The role of politics in shaping surgical training

A defining quality of professionalism is commitment to a core set of values, regardless of divergent external pressures. The external forces affecting surgical training and practice have grown in recent years. Fortunately, the values and professional commitments of surgeons have not necessarily been in conflict with these outside demands. However, over the past century, the profession has morphed in such a way as to be able to better respond to these pressures, and in turn, the training pathways have changed as well. It is unclear whether this metamorphosis will have a positive or negative effect in the long term, but it clearly will have an impact on issues that affect surgical training, including finance and health care policy, workforce shortages, work-hour restrictions, informed consent, and attending supervision in the operating room (OR).

Finance and health care policy

The health care delivery system and health care policy have had significant influence on the surgical training environment since the formal residency model was adopted in the early 20th century. Under this system, the resident is both a government employee and student; and teaching hospitals serve a dual mission of providing medical education and charitable care while operating in a competitive marketplace.1,2

Until the 20th century, surgeons trained via informal pathways, including apprenticeships, training abroad, or short graduate courses. The length and quality of training varied and the financial arrangements between the apprentice and the “master surgeon” were made in a free-market environment.3 William S. Halsted, MD, FACS, developed the first formal surgical residency model in 1889. In the true Halstedian model, residents trained in a teaching hospital and attended to ward and OR tasks under graduated levels of supervision in exchange for room and board and a small salary.4,5 Teaching hospitals at this time served patients who were largely receiving charitable care and who generally accepted that training physicians would be providing some of their hospital care.6

Fueled by the growing safety and sophistication of modern surgery, by the 1920s, a new kind of patient sought hospital services: middle- and upper-class Americans who were willing and able to pay for increasingly elective care.7 This population did not last long because the costs of health care quickly rose to an unaffordable height. However, these private-payment patients played a significant role in shaping the view that medical care was a product that could be purchased and should be provided by fully trained physicians and surgeons—not residents.8 Surgical residents necessarily assumed less independent roles, and hands-on learning was replaced with increasingly menial tasks.9

To address the problem of increasing medical costs, the nation turned to prepaid insurance plans, and by the early 1960s, most Americans had employer-based health care insurance.7 This payor solution served to increase the “paying” patient population, heightening competition between hospital systems. Teaching hospitals were not protected from these market forces and because resident care and teaching activities are economically inefficient, these realities further restrained the educational mission.

In 1965, Medicare and Medicaid were established to support the two populations that had been left out of the employee-based system: the elderly and indigent. While this was an important and just payor solution, the legislation only worsened the commercial pressure on teaching hospitals. Recognizing this conflict, the federal government pledged financial support of graduate medical education (GME) by increasing reimbursement to teaching hospitals with greater funding than nonteaching hospitals on a per-patient basis under Medicare Part A.5 Training physician costs were initially covered in Medicare Part B, but a major movement in 1969—in which Medicare refused to pay for services performed by residents—affected teaching hospitals in a negative way. The next decades saw political battles over reimbursement for resident services, and although some deals were worked out, the ultimate consequence was a steep downturn in the number of operations that residents performed. The issue largely remains unresolved today.7

New reimbursement regulations were put in place in 1984 in an effort to respond to increasing GME costs with the enactment of Medicare’s prospective payment system (PPS). Under this system, which is still in use today, hospitals are reimbursed for GME based on number of residents, estimated costs based on Medicare patient volume, and other factors. Medicare pays hospitals for direct medical education expenses (DME), which covers resident salaries, funding for faculty teaching, and educational facility costs—and indirect medical expenses (IME), which include the increased costs teaching hospitals incur due to increased lab tests and increased complexity of disease and care. DME is calculated on a per-resident basis with the amount varying between hospitals based on the proportion and number of Medicare patients treated.10

Simultaneously with the PPS came managed care trends with payment based diagnosis-related groups (DRGs), which reimburse hospitals a fixed amount of money for a specific diagnosis rather than for actual costs. Managed care reimbursement rewards volume and lower prices, which not only increases pressure for teaching hospitals to run in a commercial fashion, but puts pressure on faculty to concentrate on treating more patients faster.2 This environment increases the number of admissions with quicker turnover/discharges, essentially increases administrative work for residents, and dampens opportunities for bedside learning.11

Historically, surgical training has benefited from—but has also and tragically been impeded by—political and financial forces. After all, federal policymakers control reimbursement of hospitals for activities related to GME, which stands to fund appropriate facilities and competent faculty for teaching. They also dictate the financial pressures of the health care marketplace, which affects the balance between commercialism and the educational mission of academic medical centers. Furthermore, the delivery system indirectly influences cultural trends in patient expectations, which affects the ability of a surgeon-in-training to participate in providing meaningful patient care. In an era of health care reform and ongoing debate about federal funding of GME, it is important to understand how the political climate has influenced surgical training throughout history and its potential impact moving forward.

