Surgical Education Practice administration training needs of recent general surgery graduates Mary E. Klingensmith, MD,a Thomas H. Cogbill, MD,b Kelli Samonte, MA,c Andrew Jones, PhD,c and Mark A. Malangoni, MD,c St. Louis, MO, La Crosse, WI, and Philadelphia, PA
Introduction. Practice administration education and experience during surgery residency are variable among residency programs. To better understand these issues, a survey of recent General Surgery residency (GS) graduates was compared with the results from a survey of GS program directors (PD). Methods. All GS graduates completing residency from 2009 to 2013 (n = 5,512) were surveyed to assess opinions regarding the desire for more instruction during residency in practice administration. General surgeons were defined as those not pursuing fellowship training; specialist surgeons (SS) completed additional training after their GS residency. Separately, all GS residency PDs were surveyed regarding practice administration education in their programs. Results. A total of 3,354 responded to the GS graduate survey (response rate = 61%). GS comprised 26% of the respondents. The vast majority of all respondents desired more training in practice administration. There were no significant differences in the degree to which instruction was desired among GS, SS, residency program type, or current practice setting. The GS PD response rate was 68% (171/252 programs). Only 28% of programs included practice administration in the residency curriculum. Conclusion. Practice administration education is highly desired by GS and SS graduates. Our findings indicate a clear need for a curriculum in practice administration during residency. (Surgery 2015;158:773-6.) From the Department of Surgery, Washington University in Saint Louis,a St. Louis, MO; Gundersen Health System,b La Crosse, WI; and American Board of Surgery Inc,c Philadelphia, PA
(GS) residency programs do not feel prepared for independent practice.1 This concern is shared by fellowship directors and fellows of the American College of Surgeons.2-4 One contributor to this feeling of unpreparedness may be a lack of practice administration education and experience gained during residency. Practice management education during residency has been shown to be limited and highly TRAINEES OF GENERAL SURGERY
The American Board of Surgery provided financial support for the survey portion of this study. Presented at the 10th Annual Academic Surgical Congress in Las Vegas, NV, February 3–5, 2015. Accepted for publication February 8, 2015. Reprint requests: Mary E. Klingensmith, MD, Department of Surgery, Washington University in Saint Louis, 660 South Euclid, Campus Box 8019, St. Louis, MO 63110. E-mail: [email protected]
0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2015.02.028
variable among residency programs.2,5 An ability to effectively attend to the business of medicine, from billing and coding to contract negotiations and liability management, are skills necessary for successful surgery practice. To better understand the current status of practice administration training during residency, recent GS residency graduates in the United States were surveyed about their exposure to this topic. During a similar time frame, GS program directors (PDs) also were surveyed for comparison. METHODS All US allopathic GS graduates who completed residency from 2009 to 2013 (n = 5,512) were anonymously surveyed by the American Board of Surgery to assess opinions regarding their desire to have received more instruction and experience during residency in the following areas of practice administration: coding, contract negotiations, practice management, insurance billing, billing the uninsured, liability, insurance for one’s own practice, and retirement planning. SURGERY 773
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Surveys were distributed by mail in November 2013 with up to 2 follow-up mailings to nonrespondents. For the purposes of analysis, general surgeons were defined as those who did not pursue fellowship training whereas specialist surgeons (SS) completed additional training after GS residency. In a separate survey, all GS residency PDs in the United States (n = 252) were surveyed by e-mail during October and November 2013 regarding the inclusion of practice administration education in their residency programs. Reminder e-mails were sent on 2 subsequent occasions to increase response rate. For the GS graduate survey, responses were analyzed by the use of statistical comparisons based on the following variables: program completion year (2009 vs 2010 vs 2011 vs 2012 vs 2013); residency program type (university-based vs independent vs military); surgeon type (GS vs SS). Confidence level was ±5% at 95% confidence level for all results. RESULTS There were 3,354 respondents to the GS graduate survey (response rate 61%). GS comprised 876 of the total respondents (26%) with SS accounting for the remaining 74%. The vast majority of all respondents desired more training in all areas of practice administration that were queried: billing and coding instruction (desired by 86%), contract negotiations (84%), practice management (83%), insurance billing (82%), billing of uninsured patients (77%), professional liability management (76%), professional liability insurance (75%), and retirement planning (72%). There were no significant differences in the degree to which these areas of instruction were desired among graduate year cohorts, residency program type, or current practice setting (university vs community). Coding, contract negotiations, practice management, and insurance billing were the areas for which most GS and SS graduates desired additional training (Figs 1 and 2). SS tended to want additional education about liability and retirement planning more than GS, but these differences were not significant. The survey of GS PDs had a response rate of 68% (171 of 252 programs). Among respondents, only 28% of programs included practice administration education as part of the residency curriculum. There were no differences in how often this education was included when results were stratified by size or type (university, community, or military) of residency program.
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Fig 1. Survey responses by GS residency graduates who did not pursue fellowship training regarding desire for more practice administration education during training.
Fig 2. Survey responses by fellowship-trained residency graduates regarding desire for more practice administration education during training.
