Russell J C, Kaplowe J, Heinrich J
New Britain General Hospital, CT 06050, USA.
Acad Med. 1999 Jun;74(6):641-5. doi: 10.1097/00001888-199906000-00007.
The downsizing of residencies and the migration of residents to outpatient settings create an increasing need to protect residents' educational experiences and to maintain standards of hospital care. Some hospitals have solved this dilemma by using mid-level practitioners (MLPs), including physician assistants (PAs), to augment the diminished staffs of residents in their surgical residencies. The authors describe how their hospital has done so. Their surgical PA program, begun in 1979, seeks to meet the hospital's expectations for in-house coverage of surgical patients, to protect the educational integrity of the physician residency program in surgery, to allow protected time for residents' conferences and clinics, and to prepare residents for future practice in multidisciplinary teams. The PA and residents' services are partly separated, which reduces the potential for resident-PA conflict. Responsibilities for both residents and PAs are stratified (junior vs senior status). Both services are teaching services, which helps motivate PAs to be committed to the service and helps foster the equality between residents and PAs that the program strives for. The residents have come to value the PAs, and the program's goals have been achieved, including protecting time for residents' education and maintaining humane on-call schedules for residents. The authors discuss job satisfaction, turnover, and the hard financial realities of paying for PAs' salaries, benefits, and educational programs, as well as the loss of Medicare DME and IME reimbursements when a PA replaces a resident. Ways some of these costs can be recovered are outlined. The authors conclude with recommendations on how to deal with six key issues of PA or other MLP programs: need for institutional commitment; importance of local circumstances; emphasis on partnership, not competition, between PAs and residents; value of an education component; need to build a cohesive program, and the importance of effective PA leadership.
住院医师培训规模的缩减以及住院医师向门诊科室的转移，使得保护住院医师的教育经历和维持医院护理标准的需求日益增加。一些医院通过使用中级医疗人员（MLP），包括医师助理（PA），来扩充其外科住院医师培训项目中减少的人员，从而解决了这一困境。作者描述了他们医院是如何做到这一点的。他们的外科医师助理项目始于1979年，旨在满足医院对手术患者院内护理的期望，保护外科医师住院医师培训项目的教育完整性，为住院医师的会议和门诊留出受保护的时间，并使住院医师为未来在多学科团队中的执业做好准备。医师助理和住院医师的服务部分分开，这减少了住院医师与医师助理之间发生冲突的可能性。住院医师和医师助理的职责进行了分层（初级与高级地位）。这两种服务都是教学服务，这有助于激励医师助理致力于该服务，并有助于促进该项目所追求的住院医师与医师助理之间的平等。住院医师已经开始重视医师助理，并且该项目的目标已经实现，包括为住院医师的教育留出时间以及为住院医师维持人性化的值班安排。作者讨论了工作满意度、人员流动率，以及支付医师助理的工资、福利和教育项目所面临的严峻财务现实，以及当医师助理取代住院医师时医疗保险耐用医疗设备（DME）和独立医学评估（IME）报销的损失。文中概述了一些可以收回这些成本的方法。作者最后就如何处理医师助理或其他中级医疗人员项目的六个关键问题提出了建议：机构承诺的必要性；当地情况的重要性；强调医师助理与住院医师之间的合作而非竞争；教育组成部分的价值；建立一个有凝聚力项目的必要性，以及有效的医师助理领导力的重要性。
