The protection of resident curriculum by work redesign

Abstract In recent years at the Yale School of Medicine, operative services work volume has increased dramatically, including a 24% increase in cases and a 17% increase in inpatient discharges. At the same time, ambulatory care has surged, reducing hospital length of stay by 26%. The institution has also been through 2 budget reviews, which reduced the operating budget by 10% each time. The result has been a rise in patient acuity, a rise in patient volume, an increase in outpatient work, and a reduction in hospital personnel available to participate in patient care. As a result, the hours of our residents have increased as they have assumed responsibility for both the volume increase and the decrease in hospital personnel. At the same time, the number of house staff positions has been reduced as a result of a training program amalgamation, and preliminary positions and time spent by specialty categorical residents in general surgery have decreased. Therefore, a work redesign project was undertaken to examine the activities of first-year trainees. The tasks of first-year trainees were divided into educational benefit (OR, rounds, conferences), service (paperwork, finding films), and tasks that were indeterminate. The service tasks were redistributed within a new service structure to include a physician associate (PA) role. The trainees were then available for educational activities, including the OR. The relationships among the nurse, PA, attending surgeon, senior resident, and patient were redefined to emphasize the role of the trainee. Under the new system, the PA spanned the roles of the attending surgeon, trainees, and nurses during the day to support managed care pathways, paperwork, nursing care plans, and questions that in the past were directed to the house staff. While reporting directly to the associate program director, the PA performed the patient care tasks on assignment from both the house staff and attending surgeons during the day, leaving little in the way of accumulated tasks for the evening. The PA also participated in the check-out rounds of the house staff and in the nursing shift meetings. Physician associates were hired for the major general surgery services and did not perform night duty. They were never perceived as replacements for house staff but rather as health care workers in a new role as defined by work redesign. The first-year trainees continued to perform 80–100 cases per year despite drastic changes in the work expectations that otherwise would have fallen to them. The evaluation of services by the residents increased substantially. Nursing evaluation of the program was completely positive, and the attending surgeons found the new system completely acceptable. Work redesign is a tactic that can preserve the educational aspects of resident training even in the face of severe resource constraints and conflicting demands on time.