The Problem: Changes in Case Mix, Resources and Staffi ng in Acute Hospital Care
Case Mix
By 2015 several of the contributors to this book will be approaching, or have en- tered, retirement, joining the growing population of pensioners worldwide who will in time need assistance from their health services. The health care systems on which they depend will have changed in several respects from those of today, with developments in information technology and decision support for both pa- tients and staff, in availability and utility of monitoring and imaging equipment, and in systems for improving patient safety. There are likely to be two streams for patient care: a small and predictable pathway for elective medical care in- cluding surgery and complex medical diseases, and a large, heterogeneous group requiring acute and emergent care. If current trends continue [1, 2], this latter component will constitute an even greater component of hospital activity than it does now. Given the aging world population [3], it therefore seems possible that an increasing proportion of the hospital budget may be spent on the emergency care of elderly patients.
Resources
At the same time that demand is increasing, health systems are trying to con- strain rising costs, mainly by reducing hospital in-patient beds and increasing throughput [4, 5], by making greater use of day-case or out-patient settings for low-risk interventions [6], or by overt or covert rationing. This has the effect of further focusing hospital care on emergency work, while working to capacity requires meticulous process control if staff are to improve patient safety. This is a particular problem for acute and emergent care [7] because health systems do not have consistent methods for process control of the acutely ill patient, with the consequence that many such patients appear to follow unpredictable path- ways. This is not of course true for all acutely ill patients – those who present with clearly characterized syndromes such as acute chest pain or asthma or dia- betic ketoacidosis are now much more likely to be recognized early and treated appropriately using evidence-based guidelines. However, this improvement in
Training Pathways – Physician and Non-Physician
J. Bion, H. Barrett, and T. Clutton-Brock
process control has taken many years to achieve; the management of acutely ill patients with less obvious diagnostic or specialty ‘labels’ is still far from per- fect.
Staffing
In addition to the impact of changing case mix and resources, there are also problems with health care personnel. Many countries at all levels of develop- ment are experiencing diffi culties with nursing recruitment and retention, for complex reasons which include an aging workforce, suboptimal working condi- tions, and alternative employment opportunities [8, 9]. Several major developed countries need to expand their physician workforce, but it is unlikely that physi- cian extenders will be able to substitute effectively for doctors in all aspects of a complex healthcare environment [10]. Legislation to reduce hours of work for doctors have also produced additional challenges [11-13]; the potential benefi ts to patients from reducing medical staff overwork could be offset by failures in medical communication and continuity [14] caused by the transition to shift working and dismantling traditional medical teams, and by less experienced (even though better trained) doctors.
Potential – but partial - solutions to these problems have included the use of physician assistants and non-physician clinicians [15, 16], and new ways of work- ing in acute care, including nurse-led outreach care [17-19], medical emergency teams (METs) [20, 21], hospital-at-night teams [22], and in the USA, the new spe- cialty of ‘hospitalists’ [23] practising as general physicians. The effi cacy of these new approaches remains to be determined [24], though whether improvements in process have to be mirrored by quantifi able improvements in outcomes is a matter of debate [25].
In addition to changes in workforce utilization, the attitude of the public to-
wards doctors is also becoming less deferential, more demanding, and less toler-
ant of adverse outcomes [26]. Recent events (‘high profi le failures’) in the United
Kingdom may have messages for other countries: the enquiries into pediatric
cardiac surgery in Bristol [27, 28], post-mortem organ retention at Alder Hey
[29], and the mass murderer who was also tragically a general practitioner, Ha-
rold Shipman, [30], have done much to undermine the concept of professional
regulation and reduce the authority and self-confi dence of the medical profes-
sion [31], factors which politicians have almost certainly found helpful in ‘mod-
ernizing’ the public health service towards a more commercial model involving
the private sector [32]. The fact that a MORI poll has shown that the medical
profession is trusted to tell the truth by 92% of the UK population while only
23% of politicians command a similar level of confi dence [33] is not an excuse
for complacency.
The Challenge: Different Ways of Working
Healthcare workers will need to respond to the problems outlined above by adopting new ways of working. Hospitalized patients, particularly those requir- ing emergency care, will be attended by transdisciplinary teams whose members will come from a diversity of backgrounds, who will adopt new evidence-based technologies and interventions rapidly, and use electronic systems for informa- tion management and decision support. The comparisons often drawn between aviation and healthcare safety, much to the detriment of the latter, should in the case of acute and emergency care perhaps be based on military, not civil- ian, aviation; and the error rate contrasted with that of ‘friendly fi re’ incidents.
Thus the mind set for the new acute hospital will not be the traditional, leisured, linear and hierarchical approach to diagnosis and treatment of disease; it will be open-architectured, fl exible, and focused on physiological safety. We will need to improve our management of the unexpected, of planning for uncertainty, and our understanding of risk [34] and its communication to patients and relatives [35, 36]. The care of the acutely ill patient will need to become a coherent entity, rather than remaining ‘boxed up’ in vertically orientated silos categorized by diagnosis or medical speciality. These developments will need to be refl ected by improvements in hospital design to facilitate communication and teamwork- ing.