Surgeon shortages

National politics has long played a significant role in determining the distribution of the medical and surgical workforce. Within a span of more than three decades, from the late 1970s and early 1980s to the present time, the pendulum has swung from a perceived excess of physicians and surgeons to an acknowledgment of severe shortages of physicians, particularly in surgery and primary care. Among the many statutes affecting GME and, as a result, the surgical workforce, perhaps the most significant piece of legislation has been the Balanced Budget Act of 1997, which capped the number of residency training positions that Medicare would fund.12

Surgical training timeline

1889: William S. Halsted, MD, FACS, institutes first formal surgical residency model at Johns Hopkins University, Baltimore, MD.
1914: Judge rules that patients have the right to refuse medical care.
1920s: Patients begin seeking out elective procedures from fully trained attending surgeons.
1950s: Employer-based health insurance coverage becomes the norm.
1957: Court rules that patients must be informed of potential risks and complications associated with a procedure in order to make medical decisions in their best interests.
1965: Medicare and Medicaid Act expands coverage to elderly and indigent patients—dramatically affecting the funding model for GME.
1969: Medicare moves resident reimbursement out of Part B.
1984: Medicare institutes a prospective payment system to reimburse hospitals, under which hospitals are paid for DME and IME.
1984: Libby Zion dies in a New York hospital due in part to misdiagnosis by two residents who had been working for 18 continuous hours. Sparks calls for resident work work-hour restrictions.
1992: Medicare begins using relative value units to determine physician payment.
1997: Balanced Budget Act caps the number of Medicare-funded residency positions.
2000s: Multiple studies indicate growing shortages in the number of general surgeons available to care for an aging population, particularly in rural areas.
2003: ACGME issues work-hour restrictions for interns and residents.
2008: Institute of Medicine recommends residency training programs increase on-site supervision.
2010: Affordable Care Act is enacted, requiring all Americans to have health insurance, thereby likely increasing patient load.

Fast-forwarding to 2009, the American College of Surgeons (ACS) Health Policy Research Institute (HPRI) revealed some startling statistics in its report Surgical Deserts in the U.S.: Places without Surgeons. In 2006, 30 percent (925) of the 3,107 U.S. counties lacked a single surgeon, had a total population of nearly 9.5 million Americans, and had 433 critical access hospitals.13 A study by Etzioni and colleagues in 2003 noted that due to an expanding/aging population, there would be a 31 percent increase in surgical services between 2001 and 2020.14 This combination of circumstances will likely result in a 9 percent shortage in the general surgical workforce, with greater shortages in other surgical specialties.15 The Dartmouth model used to benchmark regional procedures and specialist variations also shows that the degree of the variation in regional physician supply is significant. The number of physicians per capita was 1.6 times higher in high-supply versus low-supply regions.16

Other issues that have affected the surgeon shortage include the declining number of medical student applications for general surgery residency; a desire among current trainees for a more balanced lifestyle; increased subspecialization; the liability crisis; and declining reimbursement.17 Whereas the implementation of the 80-hour workweek has resulted in significant improvements in the current quality of life of residents, many concerns have been expressed with regard to the potentially negative effects on professional development, including young surgeons feeling less comfortable starting out in solo practices, especially in rural areas, where they may be the sole surgeon in the county.18

In the early 1990s, Medicare introduced the relative value unit (RVU),and it is now a prominent component in determining physician reimbursement.19 Because the health care system could no longer support the “historical fees” general surgeons charged, Medicare developed a list of procedures it deemed overvalued and downwardly adjusted payment accordingly.20 The early 1990s also saw a redistribution of funds from surgeons to primary care physicians as Congress shifted its focus to the management of chronic illness. The primary care fee schedule was readjusted upward at the expense of “proceduralists.” All of these changes in payment undoubtedly discouraged surgeons from remaining in practice any longer than necessary and medical students and residents from pursuing surgical training. Some studies have noted that the attrition rate among general surgery residents ranges from 14 to 32 percent nationally, and the economics of the profession have had a role in this high drop-out rate.21,17

The cost of practicing surgery, in operational expenses and liability insurance premiums, has a major impact on the decision to enter the profession. Limiting liability and potential economic disaster could attract more graduating students to a surgical career. Damage caps, which directly limit the magnitude of a liability award and thereby theoretically lower liability insurance premiums, are one means of protection. Legislative reform has resulted in non-economic damage caps in many states.22

