UT Southwestern’s written response to questions from The Dallas Morning News
UT Southwestern Responses to Dallas Morning News
July 9, 2010
UT Southwestern (UTSW) encloses its responses to the 12 questions posed by the Dallas Morning News (DMN) on Friday, July 2, 2010, concerning resident physician training and clinical care provided by UT Southwestern. We have focused specific comments on surgical services and training because of the apparent particular interest in these issues. However, we wish to emphasize that the underlying principles and approaches are similar for all clinical disciplines. The responses are necessarily lengthy, due to the inherent complexity of graduate medical education. Moreover, several of the presumptions embedded in the questions are simply wrong, and we wish to correct those as thoroughly as possible, so that the DMN has an accurate basis for any story it may wish to write. To ensure that the answers are understood in the broader context of academic medical centers and medical training in general - and UT Southwestern in particular - UT Southwestern would like to emphasize the following points before turning to the questions: • As one of the leading academic medical centers in the country, UT Southwestern is deeply committed not only to its missions of education, patient care, and research, but also to the fundamental value to patients and society of the integration and interdependence of these three activities. This integration is a defining characteristic to every one of the most highly ranked and widely respected medical schools and hospitals in the country. Graduate medical education (GME) - the three to eight years of residency and fellowship training that follows medical school graduation - is overseen by national bodies, most importantly the Accreditation Council for Graduate Medical Education (ACGME), which sets the national standards for residency programs in a given specialty and conducts regular reviews of such GME programs. It is also worth noting that the number of GME program positions supported by Medicare was capped at the 1996 level as part of the Balanced Budget Act of 1997, i.e. when what is now University Hospital-St. Paul was still a community hospital and had not yet been acquired by UT Southwestern, which is the principle reason why there are fewer GME
program positions at University Hospital-St. Paul, compared to Parkland Memorial Hospital (Parkland). • With the welfare of patients as the foremost priority, the essence of all residency programs is to provide graduated supervision to resident physicians as they progress through the residency program, with the goal of producing physicians fully ready to independently perform their chosen specialty. Against this backdrop, UT Southwestern Medical School sponsors 95 residency and fellowship programs and has prepared, at least in part, more than half of the physicians who currently practice in North Texas. UT Southwestern-sponsored residency training programs are stringently scrutinized by the ACGME. We note that UT Southwestern operated hospitals also fulfill all requirements of The Joint Commission, the national accreditation organization for hospitals. UT Southwestern adheres to ACGME standards irrespective of whether residents are assigned to rotations in UT Southwestern owned and operated hospitals and clinics, or to UT Southwestern affiliated hospitals, including Parkland, Children’s Medical Center, the North Dallas Veteran’s Administration Medical Center, and other private hospitals in North Texas. The philosophy underlying residency training is best summarized in the ACGME’s own words about its common program requirements: “Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the resident physician to assume personal responsibility for the care of individual patients. For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty who give value, context, and meaning to those interactions. As residents gain experience and demonstrated growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence. This concept – graded and progressive responsibility – is one of the core tenets of American graduate medical education. Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to the individual patient; assuring the development of the skills, knowledge, and attitudes in the resident required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth.”
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UT Southwestern’s responses to the DMN’s questions will focus on the UT Southwestern General Surgery Residency Program, given the DMNs particular interest in this area. We note at the outset that this program adheres to the ACGME’s graduate medical education philosophy and program requirements so effectively that at its last accreditation review (2007), it was given full continued accreditation without citations and assigned a 5-year review cycle (the longest review cycle granted by the ACGME Surgical Residency Review Committee). A number of the DMN questions are based on a report that is now 6 years old, and even when it was first issued had serious limitations. That report was prepared by Health Management Associates (HMA), a proprietary consulting and hospital management firm hired by Parkland. HMA reported that over a six-month period its consultants interacted with “more than 250 governmental officials, health care and business leaders, civic and advocacy group representatives, doctors, patients, and other front line clinical and administrative staff.” However, the HMA representatives had very little interaction with UT Southwestern administration and leadership and lacked significant input for the assessment. As a result, when the report was issued, UT Southwestern found that it was flawed and at that time expressed in writing its disagreement and concern regarding the quality of the data considered by HMA and the accuracy of the resulting conclusions and recommendations. UT Southwestern is equally concerned today that the DMN would find such a dated and discredited report relevant in 2010, especially given the many changes that have occurred in the landscape of health care delivery nationally and at both UT Southwestern and Parkland in the intervening years. To address a central underlying premise of a