If this perspective is accurate, it will make major demands on the interper- sonal and communication skills of individuals in the healthcare team, including their capacity for collaboration across geographical and professional boundaries [37, 38], and continuing professional development. We will need to fi nd meth- ods for operationalizing two key elements in professional practice: good man- agement (process control), and leadership (direction and policy). Some medi- cal disciplines have achieved effective process control for specifi c diseases – for example, acute chest pain, asthma, or diabetic ketoacidosis – by introducing protocol-driven care and adopting a systems approach to management from the point of fi rst contact with the patient. Improvements have taken many years to achieve however, and have been made easier by the specialty-specifi c nature of the diseases. How can we fi nd ways of improving the generic care of the acutely ill patient in the next fi ve to ten years, and how can we ensure that improvements are sustained in an environment of rapid change? Part of the answer lies in train- ing and education. We will now consider how this may be achieved.
Solutions: New (Path)Ways of Training
It would be naive to suggest that all that is required for effective health care delivery is better training and education. Moreover, there is little evidence for the superiority of one educational method over another [39], partly because of the scarcity of appropriate research methodologies, and because so many other confounding factors infl uence clinician behavior over the course of many years.
Despite this, conventional syllabus-based curricula or problem-based learning
are gradually being supplemented or replaced by outcomes-based methods for
postgraduate and undergraduate education in the UK, Canada, the USA, Aus- tralia and New Zealand, and more recently Spain, with intensive care medicine leading the way at postgraduate level [40]. Given the concurrent emphasis on maintenance of professional standards and continuing medical education af- ter specialist appointment, and the developments outlined above, educational systems will need to fi nd ways to facilitate life-long learning of physicians and integrate this with that of non-physician clinicians.
Outcomes-based (competency-based) Training
Outcomes-based training, which we will refer to as competency-based train- ing, has a number of practical and theoretical advantages. Rooted in vocational training and thus in the tradition of craft apprenticeship and practical experi- ence in the workplace, it requires prior defi nition of the outcomes of training – not ‘this is our knowledge base: you can adapt it to later requirements’, but
‘this is what you must be able to do in your chosen role’. In essence, it demands a
‘product specifi cation’ as the fi rst step. The product (person) specifi cation can be stated as a collection of competencies (or ‘can dos), each of which is described in terms of knowledge, skills and attitudes. Each competence must include a meth- od of assessment to benchmark the level of profi ciency expected. The knowledge component essentially defi nes the syllabus, and the attitudinal elements can be grouped to form behavioral competencies.
There are several advantages to defi ning training in terms of competencies.
First, it makes it clear to the trainee, the trainer, and the customer – patient or employer – what the practitioner will be expected to be able to do. Second, it clarifi es the relationship between skills and the knowledge required to support those skills. Third, it makes it easier to monitor progress, correct defi ciencies in training, and identify areas that require attention. Fourth, it permits assessment of competence during clinical practice in the workplace, which is a more natural environment than a formal examination. Fifth, assuming a standardized proc- ess for assessment in the workplace, it promotes fl exibility of the workforce by facilitating free movement of professionals across borders and sharing of skills across professional groups, the latter being an essential element for transdis- ciplinary team-based care. Sixth, by defi ning the competence of a specialist, it can also be used as the template for maintenance of professional standards or continuing professional development [41]. Finally and importantly, it is readily modifi able to permit incorporation of new knowledge, thus ensuring that prac- titioners are kept up to date with progress through research.
Competency-based training has potential weaknesses as well. By defi ning
‘core’ (and therefore the minimum) skill sets, it provides a target that most should attain, rather than an aspirational level of excellence. Some clinicians and educators fear that setting a minimum standard will ‘level down’ the quality of all practitioners. There is no agreed method for deciding which competencies to include, or for setting reproducible standards for assessment of competence.
Finding (or funding) the time and support for trainers to make these assess-
ments is a particular challenge. A wide range of educational resources needs
to be provided in an accessible format linked to each competence, with further links to the knowledge base (syllabus).
Solutions to these problems are now being developed. Consensus techniques are being used to develop an international training program for intensive care medicine in Europe (CoBaTrICE) and other world regions [40], and it is possible that this methodology might be adopted by other disciplines as well. Input from a large number of ‘stakeholders’ (specialists, trainees, nurses and other health care professionals, patients and relatives) is being incorporated using a variety of survey techniques. Once the competencies and the workplace-based assess- ment methods have been agreed, the knowledge base is identifi ed and linked to the other two elements by an electronic curriculum map [42] which also permits integration with the many other aspects of a comprehensive training program.
