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

1. 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

2. 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)

4. Decision-making Compassion Technical Skill Communication

5. 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.

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

7. 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

8. 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)

9. Background • Over the past century: • Little change in the fundamental structure of training programs, BUT • Substantial change to healthcare delivery

10. Background: Changes in Healthcare Delivery • same day admission for surgery • ambulatory surgery • limitations on resident work hours • limited operating room resources

11. 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

12. 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.

13. 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.

14. Patient Resident Methods: Data Collected • date • hospital • procedure • surgeon • nature of procedure • PGY level • operative role

15. 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

16. Methods • Missing data was identified and completed through interviews with residents. • Methodology validated through previously performed pilot study with vascular surgery residents and fellows.

17. 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

18. Results • Resident Role: • Primary operator – 60.3% • 1st assistant – 29.9% • 2nd assistant – 9.1% • 3rd assistant – 0.2% • Teaching assistant – 0.5%

19. Operative Cases by Type of Admission

20. Results: Procedures Performed

21. Results: Overall Continuity of Care

22. Factors Affecting Continuity of Care: Electivevs. Emergency * P<.001

23. Factors Affecting Continuity of Care: Same-day vs. Previously Admitted Elective Surgery *P<0.001

24. Factors Affecting Continuity Of Care: Academic vs. Community Hospital *P<.001

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

26. 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)

27. 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%)

28. 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

29. 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.

30. 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

31. 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.

32. Thank-You Thank-you