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As a surgery intern 5 years ago, I watched as chief residents performed operative procedures on their own. Attendings were always in the hospital to supervise care, particularly at the university hospital. But the degree of independence afforded the chief residents an opportunity to start cases themselves. On the floors, senior residents and chiefs performed minor procedures without direct supervision.
Today, Medicare's antifraud and abuse programs have put an end to any degree of quasi-independence for even the most senior residents. Medicare's rules require that attending surgeons be present for the ill-defined "crucial" part of every procedure and personally examine and evaluate new patients.1,2 The new rules require attendings to actively participate in "examining patients and doing procedures." This broad language guarantees that the new rules cover essentially every aspect of a resident's training.
Many of Medicare's rules are vague and their interpretation and enforcement capricious, yet they are being supported with vigorous resources. Antifraud units will receive more than $100 million this year, and the figure will increase to $200 million in the year 2002. The FBI has 350 agents working on more than 2300 health fraud cases. The Internal Revenue Service and Department of Health and Human Services have each doubled the size of their health care fraud units. Signaling increasing resolve, the Justice Department has just hired 115 additional lawyers to prosecute these cases in court.3
Aware of the impressive collection of resources being used to enforce the Physicians at Teaching Hospitals (PATH) antifraud initiative,4 attending physicians at teaching hospitals have grown cautious of running afoul of the new rules. As a result, attendings believe they must perform essentially all care on their patients. PATH is therefore having profound effects on how residents are trained: "See one, do one, teach one" is often being replaced by "See one, see another, watch as one is taught."
The Past: Young Physicians Running Amok?
The PATH initiative results from concerns that in the past partially trained physicians performed procedures that should have been undertaken by fully trained physicians. Its architects hope to prevent mistakes and their attendant morbidity and mortality. Regulators are also concerned with the way Medicare funds are spent since residents' salaries are indirectly drawn from these monies. If a resident performs a procedure that an attending does not supervise yet submits charges for, then Medicare is paying twice for that procedure. That practice could reasonably be labeled fraud or abuse. If a military contractor practiced that sort of government billing policy, few would defend it.
Independence has educational value, however. This is especially true in surgery, where there is no substitute for actually performing the procedure. William Halsted, the father of modern surgical training, advocated a graduated increase in responsibility and independence for residents.5
Once I have the requisite background and training, I will learn more as a surgery resident if I hold the scalpel, examine the abdomen, and read the computed tomography scan at 2 AM. If my attending is by my side for each of these maneuvers each time I do them, I may still learn but I will not learn as quickly or perhaps as well. Independence with a safety net lets me feel the anxiety of responsibility while protecting the welfare of my patients.
Unfortunately, there is no reliable way to quantify whether and how any of these changes will actually affect the performance of those graduating from these residency programs. We will not learn of any adverse effects until years from now.
The Future: A Search for Balance
What is needed is a plan for the future of resident education that is fair to patients, taxpayers, attendings, and residents. The government must understand the goals and necessary processes of the education they are funding. Attendings must know precisely what the government is now requiring of them in terms of supervision. Patients must understand that even when a resident is taking a conspicuous role in performing their care, an attending physician is supervising and assuring quality.
Perhaps part of the social contract that allows hospitals to receive government funding for health care should include the training of young physicians. Close monitoring and controls must of course be kept in place. Institutions that do not want to participate in federal programs can pay for patient care themselves or through private insurance. While this solution is hardly perfect, it offers a starting point.
Krieger LM. Medicare Antifraud Initiatives: Effects on Resident Education. JAMA. 1999;281(13):1227. doi:10.1001/jama.281.13.1227-JMS0407-3-1
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