Continuity of Patient Care: A Value Worth Preserving


Along with many others who are rapidly fading from the American surgical scene, I was born as a baby boomer. Most of us from that generation who embraced surgery as a career held fast to the values of the era. First and foremost among these was a high premium put on hard work, long hours, and an unwavering dedication to our profession and to our patients. We were particularly proud of the continuity of care that we provided to our patients.

During my early years as a surgeon, it was a 24/7 job. Saturday mornings were consumed by Surgery Grand Rounds followed by usually prolonged and detailed patient rounds. Most of us visited our hospitalized patients 7 days a week. When one of my patients developed a complication, I, rather than the surgeon on call, managed it. I missed soccer matches, baseball games, dance recitals, and even some family birthdays because etched into my conscience was the concept that duty to my patients trumped duty to my family. Although there is much to admire in this singular focus on patient care, it took its toll on the other aspects of what should be a more balanced professional life.

Two factors, one of them cultural and the other regulatory, have altered this all-consuming aspect of a surgeon’s life, with implications for the ideal of continuity of care. First was the arrival of freshly minted surgeons from generations X and Y who had a different set of priorities than their predecessors. They insisted on a more even balance between professional and family obligations. In part this resulted from the need for them to be more involved in child rearing since many of their spouses were engaged in time-intensive careers of their own. As they gravitated onto academic surgical faculties and joined private practice groups, they insisted on moving educational programs such as Surgery Grand Rounds to weekdays so they could participate in family activities. They entrusted the care of their patients to their partners, freeing them for entire weekends that could be devoted to family events.

The healthier balance they have brought to a career in surgery is to be admired. Much to the benefit of their senior colleagues, it has become their way of life as well. The trade-off has been some decay of the ideals of patient ownership and continuity of care.

The next and potentially more serious challenge to the cherished concept of continuous care of our patients was the mandate of an 80-hour work week by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. As to its effects on graduate surgical education, I believe the 80-hour work week has been a double-edged sword. On the positive side, at a time when interest in general surgery was waning, institution of duty hours restrictions along with the advent of minimally invasive surgery made our specialty more attractive to medical school graduates, including women, who now constitute 50% of most medical school classes. Another plus was that teaching hospitals were forced to hire physician extenders and other personnel to perform some of the noneducational tasks previously carried out by residents.

On the negative side, since many of the lost hours were in the evenings and weekends, residents’ exposure to urgent and emergency cases was diminished. More significantly, surgery residents began to work in shifts to accommodate increasingly inflexible rules. Ownership of their patients could no longer be held as a high priority in surgical education. Several classes of surgery residents who were educated under these fairly restrictive guidelines have now graduated and have brought a "shift mentality" with them to their positions in private practice groups and on academic faculties.

Since work hour restrictions are highly unlikely to disappear from our training programs and may in fact be applied in the future to all working physicians and surgeons, what can be done to preserve the time-honored value of continuous care of our patients? The answer probably lies in seeking reasonable flexibility within the rules rather than elimination of them. A bright light in this regard is an upcoming randomized controlled trial to assess the feasibility of more flexible work hours rules for general surgery residents. This trial is sponsored by the American Board of Surgery and the American College of Surgeons, and has the support of the ACGME. It will be conducted in hospitals that have instituted the National Surgical Quality Improvement Program (NSQIP) and also sponsor general surgery residencies. Beginning in July 2014, these residencies will be randomized to one of two arms – one using the extensive and rigid present duty hour standards and the second utilizing more flexible standards limited to an 80-hour work week, one night in three on call, and one day in seven free of clinical responsibilities, all averaged over a month. Patient outcomes in each arm will be determined from NSQIP data.

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