DISCUSSION The climate of surgery practice has changed significantly during the past few decades, with greater liability concerns, increased regulations for billing compliance, and greater complexity to coding as several features of modern practice. Despite increased requirements for GS residency training programs mandated by the Accreditation Council for Graduate Medical Education and American Board of Surgery in other areas, there is currently no requirement for trainees to receive practice administration education. The current study confirms that this subject is seldom included in the curricula of training programs; only 28% of programs offer such training suggesting it is a systemic shortfall common to residencies of all sizes and types. Education in practice administration, however, is very strongly desired by recent residency graduates who currently work in a range of practice types and locations. Practice administration is recognized as an important area for understanding on entering clinical practice and acquisition of knowledge in this domain is considered essential.4,6-9 Practice management education during residency is needed to prepare trainees for independent
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practice. The perceived lack of preparation in this area may be a contributor to the reported lack of confidence recent graduates feel going into practice directly after residency. All graduates should be given the necessary financial and administrative skills to succeed in practice whether they choose GS or SS, with our survey suggesting both groups strongly desire such training. Furthermore, our study suggests that this need is desired by graduates who currently work across a range of practice locations and types, from academic to group to private practices, and in a range of geographic locations. The value of effective billing practices has been demonstrated in numerous studies10-12 in which optimizing clinical productivity has been shown to be beneficial to the overall mission of academic departments of surgery; certainly the same is true for independent, nonuniversity-affiliated practices. Three other recent survey studies support our findings. In a study of American College of Surgeons fellows, younger surgeons (to greater degree than older surgeons) desire formal training in financial, coding and billing, compensation, and hiring issues.2 ‘‘Business administration’’ also was cited as a deficiency among graduating chief residents who were surveyed regarding their opinions of confidence gained in training.13 Fakhry et al4 surveyed 5 residency programs and found that residents and attending surgeons concurred about the lack of adequate training in billing and coding practices. This deficiency is not unique to GS training. Several recent studies across a range of specialties suggest similar needs for increased practice administration training during residency. This shortcoming in current residency training and graduate experience has been reported in Orthopedics,14 Neurology,15 Dermatology,16 and Otolaryngology.17 Including practice management within the curriculum of a residency program allows trainees a mentored environment for learning key principles, and an opportunity to apply them in a semi-autonomous setting; thus a residency graduate---regardless of eventual practice type or setting---will possess key knowledge in these important areas. There are several potential means to address this educational gap. First, didactic curricular content delivered during residency could be an effective means for addressing this need. The general surgery residency at Methodist Medical Center in Dallas demonstrated that a didactic program on practice management resulted in improved coding compliance by residents as well as greater satisfaction among residents with the topics covered, including among those who transitioned to independent practice.5 The content can be delivered in
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Table. Essential elements of practice administration curriculum Contract negotiations Coding and reimbursement Third-party payor preauthorization and billing Patient billing Professional liability management Professional liability insurance Practice management skills Retirement planning
a didactic, ‘‘curriculum conference’’ format, or in a digital content that can be accessed by trainees for independent learning. MDContent, available on the Surgical Council for Resident Education web portal, has been demonstrated to increase knowledge of residents on business of health care principles and concepts.18 This online curricular content covers the ‘‘Systems Based Practice’’ competency and includes such topics as operations management, physicians reimbursement, medical liability, and negotiations and physician contracting. (www. surgicalcore.org). On the basis of the results of our survey, we propose a list of the essential components of a surgical residency curriculum in practice administrative principles (see Table). Second, a mentored experience with a general surgeon during later residency years could be used to introduce trainees to the practical aspects of practice management. Deveney et al19 demonstrated that trainees with experience in a rural practice location were more likely to practice community-based general surgery than those who lacked such an experience. One can speculate that the experiences included exposure to practice management components, leading to increased confidence in this area among graduates who selected community practices. A GS rotation specifically designed to provide a mentored experience in practice management would be an ideal method for providing this education during residency. Third, autonomous or semiautonomous experiences during the chief year---a resident managed ‘‘chief service’’ on which the resident learns to run their own outpatient clinic, schedule OR cases, interact with insurance carriers, and code their own cases is a tremendous learning opportunity. Performed with attending oversight, this immersive experience was a frequent method for teaching these concepts when these services were more common in residency programs; many programs are still able to offer these experiences and they are well received by trainees (B. J. Jarman, 2012 Association of Program Directors in Surgery Workshop).
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The general surgery residency program at Georgetown University has reported on a novel immersive workshop for training residents in certain aspects of practice management including coding and billing during the outpatient clinic experience.20 Residents involved in this training demonstrated increased knowledge after the intervention. Although this intervention was limited to the outpatient setting, feasibility may be greater than the increasingly rare ‘‘chief service’’ offered so often in the past. Finally, practice administrative education should be continued during the post graduate year(s). The American College of Surgeons Transitions to Practice Program (TTP) has imbedded practice management education as 1 of its 5 key components for the TTP year (www.facs.org/education/program/ttp). This fundamental aspect of the experience during the transition between residency and practice is emphasized to give those who complete the TTP experience the knowledge and confidence for successful independent practice. Many other SS training programs mention ‘‘systems-based practice’’ in their core curriculum; the degree to which specific practice management principles are taught is not clear and remains an area for investigation (https:// fellowshipcouncil.org/fellowship-programs/curri culum/). Despite inclusion of these principles in the curricula for fellowship training, the results of our survey suggest there is an ongoing, unmet need for training in this area, regardless of whether an individual obtains additional fellowship training beyond general surgery residency. Our study has several limitations: first, the surveys of residency graduates and program directors relied on subjective responses and could have been influenced by recall bias. Curricular content of practice management offerings in actual training programs was not evaluated to confirm (or refute) presence or absence among reporting programs, nor breadth nor thoroughness of content covered. Practice management education is an important component of residency training. Current offerings appear limited across residency programs of a variety of type and size. This systemic shortfall is noted by recent residency graduates, regardless of whether they are GS or SS surgeons. Our findings indicate a clear need for an improved curriculum in practice administration during residency.
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