number of the questions posed, we want to state unequivocally that UT Southwestern does not support two standards of patient care and embraces the same approach to care provided at Parkland and the University Hospitals. There is a distinction, however, in how patients access care at Parkland versus the UT Southwestern operated hospitals. The great majority of Parkland inpatients are admitted through the Parkland emergency department. Relatively few Parkland inpatients arrive with established relationships with faculty physicians, and they are therefore assigned to UT Southwestern physicians upon admission. In marked contrast, the great majority of inpatients at University Hospital- Zale Lipshy and University Hospital-St. Paul have an established relationship with faculty physicians prior to admission. However those patients who do present to the University Hospital-St. Paul emergency department without a prior physician relationship are assigned to a faculty physician similar to the procedure at Parkland. (University Hospital-Zale Lipshy does not operate an emergency department.) Just as at Parkland, faculty physicians care for patients at the University Hospitals in conjunction with resident physicians – although for the historical reasons noted above, there
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are fewer resident physicians at these sites. Indeed, expanding the cadre of resident physicians at the University Hospital sites is a long-term goal of UT Southwestern, consistent both with our educational mission and our firm belief that embedded graduate medical education is integral to clinical excellence. • UT Southwestern is unclear as to what is meant by the “Duke model” in Question #3, even though many of UT Southwestern’s current faculty have spent time at Duke, including most notably, the current Provost and Dean of the Medical School, who is a graduate of Duke Medical School and spent several years as a member of its faculty. All ACGME-accredited residencies are judged by the same requirements and must be in compliance with these universal standards to maintain accreditation (the “ACGME model”). Although minor variations may exist between and among general surgery residency programs at accredited schools throughout the U.S., these variations by definition are inconsequential because of the stringent requirements imposed by the ACGME. As a reflection of UT Southwestern’s national stature, UT Southwestern physicians and physician-administrators frequently visit other academic medical centers, such as Johns Hopkins, the University of California, San Francisco, the University of Pennsylvania, Massachusetts General Hospital, and the University of Michigan as invited guest experts and/or as program reviewers. Through these first-hand experiences, they are in a position to compare UT Southwestern training programs with those widely regarded as among the very best in the country. While they may bring back ideas for “tweaking” UT Southwestern programs, this knowledge of other institutions confirms the fundamentally common approach to the philosophy and operation of residency training programs across the country.
We hope you find these comments helpful as a framework for the responses, which follow.
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Responses to Questions
In 2004, consultants hired to study long-term issues at Parkland urged a move away from the “dominance of the teaching model” because it had “serious impacts” on patient care. The report also noted that residents historically had only “nominal supervision” from UTSW faculty, and said that even though improvements had been made shortly before 2004, more improvement was required. How would you characterize the training model at Parkland before and after that study?
The HMA allegations were incorrect and UT Southwestern expressed its disagreement with the report at the time it was issued in 2004. It has never been true that the Medical School imposes a “teaching model” at Parkland that is detrimental to patient care, or that the structure of the clinical services is “dictated by the teaching needs of the University” [pg. 68]. The HMA report failed to note that medical education, including resident training programs, is an integral part of Parkland’s mission as well as UT Southwestern’s. Resident physicians at Parkland are important providers of patient services, while being trained and supervised by UT Southwestern faculty. Parkland’s resident physicians are highly capable physicians who provide excellent care. They are M.D. graduates from accredited and acclaimed medical schools who are licensed under Texas law to practice medicine under the supervision of the Medical School’s faculty while they pursue post-graduate training leading to qualification as board-certified specialists. The quality of the resident physicians attracted to Parkland for training under UT Southwestern faculty is exceptionally high, and the resident physicians provide more and better care, at a lower cost, than would be possible with non-physician “midlevel” providers alone. Moreover, approximately 50% of the practicing physicians in Dallas County trained at Parkland, so the ability of UT Southwestern and Parkland to attract physicians who are among the best in the country provides great long-term benefit for the quality of care county-wide. Before the 1980s, UT Southwestern’s clinical faculty was quite small, and the faculty’s involvement in actual patient care and direct supervision of residents at Parkland was modest. However, in keeping with the progressive increase in national requirements for greater faculty involvement under the ACGME residency program accreditation standards, since the 1980’s the number of clinical faculty at UTSW and their role in providing supervision and clinical care at Parkland expanded greatly. By 2004, and continuing today, the faculty were actively involved in all aspects of patient care at Parkland. Commensurate with this expanded commitment, the residency program has consistently received the highest accreditation from the ACGME. Accreditation by this external national regulatory authority is specifically dependent on demonstration of adequate faculty supervision refuting any notion of “nominal supervision.”
