Surgical Education and Health Care Reform: Defining the Role and Value of Trainees in an Evolving Medical Landscape.

OBJECTIVE: Health care reform and surgical education are often separated functionally. However, especially in surgery, where resident trainees often spend twice as much time in residency and fellowship than in undergraduate medical education, one must consider their contributions to health care. SUMMARY BACKGROUND DATA: In this short commentary, we briefly review the status of health care in the United States as well as some of the recent and current changes in graduate medical education that pertain to surgical trainees. METHODS: This is a perspective piece that draws on the interests and varied background of the multiinstitutional and international group of authors. RESULTS: The authors propose 3 main areas of focus for research and practice- (1) accurately quantifying the care provided currently by trainees, (2) determining impact to trainees and hospital systems of training parameters, focusing on long-term outcomes rather than short-term outcomes, and (3) determining practice models of education that work best for both health care delivery and trainees. CONCLUSIONS: The authors propose that surgical education must align itself with rather than separate itself from overall health care reform measures and even individual hospital financial pressures. This should not be seen as additional burden of service, but rather practical education in training as to the pressures trainees will face as future employees. Rethinking the contributions and training of residents and fellows may also synergistically work to impress to hospital administrators that providing better, more focused and applicable education to residents and fellows may have long-term, strategic, positive impacts on institutions.

Patient-centered care and the electronic health record: exploring functionality and gaps.

OBJECTIVE: Healthcare systems have adopted electronic health records (EHRs) to support clinical care. Providing patient-centered care (PCC) is a goal of many healthcare systems. In this study, we sought to explore how existing EHR systems support PCC; defined as understanding the patient as a whole person, building relational connections between the clinician and patient, and supporting patients in health self-management. MATERIALS AND METHODS: We assessed availability of EHR functions consistent with providing PCC including patient goals and preferences, integrated care plans, and contextual and patient-generated data. We surveyed and then interviewed technical representatives and expert clinical users of 6 leading EHR systems. Questions focused on the availability of specific data and functions related to PCC (for technical representatives) and the clinical usefulness of PCC functions (for clinicians) in their EHR. RESULTS: Technical representatives (n = 6) reported that patient communication preferences, personalized indications for medications, and end of life preferences were functions implemented across 6 systems. Clinician users (n = 10) reported moderate usefulness of PCC functions (medians of 2-4 on a 5-pointy -35t scale), suggesting the potential for improvement across systems. Interviews revealed that clinicians do not have a shared conception of PCC. In many cases, data needed to deliver PCC was available in the EHR only in unstructured form. Data systems and functionality to support PCC are under development in these EHRs. DISCUSSION AND CONCLUSION: There are current gaps in PCC functionality in EHRs and opportunities to support the practice of PCC through EHR redesign.