Recognizing that the residency caps from the Balanced Budget Act need to be repealed if the number of U.S. physicians is to increase, Sen. Bill Nelson (D-FL) and eight other co-sponsors introduced the Resident Physician Shortage Reduction Act of 2009. This bill proposed a 15 percent increase in the number of residency positions funded through Medicare. Of great interest to general surgeons was the fact that the bill included provisions that would give specific preference for increasing direct GME funding and indirect medical education slots to hospitals that submit applications for new primary care and general surgery residency positions.12 This important piece of legislation was reintroduced in 2013 by Senator Nelson and the bill’s other co-sponsors and is currently in the Senate Finance Committee.

Rural areas in particular are known to have a surgeon-to-population ratio that is significantly lower than non-rural areas.23,24 If the goal is to alleviate shortages, simply increasing the number of general surgeons will not necessarily lead to an increased supply of surgeons in the areas where the need is greatest. Research has shown that new physicians preferentially settle in areas where supply is already high.12 Political support is imperative to achieve geographically focused recruitment/retention with immigration visas, loan forgiveness, improved reimbursement, and other incentives to optimize the delivery of care in underserved areas.

Other recent changes on the political front will affect surgical training in the near future, directly and otherwise. The Affordable Care Act of 2010 increases access to insurance coverage for Americans, which theoretically will increase patient load. Additionally, on March 1, the budget sequestration cuts took effect, which will reduce Medicare spending by 2 percent. This funding cut is likely to affect the creation of more surgical training positions.

Political support similar to that for encouraging surgeons to practice in underserved areas could likely be the tipping point for medical students to consider surgical residency.

Work-hour restrictions and public pressure

The health care landscape was categorically different in the U.S. before World War II, as many illnesses were untreatable, hospital length of stay was extensive, procedures were less technically complex, and the volume and nature of surgical practice was quite different.25 When the resident training system originated in 1889, trainees were expected to reside at hospitals, always be on call, and not marry. Though these expectations changed somewhat over the years, in spirit they remained relatively constant until recently, with physicians self-regulating work hours without much input from the rest of society. Even in 1975, when residents at New York City hospitals went on a one-day strike for a reduction in on-call frequency, their concerns were addressed directly by area training institutions.26

National attention to resident work hours dramatically increased in the late 1980s when 18-year-old Libby Zion, the daughter of a prominent journalist, died at New York Hospital, partly due to misdiagnosis by two exhausted emergency room residents. Working for 18 continuous hours, the first- and second-year residents attempted treatment that resulted in a lethal drug interaction with Ms. Zion’s outpatient medication.26 In the years following her death in 1984, New York State’s Bell Commission was formed in response to the public perception that residents were overworked and undersupervised. The commission evaluated resident work hours and ultimately recommended restricting residents to 80 hours of work per week averaged over four weeks with a maximum of 24 consecutive hours per shift.27

New York codified the recommendations of the Bell Commission Report in 1989. Residents continued to work long hours, though it wasn’t until 10 years later that New York State mandated an 80-hour workweek enforced through fines on noncompliant teaching hospitals. The issue of work-hour limits catapulted to the national stage. The U.S. Department of Health and Human Services found that long work hours may impair physician performance, but the federal government hesitated to adopt a national policy on resident work hours. The department deferred this responsibility to the Accreditation Council for Graduate Medical Education (ACGME), which in 2003 mandated nationally what the Bell Commission Report recommended a decade earlier for New York.26 The ACGME’s restrictions applied to all specialties in all residency programs across the country. The ACGME further restricted interns to 16-hour shifts in 2011, in line with the Institute of Medicine’s quality improvement recommendations.

These regulatory measures failed to change actual work hours, as residents continued to work more than 80 hours per week. To maintain continuity of care, residents applied work-arounds, such as swiping cards and returning to work, and underreporting actual work hours, to avoid loss of their program’s accreditation. Before the ACGME mandate, surgical residents easily experienced weeks of more than 100 actual work hours, and some reported on-call shifts of up to 60 consecutive hours.28 Although surgical residents report better quality of life and reduced burnout since the work-hour restrictions went into effect, the realities of patient care are unchanged.18 Residents need to be at the hospital both for the well-being of their patients and for the sake of their education. The volume and quality of work performed in those 100 hours must in some way benefit the patient.

