Clinical Efficiency and Resident Education: A Fine Balance
Clinical Efficiency and Resident Education: A Fine Balance
Demand for healthcare is growing at an unprecedented rate owing to an ageing population and the rising prevalence of chronic disease. In order to meet increasing demand with limited resources, clinical efficiency has become of utmost importance. Clinical efficiency balances quality of care against healthcare costs and has become a central tenet of high-functioning health systems. Increasing attention has been directed towards developing metrics that capture quality and costs of care and funding models to match. Although efforts to improve efficiency are important in today's fiscally limited, high-demand environment, top-level policies may have important unintended repercussions for frontline healthcare workers. Resident physicians, for instance, are a unique group of healthcare professionals, whose educational opportunity may be adversely affected by heightened attention to highly efficient care.
In the past decade, funding has changed from fee-for-service to non-traditional models that link reimbursement to the achievement of prespecified targets for health processes or outcomes. Examples include health-based allocation models, accountable care models and pay-for-performance. Governments have implemented wait time strategies to increase clinical volumes. In Ontario, Canada, the Wait Time Strategy dedicates resources to measuring and achieving improvements in wait times. Hospitals use this information to highlight inefficiencies, increase patient throughput and ensure that a target number of procedures are conducted annually.
Some hospitals have adopted 'lean' methodology, a management tactic to increase value-added care by streamlining processes and reducing inefficiencies. Others have implemented strategic score-cards to raise accountability to target metrics, including length of stay, 30-day readmission rates and percentage of discharge summaries completed in a timely manner. These policies, designed to optimise efficiency, can affect frontline healthcare workers, who inevitably change practices to achieve prespecified goals.
Resident physicians, for instance, provide the majority of inpatient and emergent ambulatory care in academic teaching hospitals; concurrently, resident physicians serve as trainees who have academic responsibilities to achieve the knowledge, skills and values required of independent practice. Although a service to education ratio for residents is difficult to define owing to variability in day-to-day work by specialty, geography and patient population, efforts must be made to ensure an optimal balance is achieved between providing clinical care and educational opportunity. Alarmingly, a 2003 study evaluating the value of resident work found that up to 51% of a resident's time was directed towards clinical tasks of little educational value or other unspecified activities, while 15% was spent on organised teaching opportunities (ie, rounds, conferences) and 36% on patient care in line with achieving specialty-specific objectives.
Studies published in recent years suggest that heightened focus on clinical efficiency has had further negative repercussions on fulfilling the educational mandate of academic teaching hospitals, which have struggled to adapt teaching services to emphasise education within an environment of increasing pace, complexity and intensity. In addition, studies have found that the demands of increasing clinical productivity have reduced the time spent providing resident instruction and teaching success. Unpublished data from a study that we conducted in Toronto, Canada further highlight the challenges that exist in balancing efficiency and education. Using grounded theory, we extracted key themes from 25 semistructured interviews with residents, physician-teachers and allied healthcare professionals from two distinct specialties (general internal medicine and ophthalmology) at teaching hospitals affiliated to the University of Toronto. Interviewees from across disciplines perceived that their healthcare institutions primarily emphasised clinical efficiency, potentially detracting from attention paid to trainees' educational needs. Junior residents and residents in ambulatory care settings are most likely to be affected. Factors contributing to the focus on efficiency include the following: first, at a daily operations level, immediate patient-related clinical demands take precedence over ill-defined educational goals; second, misaligned expectations among residents, staff physicians and allied health professionals about residents' educational responsibilities create an opportunity for educational needs to be overlooked; third, ambiguous accountability may result in neglected responsibilities by the parties in charge of meeting educational demands and finally, relatively intangible incentives render teaching objectives secondary to clinical responsibilities.
In today's high-volume healthcare environment, clinical efficiency is crucial. In addition to efforts aimed at improving efficiency, however, attention must be paid to protecting the education of hospital trainees in order to ensure healthcare sustainability. Targeted strategies may help to optimise the balance. First, efforts to clearly define resident responsibilities may help to realign expectations among healthcare professionals across disciplines. Second, formal efforts should be made to increase daily accountability of both residents and clinician-teachers to educational goals. Third, healthcare institutions and academic institutions can collaborate to generate increased incentives for clinician-teachers to incorporate dedicated resident education into daily practice. Finally, clinician-teachers may offer training in how to be efficient in day-to-day operations in order to help residents secure the knowledge and skills for future efficiency. As the health system burden grows, sustainability will rely on innovative solutions that can enhance clinical efficiency, optimise resource allocation and provide high-quality care, while simultaneously maintaining educational opportunity for resident physicians.
