affected resident and medical student education. Over the past 20 years there have been a number of things that have change the way physicians practice. As much as the 80 hour work week was a shock to the training system, there have been small changes in requirements for billing, resident supervision, and reimbursement, that have probably affected resident education in a more subtle way.

In the early 90's, many academic medical centers were evaluated by CMS and levied huge fees on a number of academic medical centers. From these evaluations, a number of new guidelines were set for billable encounters in teaching situations. The changes have require more of an attending presence in clinical and surgical procedures. Although this did not directly change resident education, it changed the attendings participation in patient care. The days of (billed) resident run clinics went away. The days of (billed) surgical procedures without attending presence are gone. These changes are good for patient care, but changed resident education. It increases the duration of the learning curve. There is no room for allowing the young surgeon to figure out how to get through the cases. I call this the "futz factor." Young surgeons need to "futz" to figure out what works best for them. With attendings present, they tend to become impatient with "futzing" and take over the case. Most young surgeons need to do, observation is not as helpful unless you have the experience on which to build. This change the resident attending interactions and cause many attendings to become more hands on.

Along with increased requirements for billing came a decreases in physician reimbursements. Decreases in reimbursements caused an increasing need for surgeons to become more clinically active. Department chairmans began to see the departments overall income decreasing. Systems to encourage increase clinical production (incentives) were set up. Now, you income became more like true private practice. The mentality of "you eat what you kill" began to creep into the mentality of new attendings. The days of seeing few patients, doing a couple of cases and getting a large salary are gone. With less overall (clinical) income, salaries became effected. It has caused attendings be like Snoop said, "with my mind on my money and my money on my mind."

The question may be posed, "why would this change resident teaching?" You would assume that more attending presence there should be better education. You would assume that more cases and more out-patient and in-patient experience would be better for resident education. Unfortunately, I don't see this as being the case. What I see is more patient being seen in clinic and less time for teaching. What I see is more cases being done with a limited amount of time, requiring more attending participation and less time to "futz". What I see in an increasing number of different procedures and increasing complexity of these procedures with less time to learn them. I see residents being over extended because of the increasing demand to produce clinically. I see the use of PA's and other physician extenders taking away residents ability to learn some of the basic skills, such as casting. With money being the driving factor, education suffers. Teaching does not pay, therefore education suffers.

So, as much as I harp on the "new generation" and on the 80 hour work week, I also think that our ability to educate well has also been affected. I think that we are not educating as well. Our ability to spend time educating our future surgeons has changed. We will have to develop new techniques for educating them. I fear things will get worse before they get better. I worry that we may be graduating future surgeons who are less prepared than in the past. Is this better for patient care?

“Real education must ultimately be limited to men who insist on knowing, the rest is mere sheep-herding.”
~Ezra Pound


md007 said...

I am currently an intern on a trauma (gen surg) rotation with all PAs. We must do a better job at developing quality measures to determine if patients are as well off as before with PAs managing the floor. On one hand it seems that anyone (MD, PA, NP, my little cousin) could learn to manage a floor if only in a certain setting and seeing relatively the same thing over and over. I don't dislike PAs, but one could argue that by definition they aren't as motivated (or their motivation would have subconsciously driven them to med school). The quote about people who insist on knowing might apply.

It is very frustrating to have sacrificed so much, only to see people with less years of education knowing the basics of my specialty much better than my fellow residents and I. If they can, in fact, produce similar outcomes, then is there any point?

Based on the little I know, my particular program is very strong on developing the technical skills. If what is lacking is clinical decision making, then I am going to have to push for changes in the way our 80 hours are used.

I see inefficiency in healthcare around every corner. We're getting better, but we still suck. I find another year of residency a hard pill to swallow when I see so many opportunities to better manage the time we already have.

Chrysalis Angel said...

I hadn't thought of it this way- "What I see is more patients being seen in clinic and less time for teaching. What I see is more cases being done with a limited amount of time, requiring more attending participation"

At first I was reading and it sounded good, until I read that above. That's so true, if your clipping along and having to get patients through, you don't necessarily have time for "teachable moments".

Someonetc said...

good to here from you. hope all is going well. i don't think that PA's/NP's are the answer but they do bridge the gap. problem is that they do need an experienced surgeon to watch over them because of the concerns you have listed.

i think what most residents early in there career realize is that just because you can operate doesn't mean you should. it is that clinical decision making that comes with time. it comes from developing you own style and encorperating others style.

the ineffieciency in an academic setting comes partially from the learning environment (at all levels not just physician). then there is the mindset of the institution that things just run at a slower pace. when i rotated at our private hosptial as a resident, everything was very efficient. surgeries went fast, i thought it was because of me. i realize that it actually was inspite of me. if you find a way of correcting the system, let me know.

we are not rewarded financially for teaching. reseach grants are hard to come by. so, we are evaluated base on our clinical production. there are some academic centers that have a special formula based on reseach and clinical production and amount of time teaching. that formula be comes too complicated. if you are told you take home 50-60% of you collections, that is easy math.

i personally try to teach during clinic and in the OR but sometimes it is easier and faster if i do it. the temtation to take the easier route that gets me home faster and nets me more clinical volume is hard to resist.

Chrysalis Angel said...

After doing it day in and day out, I can certainly understand. I wonder why it is the educational system pays so poorly to those in the trenches, yet administrative pay is most lucrative --at least in some venues.