Surgical Education and Health Care Reform

Defining the Role and Value of Trainees in an Evolving Medical Landscape

Abstract

Objective: 

Health care reform and surgical education are often separated functionally. However, especially in surgery, where resident trainees often spend twice as much time in residency and fellowship than in undergraduate medical education, one must consider their contributions to health care.

Summary Background Data: 

In this short commentary, we briefly review the status of health care in the United States as well as some of the recent and current changes in graduate medical education that pertain to surgical trainees.

Methods: 

This is a perspective piece that draws on the interests and varied background of the multiinstitutional and international group of authors.

Results: 

The authors propose 3 main areas of focus for research and practice— (1) accurately quantifying the care provided currently by trainees, (2) determining impact to trainees and hospital systems of training parameters, focusing on long-term outcomes rather than short-term outcomes, and (3) determining practice models of education that work best for both health care delivery and trainees.

Conclusions: 

The authors propose that surgical education must align itself with rather than separate itself from overall health care reform measures and even individual hospital financial pressures. This should not be seen as additional burden of service, but rather practical education in training as to the pressures trainees will face as future employees. Rethinking the contributions and training of residents and fellows may also synergistically work to impress to hospital administrators that providing better, more focused and applicable education to residents and fellows may have long-term, strategic, positive impacts on institutions.

The cost of health care continues to increase in the United States, and providers, educators, and payors alike are struggling to strike a balance between providing services, training physicians, and curtailing costs. Total health care spending initially slowed from 2008 to 2013 as a result of the economic recession and increased cost-sharing with patients.¹ But rates of health care spending increased again in 2014, as the Affordable Care Act led to increased coverage, reaching $3.0 trillion, or 17.5% of the US gross domestic product.² At the same time, this increase in expenditure has not translated into improved health outcomes. According to a recently published Commonwealth Fund report, the US health care system ranks last among 11 industrialized countries along multiple dimensions of health care quality including cost-related access to care, efficiency, equity, and population health.³

As health care providers face ever-increasing pressure to decrease expenditure, graduate medical education (GME) has also become a target of cost-cutting efforts. Many large academic institutions are facing economic difficulties and are already over the federal cap, leading them to freeze expansion of new trainee positions and consider eliminating positions or cutting costs previously designated to education. Additionally, regulations such as work-hour restrictions implemented in 2003 and may 2011 have significantly changed the care previously provided by trainees.⁴ Recognizing and moving to better balance the line between service and education, the Accreditation Council for Graduate Medical Education (ACGME) has appropriately placed more focus on curriculum development and residency structure to prevent the burden of service from usurping the mission of education. These reforms, while admirable from both a humanitarian and educational perspective, have nonetheless prompted struggling health care systems to assess whether they can afford the prestige of being training institutions. In fact, some would maintain that a health care system might become more efficient by eliminating or decreasing trainees—but this argument is undermined by some evidence that trainee involvement actually improves patient outcomes.^5,6 Additionally, common sense would indicate that this modification would be at the expense of having a next generation of providers, potentiating further strains on an already stressed workforce.

We would argue that holding education in a separate silo from health care delivery is counterproductive, as it holds trainees back from growing into productive members of the health care team, and that the sooner the service provided by trainees is recognized as a very integral part of the health care delivery rather than a cost sink, the sooner GME will benefit. Many speak of the conflict between service and education—yet, the most superb training and education models in complex skills are built upon progressive autonomy, which implies a level of its service. Appropriate, as health care is in the service sector. One can see hints of this in educational initiatives such as Entrustable Professional Activities (EPAs) and ACGME's publication “CLER Pathways to Excellence: Expectations for an optimal clinical learning environment to achieve safe and high quality patient care.”^7,8 In this, “expectations for supervision and progressive autonomy” are phrases that are found together. As a major tenet of education, we simply must ask trainees to perform real tasks—to both demonstrate competence and exercise their own practice-based learning in their quest for progressive autonomy. However, as of now, the results of these tasks reflect only on the trainee and are not recognized as direct service provided to the patient as the EPA is successfully completed or as autonomy is increased.