Web-based systems will make this a very powerful and fl exible tool for training and education, with considerable stakeholder involvement and ‘buy-in’.
‘Lateral’ Integration with Training of Non-Physician Clinicians
Non-physician clinicians occupy a variety of roles, from medical assistant (for example in operating theaters) through practitioner grades (anesthetic nurses, physician extenders) to independent substitutes (nurse practitioners or nurse consultants) with prescribing and interventional roles. The training programs for many of these groups, (as for physician hospitalists in the USA at present), are varied and often locally-based [16, 43, 44]. Although this diversity may re- fl ect differing needs between services and health systems, the lack of integration with other groups (particularly with the physicians they are intended to sup- plement or replace) may indicate a desire for professional autonomy and role protection. This is potentially unfortunate at a time of rapid change in health care delivery and in environments such as acute care which require team-work- ing and fl exibility in order to deliver care safely. What we need is not more pro- fessional barriers, but clear defi nitions of roles and skills focused on giving the patient the best care.
Before considering how this might be achieved, we should fi rst ask the ques-
tion – what is it that specifi cally distinguishes medical doctors from other health
care providers? Disregarding specifi c task- and context-related activities, the
main difference is that doctors are expected to diagnose diseases and plan an
overall treatment strategy; this requires skills in data integration supported by a
substantial body of knowledge. These skills and the associated knowledge base
can of course be acquired by non-physicians undertaking clearly defi ned roles
in elective and out-patient settings, or in treating well-characterized emergency
conditions such as acute chest pain; in these settings the clinical problem is of-
ten characterized by protocols and bounded by standardized treatment path-
ways. However, the acutely ill patient presents a more complex set of problems in
which the combination of clinical uncertainty, urgency and the need for thera-
peutic intervention before diagnosis makes considerable demands on the practi-
tioner, including the capacity for team leadership when care is delivered outside
routine ‘offi ce hours’. Do non-physician clinicians have a contribution to make to whole-hospital acute care?
In the USA, the national panel for acute care nurse practitioners has devel- oped competencies that include skills in diagnosis and treatment [45]. The pro- gram does not have direct input from physician intensivists, but it is endorsed by the Society of Critical Care Medicine, and the competencies have a fi rm basis in critical care practice. Given robust training and assessment processes, the in- tensive care unit (ICU) is an ideal environment for developing practitioners with cross-specialty roles in whole-hospital acute care. In the UK this has already oc- curred with the development of ‘outreach’ care, in which critical care nurses pro- vide staff support and patient care in ordinary acute wards, liaising with the ICU when necessary [17]. Discussions are now taking place in the UK about develop- ing national competencies for non-physician clinicians in acute and emergency care, but so far these have not been integrated with medical training programs.
It is essential that all such initiatives are coordinated if patient safety in acute care is to be optimized.
‘Vertical’ Integration: Life-Long Learning Undergraduate to Specialist
There is no common curriculum for training in resuscitation and acute care at undergraduate level [46, 47]. In the UK the General Medical Council, which has responsibility for undergraduate training, requires [48] that medical students are taught to recognize and manage acute illness. The Acute Care Undergradu- ate Teaching initiative [49] has used consensus techniques to develop a curricu- lum in resuscitation and acute care for undergraduates, and this will integrate well with generic (Foundation Years) training in acute care for junior doctors in the UK. The model is transferable to other countries. These developments will provide a continuum with critical care training programs within the next ten years. The challenge lies in resourcing and valuing training and methods of as- sessment [50-52].
Maintenance of Competence: Continuing Professional Development
At the other end of the spectrum is the issue of how healthcare professionals will
maintain, and demonstrate maintenance of, their competence to practice. At
present there is considerable international variation, particularly in methods of
assessment [53]. Formal recertifi cation is required in Australia & New Zealand,
Canada and the United States, the latter by examination in addition to other
measures of continued competence in six domains (Table 1). In the UK, the Gen-
eral Medical Council’s proposals for 5-year licensing periods have been suspend-
ed at the request of the Chief Medical Offi cer in order to take into account the
recommendations of the Shipman enquiry [30]; at present the only benchmark
is the disciplinary instrument involving seven domains of fi tness to practice (Ta-
Table 1. American Board of Medical Specialities (ABMS) and Accreditation Council for Grad-
uate Medical Education (ACGME).
Six domains of competence for all doctors in practice and in training:
1. Patient care 2. Medical Knowledge
3. Interpersonal and communication skills 4. Professionalism
5. Practice-based learning and improvement 6. Systems-based practice
ABMS Maintenance of Competence program Requires specialists to demonstrate:
1. Evidence of professional standing
2. Evidence of commitment to lifelong learning and involvement in a periodic self-assessment process
3. Evidence of cognitive expertise
4. Evidence of evaluation of performance in practice
Table 2. General Medical Council (UK) Fitness To Practice (http://www.gmc-uk.org/revali-