Demand for healthcare is growing at an unprecedented rate owing to an ageing population and the rising prevalence of chronic disease. In order to meet increasing demand with limited resources, clinical efficiency has become of utmost importance. Clinical efficiency balances quality of care against healthcare costs and has become a central tenet of high-functioning health systems. Increasing attention has been directed towards developing metrics that capture quality and costs of care and funding models to match. Although efforts to improve efficiency are important in today's fiscally limited, high-demand environment, top-level policies may have important unintended repercussions for frontline healthcare workers. Resident physicians, for instance, are a unique group of healthcare professionals, whose educational opportunity may be adversely affected by heightened attention to highly efficient care.
In the past decade, funding has changed from fee-for-service to non-traditional models that link reimbursement to the achievement of prespecified targets for health processes or outcomes. Examples include health-based allocation models, accountable care models and pay-for-performance. Governments have implemented wait time strategies to increase clinical volumes. In Ontario, Canada, the Wait Time Strategy dedicates resources to measuring and achieving improvements in wait times. Hospitals use this information to highlight inefficiencies, increase patient throughput and ensure that a target number of procedures are conducted annually.
Some hospitals have adopted 'lean' methodology, a management tactic to increase value-added care by streamlining processes and reducing inefficiencies. Others have implemented strategic score-cards to raise accountability to target metrics, including length of stay, 30-day readmission rates and percentage of discharge summaries completed in a timely manner. These policies, designed to optimise efficiency, can affect frontline healthcare workers, who inevitably change practices to achieve prespecified goals.
Resident physicians, for instance, provide the majority of inpatient and emergent ambulatory care in academic teaching hospitals; concurrently, resident physicians serve as trainees who have academic responsibilities to achieve the knowledge, skills and values required of independent practice. Although a service to education ratio for residents is difficult to define owing to variability in day-to-day work by specialty, geography and patient population, efforts must be made to ensure an optimal balance is achieved between providing clinical care and educational opportunity. Alarmingly, a 2003 study evaluating the value of resident work found that up to 51% of a resident's time was directed towards clinical tasks of little educational value or other unspecified activities, while 15% was spent on organised teaching opportunities (ie, rounds, conferences) and 36% on patient care in line with achieving specialty-specific objectives.
Studies published in recent years suggest that heightened focus on clinical efficiency has had further negative repercussions on fulfilling the educational mandate of academic teaching hospitals, which have struggled to adapt teaching services to emphasise education within an environment of increasing pace, complexity and intensity. In addition, studies have found that the demands of increasing clinical productivity have reduced the time spent providing resident instruction and teaching success. Unpublished data from a study that we conducted in Toronto, Canada further highlight the challenges that exist in balancing efficiency and education. Using grounded theory, we extracted key themes from 25 semistructured interviews with residents, physician-teachers and allied healthcare professionals from two distinct specialties (general internal medicine and ophthalmology) at teaching hospitals affiliated to the University of Toronto. Interviewees from across disciplines perceived that their healthcare institutions primarily emphasised clinical efficiency, potentially detracting from attention paid to trainees' educational needs. Junior residents and residents in ambulatory care settings are most likely to be affected. Factors contributing to the focus on efficiency include the following: first, at a daily operations level, immediate patient-related clinical demands take precedence over ill-defined educational goals; second, misaligned expectations among residents, staff physicians and allied health professionals about residents' educational responsibilities create an opportunity for educational needs to be overlooked; third, ambiguous accountability may result in neglected responsibilities by the parties in charge of meeting educational demands and finally, relatively intangible incentives render teaching objectives secondary to clinical responsibilities.
In today's high-volume healthcare environment, clinical efficiency is crucial. In addition to efforts aimed at improving efficiency, however, attention must be paid to protecting the education of hospital trainees in order to ensure healthcare sustainability. Targeted strategies may help to optimise the balance. First, efforts to clearly define resident responsibilities may help to realign expectations among healthcare professionals across disciplines. Second, formal efforts should be made to increase daily accountability of both residents and clinician-teachers to educational goals. Third, healthcare institutions and academic institutions can collaborate to generate increased incentives for clinician-teachers to incorporate dedicated resident education into daily practice. Finally, clinician-teachers may offer training in how to be efficient in day-to-day operations in order to help residents secure the knowledge and skills for future efficiency. As the health system burden grows, sustainability will rely on innovative solutions that can enhance clinical efficiency, optimise resource allocation and provide high-quality care, while simultaneously maintaining educational opportunity for resident physicians.