Residency Training Requirements for Perioperative Care in the Four Specialties of Anesthesiology, Family Medicine, Internal Medicine, and Surgery
Presenter: Kayla Cline, Texas A&M University
Recorded on: November 5, 2014
And what we did is a survey of emerging programs in perioperative surgical home models in the US. And when we have interest from the medical community about collaborating on a paper, and mostly that was our collaborator on this paper RahilRoopani who was MS4. We came up with maybe an idea about, so how is this relevant to future doctors and graduate medical education as we place more importance on the ability for physicians to get more involved in the perioperative surgical home?
So that's where the idea came from for this paper. And Kayla will tell you more about how we took our results and mapped them against four specialties to help us understand the needs for graduate medical education. And Kayla Cline, the lead PhD student on this project, will be our presenter today.
And pretty much everybody knows Kayla. She was the recipient of the poster award in our last fall meeting. Where's Kayla?
> Thanks Bita. This is Kayla Cline here, PhD student at Texas A&M University Health Science Center in the Department of Health Policy and Management. And I'll be presenting the project that Bita just introduced to you.
So I'll jump in. So first of all, we're looking at perioperative care, and before we do that we should lay some groundwork for why this is important. So as you can see here, the United States spends about $180 billion per year on inpatient surgical procedures in non-federal hospitals alone.
So that's a pretty huge chunk of change, and on top of that, the average cost of surgery continues to climb. So it was at 13,000 per hospitalization in 2000, and ten years later it was 18,000 per hospitalization after adjusting for inflation. So, that's a pretty big jump. And so we see the costs are rising but there are, I guess claims at the very least, that the quality of care and patient outcomes and patient experience may not be improving.
And so one would hope that if costs are going up, experience is improving, but that may not be the case. So as kind of a result or an answer to this problem, the Institute for Healthcare Improvement developed what's called the Triple Aim. A lot of you probably are familiar with the Triple Aim.
But the goal is to simultaneously reduce per-capita cost for healthcare, improve population health, and improve the experience of care for patients. And so this Triple Aim is something that's important across the entire healthcare spectrum but is very important in the surgical care setting. So one approach to these issues that we've talked about is the perioperative surgical home, or the PSH.
PSH programs aim to improve outcomes and reduce costs of surgical care by coordinating care throughout the perioperative process, engaging patients throughout the process. And using best practices throughout the pre, intra, and postoperative phases of surgery. PSH programs are usually headed by a physician, often an anesthesiologist, who oversees coordination of care.
Oversees the pre-op assessment, the operation itself, and postoperative recovery and discharge to ensure that everything that needs to get done is done. And that the patient care is coordinated across the entire spectrum. So here we have kind of a graphical or a visual depiction of what a PSH program might look like.
So you see across the top that coordination of care occurs across the entire spectrum of care, the pre, intra, and postoperative phases of care. So you see on the left side of the diagram, the preoperative phase, you see some of the most common PSH elements there, patient assessment and triage and so on.
And then we see that these factors that we discussed and discovered in the preoperative phase are used for surgery scheduling purposes to facilitate the interoperative phase. And then you see some of the activities that the PSH program is involved in at the interoperative phase, pain management, fluid management, and OR efficiency.
And then from the interoperative to the postoperative phase, the anesthesiologist or physician in charge facilitates the transition planning from the intra and postoperative phase and then from the postoperative stage to discharge and beyond. And finally we see some of the postoperative elements here, pain management, early mobilization, and transition to the home.
Throughout all three of these phases we see feed forward and feedback loops so that information about the patient and the process is being shared across all three parts of the spectrum. So sort of jumping into what we're specifically looking at in this paper. So several specialties could presumably be involved in surgical care, if we look at it as a spectrum from pre to postoperative and discharge care.
Anesthesiology is one that we've already mentioned, but other specialties are also well-positioned and have traditionally been involved in different parts of the surgical process. So for example, anesthesiology is somewhat involved in the preoperative phase, in prepping patients for surgery. And then they're involved in the intraoperative phase in providing anesthesia, and the postoperative phase, in terms of pain management.
Family medicine could presumably be involved in this process in the pre and postoperative phases as they are potentially helping patients to prepare for surgery and also helping patients with postoperative management. And the same goes for internal medicine hospitalists. They're somewhat involved in the preop phase, somewhat involved in the postop phase.