How does this tie into health care reform? This requires changing our perspective of trainees within health care delivery. The recognition of the current contributions of trainees to health care delivery could increase expectations and further the goals of surgical education as well—these are not exclusive. This was eloquently discussed in a recent commentary in the Journal of the American Medical Association (JAMA), where authors stated that we need to recognize the interdependence of education and health care delivery rather than keeping the education world in a separate silo from the business aspects of health care delivery.⁹ There is a great deal of anxiety and attention paid to the “cost” of resident physicians in academic centers, in surgery and in other disciplines, as if this inhibits the mission of the institution. Rather than asking and considering how much it costs an institution to train a resident, we would urge that the better question for educators and academic centers to ask and answer with real financial modeling is “how much does it cost to not train a resident?”

Many current studies focus on outcomes of unnecessary testing, increased operative time, and increased lengths of stay, all secondary to perceptions of more inefficient care delivered by the trainee. Instead, proper questions must revolve around 3 core concepts: (1) how would the current delivery of care change with a different distribution of trainees, length of training, or fewer resources, (2) what is the impact on our future surgery workforce and patient value if our training models change drastically in an attempt to maximize short-term revenues at the local level or decrease spending at the federal level, and (3) can we change our own training models to alleviate institutional burdens while strengthening education—for example, can the trainees help the institution and patients reach ultimate goals. The answers to these broad questions would require complex modeling but could help us reframe our question of considering the “costs” of surgical training.

Here, we outline 3 potential starting points:

1. Regarding current delivery of care: Accurately assess the costs and contributions of trainees. The truth of the matter is that we are still trying to determine what the cost of resident education is in this country and it remains unclear whether care provided by trainees is better or worse than care from which trainees are excluded.5,6 For example, it is important to consider that the bulk of perioperative care provided to some of this country's most vulnerable, most complicated, and most cost-generating populations—veterans and the under- and uninsured—is provided primarily by surgical trainees at the nation's Veteran Affairs (VA) and public hospitals, respectively. These services are not considered when individual institutions determine their own costs even though trainees are often part of both structures, often on the same campus. Thus, it is entirely possible that the net economic effect and patient value delivery of postgraduate surgical education on the American health care system is one of economic and value gain rather than loss.
2. Regarding future delivery of care: Accurately assess the future impact of decreasing funding for trainees on their ability to practice active autonomy and deliver care of value to patients. There have been many publications regarding the imminent workforce shortage but the outcomes have generally reflected patient access, a topic important but not necessarily central to financial decisions of institutions. In fact, one could argue that less access to qualified physicians actually means higher demand for services—a ploy many find attractive for job security. Instead, outcomes need to be in the same language spoken by financial officers—predicted recruitment costs, onboarding costs, retention rates (and subsequently turnover), salary impact—and also by patients—access, quality, and cost.
3. Regarding changing our own training models to alleviate institutional burden while strengthening education: Look for practice models that work synergistically between administration and education. Rather than creating additional mandates to protect education, we must work in partnership with our institutional leaders to align educational goals with both financial goals and patient value within the institution and beyond. After all, when residents leave training, they join these same institutions and immediately are living under the same expectations as their prior mentors. Program directors and residents agree that trainees in surgery need more exposure to practice administration in residency.10 If we continue to separate training from the economic pressures locally and nationally, we are actually doing an educational disservice to our trainees. Models such as teaching resource management through feedback similar to that which faculty receives, working toward progressive autonomy and even billing for procedures where residents have been “checked off” are not beyond the scope of thinking creatively about synergy between education, efficient care delivery, finances, and best preparing trainees to enter practice.

Whatever directions health care reform and surgical education take, today's surgical educators and trainees need to be active and informed contributors—service and education can be successfully combined. We feel that a major step in education of trainees in practice administration, health care delivery, and health care reform is to accurately quantify and recognize critical financial contributions trainees are already making to hospital systems, as partners in understanding these contributions and their effects. This could positively impact national, institutional, and potentially even patient perceptions of the roles of trainees in care, furthering education as well. Although daunting, the current challenges in both surgical education and health care delivery together represent an opportunity for the integrated improvement of both. We look forward to working with the next generation of surgeons to face these challenges with creativity, commitment, and a willingness to learn from each other.