Problems with surgical residents and continuity of care

How are we doing with residency training and continuity of care? Not too well if you believe a recent paper called "Continuity of Care in General Surgery Resident Education" appearing online in the American Journal of Surgery.

A group from Rush University in Chicago looked at the records of 228 patients who underwent commonly performed operations during the year 2012. They found that in only 21/228 (9.2%) of cases had the operating resident seen the patient preoperatively, and in 20/223 (9.0%) had the operating resident seen the patient in postoperative follow-up. In no case, did the operating resident see the same patient both pre- and postoperatively.

The table lists the type of cases and the frequency of resident participation in preoperative care or postoperative follow-up.

This is important because on page 18 of the Residency Review Committee (RRC) for Surgery Program Requirements for Graduate Medical Education in General Surgery, the following is stated:

A resident may be considered the surgeon only when he or she can document a significant role in the following aspects of management: determination or confirmation of the diagnosis, provision of preoperative care, selection, and accomplishment of the appropriate operative procedure, and direction of the postoperative care.

If you interpret this literally, in not one of the 228 cases that were done was the resident who performed the procedure entitled to consider herself the surgeon for purposes of taking credit in the eyes of the RRC.

Continuity of patient care is also part of the professionalism core competency.

This is not the first paper describing this problem, nor is it the first paper to find that no residents followed a single patient all the way through the process.

What is the cause of this problem? Its not the length of the rotations because the shortest rotation for a senior resident was six weeks which should have afforded the residents ample time to have established complete continuity in at least a few cases.

The authors should be commended for their candor in reporting these findings. Had their paper been published 20 or 25 years ago, their program would have been cited by the RRC for a deficiency in continuity of care.

It’s an even bigger concern in community hospital surgical programs where the majority of elective patients come from private practice offices.

Whats the solution? The easiest fix would be to change the RRC requirement. What is the point of having a rule that cant be followed?

The residents are not learning about making the diagnosis, deciding whether to operate, the informed consent discussion, and evaluating the patient after discharge from the hospital.

The real issue is that there is much more to surgery than simply doing the operation.

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