Surgeons are somewhat involved in the preoperative phase in prepping patients for surgery. Involved in the intraoperative phase in performing the surgery but not necessarily traditionally as involved postoperatively. And of course, all of these categorizations are generalizations, but none of them are 100% true 100% of the time. But generally speaking, what this table shows is that all four of these specialties are involved in the surgical process and are posed to help facilitate perioperative care.
And so the purpose of this study is to first of all identify which elements of perioperative care are most important. And then secondly, to match these elements of perioperative care to the board certification exam requirements in each of the four specialties. And as a result of this matching process, we will better understand first of all, which specialty is as it stands, based on board requirements most thoroughly trained to lead perioperative care initiatives when they graduate, when they finish their residency.
And then secondly, to identify gaps in perioperative care education across the spectrum in all four of the specialities. So to approach this problem, we first had to identify the key elements of perioperative care or the perioperative Surgical home. And we attacked this issue with kind of a two-pronged approach.
We first did a comprehensive review of the literature to determine which activities were most important and most discussed in the literature. And then we kind of verified our finding through key informant interviews with 24 anesthesiologists and practice administrators involved in 15 surgical home programs around the the United States.
So once we determined these elements, we mapped them to the curricular content of the in-training examinations for the four boards that you see here. These are the boards for the four specialties we discussed on the previous slide. Anesthesiology, family medicine, internal medicine, hospitalists and surgery. So before we go forward, a little bit about our interview approach.
We selected 15 sites. We are limited to 15 by our funding, so we wanted to interview 15 sites. We started with a list of 55 potential interview sites given to us by the ASA that they determined in a large-scale survey. And of these 55 sites is narrowed down to 35 based on two things.
Willingness to participate in the interviews and programs, and secondly their affiliation with one hospital. And then finally, of these 35 we spoke to 15 through votes of ASA committee members, and also based on their willingness to participate, their progress in PSH implementation, and to obtain broad geographic representation.
We also wanted to make sure there were some non-academic hospitals thrown in there as well, although that was not an explicit criterion. So here is a list of the 15 programs we ended up interviewing anesthesiologists and clinic administrators at. You can see the list here. I won't read through all of them, but the slides from this presentation will be available after the webinar, so feel free to dig into that a little deeper if you so choose then.
When we actually performed the interviews, they generally lasted about an hour and a half, sometimes one hour, sometimes two. And interviewees were asked a total of 54 questions that fell into the 9 categories you see here on the screen. So tell us about the program, patient and payor profiles, quality reporting, organizational barriers and enablers of success and so on.
You see the full list here. Most of the data that we used for this setting came from the PSH program details section where we asked specifically about involvement with pre-, intra- and post-operative elements. So moving on to our results. We'll go through the pre- and then the intra- and post-operative phase and then we'll kind of sum everything up and pull it together for you at the end.
In the pre-operative phase, you see here we have a total of six activities that we identified either through the literature search or through the interview process. The first column shows the percentage of 15 programs reporting activity. So when we interviewed the PSH program we said do you engage, or do you plan to engage in early patient engagement?
And 100% of the programs said yes, they do. So that's what those percentages mean. The rows that don't have percentages were not explicitly asked about in those interviews, so we don't have a percentage for those activities. Moving along to the right, you see each of the board requirements in one column.
And you can see the x's represent that the board requirements specify that this specialty should learn this skill. So as you can see, generally speaking, in the pre-operative phase, every specialty is involved, which we kind of expected in some way, some more than others. Interestingly, one activity that was very important to the programs that we interviewed, 100% reported that the activity was important, was early patient engagement.
However, as you can see, none of the board requirements had any sort of early patient engagement or education as a requirement for board certification. So it's an interesting difference there. It doesn't seem that this was necessarily important to these particular specialties, based on the board requirements. Of course, that doesn't mean that the residents aren't trained in this or aren't qualified to do this.
Moving on to the intra-operative phase, the figure is a little more sparse in this case. You can see that internal medicine and family medicine aren't involved in many of the intra-operative activities that we discussed, which is not entirely surprising. It makes sense that anesthesiology and surgery are more involved in the intra-operative phase of surgery because their specialty is directly involved with the surgery itself.