Unfortunately, the correlation between work hours and patient outcomes is dubious. Long work hours can undoubtedly make residents tired, but no statistically significant evidence is available to show that their reduction actually leads to fewer adverse events. Data from the College’s National Surgical Quality Improvement Program (ACS NSQIP®) indicate no significant improvement in quality of patient care after the work-hour restriction, and there is no conclusive evidence that decreased sleep deprivation leads to decreased medical error.18,29,30

Perhaps the biggest problem with connecting work-hour restrictions to better patient outcomes is the fragmentation of patient care that results from caps.25 The trade-off between reducing work hours and increasing hand-offs may be impossible to bypass. Errors are prone to occur during care transitions due to miscommunication and are likely to result in poor outcomes for the patient.31 An increased number of residents in programs or a higher reliance on mid-level providers may be needed to approximate the same level of care that can be achieved with a single resident working long hours. Either way, risky hand-offs are more likely to occur. Furthermore, the physician-patient relationship may be fragmented because residents must often leave the hospital rather than provide continual care to the same patient.29

The concerns of decreased continuity of care point to another drawback of work-hour caps: their negative effect on surgical residency training independent of patient outcomes. It stands to reason that reduced time in the hospital may result in fewer opportunities for hands-on training. Many hours of practice are required to achieve expertise in any field. It has been forecast that longer residency programs may be required to maintain training quality. Lengthening residency may further deter medical students from entering surgical residency.32 Another fear regarding the effect of work-hour restrictions on resident education is that they may prevent residents from receiving critical instruction in morning reports and attending rounds and other conferences.33

A counterpoint to this claim is that residents have more time for independent study; junior residents at a New York hospital experienced a significant improvement in American Board of Surgery In-Training Examination scores after the state restricted work hours.34 The ACGME’s work-hour restrictions protect six hours of time for education and hand-offs. Additionally, data from multiple studies suggest no significant change in resident operative case volume after the work-hour cap.18 One year after the restriction was implemented, 39 percent of surveyed surgical residents felt that although it worsened the quality of their training, it raised their quality of life.35

Raising resident quality of life and maximizing patient safety are not conflicting goals, so it is unfortunate that the health care system’s structure created the illusion that they are. The best way to approach scarcity of surgical residents’ time is to find efficient evidence-based ways to make the most of it. Fabri suggested that reducing redundancies, promoting collaboration, improving hand-offs, and establishing solid clinical mentorship are appropriate strategies to accomplish this goal.25 The long-term effects of work-hour restrictions on both the training of surgical residents and the health of their patients remain to be seen. Public demand for these restrictions is overwhelming since the Libby Zion case and demonstrates the effect of social pressure on how physicians are trained.36 Most likely, these restrictions are here to stay. Teaching hospitals will have to implement creative scheduling solutions to achieve the best outcomes for everyone. Additionally, as society takes an indirect role in influencing residency training, it is important to provide nonphysicians with evidence-based reasoning so that their opinions about work-hour restrictions and other matters are well-informed.

Patient safety and informed consent

Patient consent has been an important topic since Plato made the distinction between physicians and physician assistants in his dialogues, “Laws,” and since he discussed the concept of medical consent and coercion in “The Statesman.”37 However, the first legal decision addressing informed consent in the U.S. was the 1914 ruling Mary E. Schloendorff v. the Society of the New York Hospital—the first case upholding a patient’s right to refuse medical care.38 Ms. Schloendorff agreed to an exam under anesthesia to determine if a fibroid tumor was malignant. Even though Ms. Schloendorff stated she was not consenting to resection of the tumor, the surgeon removed the mass. In his final ruling, the judge in the New York Court of Appeals found the surgeon guilty of battery and wrote, “Every human being of adult years and sound mind has the right to determine what shall be done with his own body.”38 That opinion became the basis for subsequent cases involving a patient’s right to autonomous decision making.

The term “informed consent” first appeared in the case of Martin Salgo v. Leland Stanford Jr. University Board of Trustees in 1957.39 Mr. Salgo awoke paralyzed after an angiogram and had never been informed that the procedure involved the risk of paralysis. The ruling in favor of the plaintiff stated that sufficient disclosure of risks and complications—informed consent—was necessary for patients to make appropriate autonomous decisions.

Today, informed consent and the role of surgical trainees remains an important topic in surgical training. The three major ethical requirements of informed consent are disclosure, patient understanding, and patient decision making.40 The role of surgical trainees during the patient’s procedure and how it affects patient informed consent is another frontier in the evolution of general surgical training that is still being elucidated.

