Integration of Allied Health Personnel With Surgical Residents Produces Latticework of Patient Care Delivery in an Academic Medical Center

Stephen F. Sener, MD, FACS, Professor of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and Vice-Chairman Department of Surgery, Evanston Northwestern Healthcare, Evanston, Illinois.

One of the responsibilities of leadership in an academic department of surgery is to recognize, accept, and embrace the dual role of providing excellence in the care of the surgical patient while also providing all of the essential elements in a surgical residency training program. However, over the last decade changes in the environment have forced hospital and departmental operations to function perilously close to or at profit margins. There has also been a shift in the emphasis of surgical training towards the outpatient experience and reduced workloads. It is anticipated that there will be a further contraction of residency training programs, resulting in shortening of the total duration of training and in providing fewer residents to general surgery from specialty divisions at the post-graduate year-1 (PGY-1) level. The impact of these external forces has led to the integration of the non-physician workforce with surgical residents in order to allow the maturation of training programs while still maintaining excellence of patient care.

In our institution, registered nurses (RNs) and physician assistants (PAs) have fulfilled patient care roles and have allowed surgical residents the freedom to concentrate on the educational objectives of the program.

In the outpatient clinic, RNs co-manage patient care with the surgeon by providing wound care and patient education, and by ordering diagnostic tests and delivering results. Funding for RNs is provided jointly by hospital revenue, the National Cancer Institute-funded Clinical Community Oncology Program (CCOP), and physician revenues (tax).

PAs have been employed in our institution to assist in the operating room and on the inpatient surgical unit. Funding for PAs has been shared between the hospital and physician revenues (tax).

The workload assigned to PAs in the operating room primarily represents non-teaching and outpatient cases. There are two distinct advantages from involvement of PAs in these operations: first, the department of surgery can bill for PA services in the operating room; and second, the PA provides continuity in patient care between the preoperative, operative, and the postoperative management. We have estimated that our department is able to capture approximately 50 percent of the PA salary cost with appropriate billing mechanisms.

On the inpatient surgical unit, PAs provide a stable relationship between nurses and surgeons, leading to consistency in communications and expectations. Surgical residents continue to participate in the perioperative care of patients. However, there is now a more consistent level of care provided, minimizing the risk of treatment-associated morbidity and consequent medical liability, while maximizing patient satisfaction with a uniformly high quality of care. The essential element has been the establishment of a cooperative and valued relationship between residents, PAs, and surgeons. We are constantly aware of the need to create a clinical management team with expectations that are visible to all constituents. It has been our goal to make routine patient care independent of resident education and yet to maintain shared decision-making between surgeons, residents, and PAs. Our PAs are also eager to provide timely emergency consultations, performing initial clinical evaluations and data-gathering for presentations to surgeons and senior residents. It is also imperative that the PA physician manager recognize that PAs work 40 to 45 hours per week, so inclusion of PAs into the resident team requires innovative strategies.

We have also adjusted roles to create a "trouble-shooter" PA, assigned to fill in for vacationing residents, variations in service needs, and the night float vacancies.

Because we anticipated the trend towards reduced surgical resident work hours, we began the integration of PAs into our program about five years ago. However, with the abrupt transition to the 80-hour work week in July 2003, we were forced to reconfigure the program at that time. Our initial experience with the program changes has been generally favorable. The most important element in the transition has been the need for constant communication between surgeons, residents, and PAs to accomplish the dual goals of high quality patient care and resident education. Our primary goal, to create an environment in which resident education is independent of routine patient care needs, is closer but remains unfulfilled. Perhaps the next major issue for our program managers to tackle is patient care at night, since there is an arguable educational benefit to night float for residents but a clear need to provide care during these hours.

 

Revised January 18, 2005