Stahlfeld Kurt R, Robinson John M, Burton Elan C
Department of Surgery, The Mercy Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15217, USA.
J Surg Educ. 2008 Sep-Oct;65(5):354-8. doi: 10.1016/j.jsurg.2008.06.002.
The 80-hour workweek has forced surgical training programs to employ physician extenders to reduce work hours and improve the educational environment. The purpose of our study was to document objectively the specific workload provided by physician extenders and to evaluate any objective or subjective benefit provided to the residency program.
Over 4 consecutive months, all orders written by 2 physician extenders associated exclusively with the general surgery residency program at our institution were reviewed. They were categorized as daytime or evening orders and were subdivided into admission, routine preoperative and postoperative, acute care, daily laboratories, pain medications, Pro re nata (PRN), wound care, and discharge orders. Acute care issues and PRN orders were individually examined and subdivided. The appropriateness, total volume, and the orders for each category were totaled and reviewed.
Overall, 3101 total orders (1128 daytime and 1973 nighttime) were reviewed in a 4-month time period. On average, physician extenders at night wrote 35 orders per shift, compared with only 18.8 orders during the day. During the night, admission orders totaled 547 (27.7%), preoperative orders 442 (22%), acute care issues 324 (16.4%), PRN orders 239 (12%), and pain medication and PRN sleeping pills 156 (8%). During the day, routine postoperative orders totaled 305 (27%), daily laboratories 184 (16%), and discharge orders 253 (22%).
Physician extenders wrote appropriate orders and reduced resident workload. Educational opportunities increased because fewer residents left conference for acute patient care issues, and 1 fewer resident was absent during the day secondary to 1 less resident being sent home postcall. Performance on the American Board of Surgery In-Training Examination (ABSITE) increased dramatically for a focused group of residents. As the expense of each extender is approximately $90,000, justification to administration is dependent on the institutional support and efficiency of the residency program. A clear simple outcome is that by improving standing orders and clinical pathways, and by using an electronic medical record system, noneducational work hours can be reduced significantly.
每周80小时的工作时长迫使外科培训项目雇佣医师助理以减少工作时间并改善教育环境。我们研究的目的是客观记录医师助理提供的具体工作量，并评估其给住院医师培训项目带来的任何客观或主观益处。
在连续4个月的时间里，对我院普通外科住院医师培训项目专属的2名医师助理所开具的所有医嘱进行了审查。这些医嘱被分类为日间或夜间医嘱，并进一步细分为入院、常规术前和术后、急性护理、日常实验室检查、止痛药物、按需（PRN）、伤口护理和出院医嘱。对急性护理问题和PRN医嘱进行单独检查并细分。统计并审查了各类医嘱的合理性、总量及具体医嘱。
总体而言，在4个月的时间段内共审查了3101条医嘱（1128条日间医嘱和1973条夜间医嘱）。平均而言，夜间医师助理每班开具35条医嘱，而白天仅开具18.8条医嘱。夜间，入院医嘱总计547条（27.7%），术前医嘱442条（22%），急性护理问题324条（16.4%），PRN医嘱239条（12%），止痛药物和PRN安眠药156条（8%）。白天，常规术后医嘱总计305条（27%），日常实验室检查184条（16%），出院医嘱253条（22%）。
医师助理开具了合理的医嘱并减轻了住院医师的工作量。教育机会增加了，因为更少的住院医师因急性患者护理问题离开会议，且由于呼叫后送回家的住院医师减少一名，白天缺勤的住院医师也减少一名。针对一组重点住院医师，美国外科委员会住院医师培训考试（ABSITE）的成绩大幅提高。由于每位医师助理的费用约为9万美元，向管理层说明其合理性取决于住院医师培训项目的机构支持和效率。一个明确简单的结果是，通过改进常规医嘱和临床路径，并使用电子病历系统，非教育性工作时间可大幅减少。
