Practice management education during surgical residency.

BACKGROUND: Surgical education has undergone radical changes in the past decade. The introductions of laparoscopic surgery and endovascular techniques have required program directors to alter surgical training. The 6 competencies are now in place. One issue that still needs to be addressed is the business aspect of surgical practice. Often residents complete their training with minimal or no knowledge on coding of charges or basic aspects on how to set up a practice. We present our program, which has been in place over the past 2 years and is designed to teach the residents practice management. METHODS: The program begins with a series of 10 lectures given monthly beginning in August. Topics include an introduction to types of practices available, negotiating a contract, managed care, and marketing the practice. Both medical and surgical residents attend these conferences. In addition, the surgical residents meet monthly with the business office to discuss billing and coding issues. These are didactic sessions combined with in-house chart reviews of surgical coding. The third phase of the practice management plan has the coding team along with the program director attend the outpatient clinic to review in real time the evaluation and management coding of clinic visits. RESULTS: Resident evaluations were completed for each of the practice management lectures. The responses were recorded on a Likert scale. The scores ranged from 4.1 to 4.8 (average, 4.3). Highest scores were given to lectures concerning negotiating employee agreements, recruiting contracts, malpractice insurance, and risk management. The medical education department has tracked resident coding compliance over the past 2 years. Surgical coding compliance increased from 36% to 88% over a 12-month period. The program director who participated in the educational process increased his accuracy from 50% to 90% over the same time period. CONCLUSIONS: When residents finish their surgical training they need to be ready to enter the world of business. These needs will be present whether pursuing a career in academic medicine or the private sector. A program that focuses on the business aspect of surgery enables the residents to better navigate the future while helping to fulfill the systems-based practice competency.

Can a computed tomography scoring system predict the need for surgery in small-bowel obstruction?

BACKGROUND: Small-bowel obstruction (SBO) is a common dilemma faced by general surgeons. A timely and accurate diagnosis is crucial, based on history, physical examination, and radiographic studies. A computed tomography (CT) scan has become an increasingly common diagnostic modality. The aim of this study was to define a set of CT criteria that may help determine whether a patient would require operative intervention. METHODS: A retrospective chart review was performed over an 18-month period. Patients diagnosed with SBO or partial SBO (PSBO) who had a CT scan performed were included. CT scans were then reviewed independently by a staff radiologist blinded to the clinical outcome. A scoring system based on 7 radiographic criteria was then developed. Statistical analysis was performed on the data. RESULTS: From March 1, 2004, to August 30, 2005, 96 patients were found to have the diagnosis of SBO or PSBO and a documented CT scan. Seventy-four patients had undergone prior intra-abdominal procedures. Fifty-five percent were taken to the operating room (OR) over an average of 1.9 days (range 1-12 days). Seventy-nine percent of these patients went to the OR within the first 24 hours. Lysis of adhesions was performed in 38%, small bowel was resected in 47%, and incarcerated ventral hernias were found in 11%. Ischemic bowel was found in 11% of the cases. The CT scoring system was then correlated with the actual treatment. A score of 8 or higher predicted the need for surgery 75% of the time. When looking at the criteria individually, patients with a CT reading of complete obstruction, dilated small bowel, or free fluid were operated on 77%, 66%, and 65% of the time, respectively. CONCLUSION: A CT scoring system can successfully predict the need for surgery 75% of the time. Likewise, specific criteria, when present in combination, can predict the need for operative intervention in 79% of cases with SBO.