But even that said, there are a lot of gaps even in those two columns. And you'll notice that a lot of the initiatives that we asked about in the intra-operative phase, things like quality improvement, reducing delays, OR scheduling and so on, they're a little bit less clinical in nature, maybe a little more business or organization in nature.
And so again, it's not totally surprising that these activities aren't required by board examination. But at the same time they do appear to be very important to the PSH programs that we spoke to. All the percentages are very, very high. And so it does potentially point to a mismatch between a skill set that is developed in residency programs and what is demanded in actual peri-operative care management.
And then on the post-operative side we see kind of similar. It appears that anesthesiology and surgery are explicitly required to master some of the activities we identified in the post-operative phase of surgery. Whereas family medicine and internal medicine are not, based on board requirements, involved in or required to be trained in this activities.
You can see that anesthesiology is a little more heavily involved in the post-operative side. This surgery was solely based on the number of x's. But you can also see that there are a lot of gaps here. So things like discharge phone calls and discharge planning, early mobility therapy, things like that.
No one seems to be trained in providing activities for patients, and yet they seem to be something that PSH programs are doing to some degree. The percentages are 60% and 40%. What's interesting about this is that while these elements, the discharge planning, discharge phone calls and early mobility therapy, are not emphasized in board training requirements, they are mentioned as being important to PSH programs, but they are not as highly emphasized as some of the other elements that we see.
So pain management, 100% of the programs are doing it, but only 60% of the programs are doing discharge planning or early rehabilitation. So it's interesting. It seems almost that there's a gap in the training requirements and there's also a bit of a gap in the actual PSH programs themselves.
And so this is perhaps Something that increased training or education for residents to improve, would not only prepare them for how practice is already going, but maybe help them improve practice going forward in the future. So a couple of summary points. The pre-operative state is the most populated of the three phases.
So, it seems that the specialties are the most heavily trained on pre-operative activities, pre-operative testing, patient education, and things like that at the beginning. And so, all specialties seem to be well positioned to provide the pre-operative elements of care. The intraoperative phase, overall, is probably the least populated, but this is not entirely surprising like we talked about earlier, because many of these intraoperative components are less clinical, and more administrative in nature.
And so the lack of, I guess, these elements on board certification exams are not entirely surprising. For both the intra- and post-operative phases, only surgeons and anesthesiologists appear to have formal training in the initiatives that we identified based on board certification requirements. Also, some of the noticeable gaps that we discussed.
So, 100% of anesthesiologists indicated that patient coordination, engagement, activities so that education about the risks and benefits of surgery. Communication about preparation were important. Not a single curriculum required training in patient surgical training as part of a board requirement. That's really interesting and seems to be very important in practice not emphasized on the examination.
Again, this does not mean that residents aren't trained in this, it just means they're not necessarily tested, but it still potentially points to a gap. Similarly, the lack of education related to interoperative management, like we talked about a lot of the administrative OR schedule and facilities optimization initiative, were not heavily emphasized or are not emphasized at all in board requirements, but they seem to be very important to the effective functioning of a PSH, and so.
And in talking with some of the physicians that we've worked with, this seems to kind of ring true. That a lot of these physicians are not trained in maybe Lean or Six Sigma when they're in school. But then they're expected to do that and be proficient at that when they're working.
And so, that's something that we noticed in our results. And kind of similarly a lot of the, not similarly, excuse me, on the post operative side some of the gaps are more clinical in nature, so post discharge planning and post op rehabilitation are more clinical and administrative, but are not covered in any of these specialty board requirements, and so it does seem to be sort of a gap in the current, the way the education for these specialties stands now.
And so, kind of the take away from this is that if any of these specialties want to pose themselves as the perioperative of the future. These are maybe some areas that they can beef up their training requirements. So overall if we tallied up the matches from the surgical homes, activities, and the board requirement you see that the American Board of Anesthesiology.
So seven matches surgery side, internal medicine three, and family medicine 2. As based on tally alone, it appears that anesthesiologists appear to be the most qualified to deliver perioperative care. That being said anesthesiolgy curriculum matched to the seven of the 25 activities that we looked at 28%, so that's still pretty low.