Knifed and colleagues surveyed surgeons (n=274)at the University of Toronto, ON, to determine what surgeons tell patients about the role of residents in their care and found that only 17 percent explicitly inform patients—without being asked by the patient—that residents may do portions of their operation.41 During qualitative interviews with surgeons, several themes emerged, which were that surgeons are comfortable allowing residents to operate with graded responsibility, see residents as important assets beneficial to patient care, and recognize the trust patients place in them. However, another theme emerged from these qualitative interviews, which is that surgeons do not routinely voluntarily inform patients about the role of residents in the OR. Researchers also qualitatively interviewed patients undergoing elective neurosurgical procedures about the role of residents in their surgery.42 Most patient respondents had a low level of knowledge about what residents are and do, but also had some anxiety about the involvement of residents. Most of these patients were unaware that residents have medical degrees and did not know the difference between medical students, junior residents, and senior residents. However, they understood that residents would be present in the OR, supported residents’ educational needs, and overall stated they trusted the medical system. These respondents understood and accepted that hands-on training is essential for residents to become competent surgeons, with at least one respondent stating, “It’s better for them and just for the future of medical practice that they’re in surgery.” However, most patients thought surgeons should be responsible for informing them about resident involvement in their operation and indicated that they would like to meet the residents involved before the operation. Only 24 percent of surgeons surveyed require that residents meet the patients before operating on them.42

Cowles and colleagues also surveyed general surgery patients (n=200) regarding their perceptions of resident involvement in their surgical procedure.43 In contrast to the study by Knifed et al, most of these patients, 70 percent, knew that residents had completed medical school. Among these patients, 91 percent believed resident involvement in their care was important to help in the education of future surgeons, and 86 percent were comfortable with resident involvement.43 However, only 64 percent were willing to allow residents to perform some of the procedure. When examining patient expectation and association with patient attitudes regarding resident involvement, the awareness that there would be multiple physicians involved in their care was positively correlated with positive patient attitudes toward the role of residents in their care. When patients anticipated that several physicians would be involved in their medical care, they were more likely to feel it was important to help in the education of future surgeons, to know who was in charge of their care, to feel that surgical residents helped them better understand their plan of care, and to have positive responses to resident involvement.

Porta and colleagues surveyed patients (n=316)  specifically about disclosure of resident participation and its effect on patient informed consent.44 They found that 94 percent of patients had consented to having a resident participate in their operation, and 91 percent believed that their care at a teaching hospital was equivalent to or better than that of a private hospital. Most patients believed that they received personal benefit from participating in resident training and that their participation would benefit other patients. However, most patients wanted to be informed if a resident was going to be involved in their operation (87 percent for a minor procedure and 95 percent for a major procedure). Additionally, 92 percent wanted to be informed if this was the first time the trainee was performing a particular procedure, with 55 percent stating that this information would make them less likely to consent. Patient belief that there was a societal or personal benefit associated with the participation of residents in their procedure correlated with their willingness to consent to resident involvement.

These studies show that, in general, patient knowledge about surgical trainee involvement in an operation is low but has a large impact on patient informed consent. Also, when patients anticipate that their care will be provided through a team approach, are given the opportunity to meet the resident members of their surgical team before the procedure, and understand the personal and societal benefits of resident participation, they are more likely to consent to having a trainee assist in their operation.

Supervision in the OR

While surgical trainees in the past were free to independently manage the care of indigent patients, today’s training programs require an increasing amount of attending supervision due to economic and social pressures, including an increasing number of paying patients and a social trend toward a single standard of care.45 In 2008, the Institute of Medicine recommended that residency training programs increase the amount of supervision of trainees through on-site supervisors.46 In addition, the ACGME has instituted requirements for general surgery residency training programs that include specific recommendations for resident supervision.47 These requirements contain guidelines for senior resident supervision of junior residents, as well as attending supervision of all residents. The stated goals of attending supervision include ensuring patient safety, resident education, and fostering professionalism. While the intended purpose of increased faculty supervision is lauded, the effects of these policies have, in some instances, been perceived as negative.

Theoretically, greater attending involvement has led to less resident autonomy and consequently ill-prepared residents. Many residents report feeling under-trained.48 This perception is reflected in the increased number of residents pursuing fellowship training.49 It is likely that this sentiment stems from a combination of less resident autonomy and reduced duty hours. This concern is less commonly expressed among other nonsurgical specialists who report that increased attending involvement has proven to be beneficial to their education and patient care.50 However, the unique procedural and acute nature of surgery requires a gradation of responsibility to fully develop an independent surgeon.

Loss of resident autonomy has been a consequence of social, economic, and political pressures. Although the effects of increased attending involvement in the operating room are not well studied, it is imperative that technical skills and intraoperative decision making are taught through alternative methods to ensure the continued development of skilled surgeons.


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