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The HMA consultants made the erroneous and unsupported allegation that it was “very difficult, for example, to schedule a routine gall bladder or hernia operation in the Parkland ORs” because resident physicians “will often look for the most ‘interesting’ cases, leaving general surgeries behind.” In fact, in 2004 Parkland was among the nation’s leaders in the number of gall bladder surgeries performed. Furthermore, the consultants did not acknowledge, although they were surely aware, that the reason elective surgeries were postponed at Parkland was to cope with an increasing number of emergencies in the overcrowded ORs – not the preference of resident physicians. UT Southwestern, both before and after the 2004 HMA report, has been committed to providing the highest level of care to Parkland patients, a challenging task given that the number of patients and amount of care delivered has grown by more than 50% over the last 6 years. The responsibilities for patient care are met in part by faculty delivering care directly and in part by faculty supervising resident physicians in residency programs. At UT Southwestern, as at all other top tier academic medical centers, resident physicians are carefully supervised and have graded and progressive responsibility, designed to assure that they are fully capable upon completion of training to enter the Dallas and other medical communities with a high level of experience and technical competence. In this way, the resident training model is characterized today, as it was prior to the HMA 2004 report, by careful mentorship, graded and progressive responsibility, and a commitment to lifelong learning. 2. What does UTSW do to ensure that a resident is competent to perform given operations or to deliver care in other ways (such as exams or taking patient histories) outside the presence of UTSW faculty physicians?
Within the United States, M.D. degrees are awarded by LCME-accredited medical schools. The Liaison Committee on Medical Education is an independent body sponsored by the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA). Accredited medical schools must have a system in place for assessment of medical student achievement that employs a variety of measures of knowledge, clinical skills, behaviors and attitudes. Each medical education program must include ongoing assessment activities that ensure that medical students – some of whom become resident physicians with UT Southwestern – have acquired and can demonstrate on direct observation the core clinical skills, behaviors and attitudes that have been specified in the program’s educational objectives. In addition, the majority of medical schools require the passage of the United States Medical Licensing Examination or the Comprehensive Osteopathic Medical Licensing Examination (USMLE, COMLEX, or simply “the boards”) before graduation. The USMLE and the COMLEX consist of four parts that test (1) mastery of the basic sciences as they apply to medicine; (2) mastery of the management of ill patients; (3) mastery of clinical skills using a series of standardized patient encounters; and (4) physicians’ ability to independently manage the
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care of patients. As the result of these requirements at the medical school level, entry-level resident physicians have mastered the fundamentals of patient care such as taking a history, performing a comprehensive clinical examination, and demonstrating clinical skills for such standardized patient encounters. After becoming a member of the UT Southwestern General Surgery Residency Program, a resident’s competency is evaluated as follows: The ACGME Residency Review Committee (RRC) in Surgery requires that the surgery training program, and the specific expectations for resident physicians at each level, must be spelled out in documents called “Goals and Objectives" and "Lines of Supervisory Responsibility". These written documents outline expectations for resident physicians at each postgraduate year of training and are specific to each service to which the resident physician is assigned. The Goals and Objectives and Lines of Supervisory Responsibility for the surgery residency program at UT Southwestern have been available and continuously updated since 1998. Both documents were reviewed and approved by the RRC of the ACGME during each of three past site visits including most recently in 2007 (and subsequent to the HMA report). The documents are distributed to resident physicians and faculty each year and are publicly available on the General Surgery Residency education website. To ensure that resident physicians are competent and progressing in a satisfactory manner, UT Southwestern resident physicians are continually evaluated according to the expectations expressed in the Goals and Objectives document. Resident physicians are evaluated in five specific ways: (1) Each resident physician receives a monthly written evaluation from his or her supervising attending assessing the individual's performance in each of the 7 competencies. Resident physicians also receive written evaluations from patients, nurses, and medical students that assess professionalism and interpersonal skills. Any evaluations below acceptable levels are immediately transmitted to the program director, the resident physician’s faculty advisor and/or the department chair, and are dealt with as appropriate. Low performing resident physicians are referred to the department Residency Evaluation Committee for decisions regarding remediation and whether to promote to the next level of training (see below). A Department of Surgery Residency Evaluation Committee comprised of the program director and 6 surgical faculty meets quarterly to discuss resident physician performance. Resident physician performance is reviewed by this committee, and decisions are made regarding promotion to the next level of training. Low-performing resident physicians are discussed in detail, and
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decisions are made regarding the need for special proctoring, remedial years of training, academic probation, and termination from the program. (3) Resident physicians are assigned faculty advisors who serve as advocates. Each resident physician meets at least twice each year with his or her advisor to review evaluations, assess progress, identify areas of weakness, and discuss career goals. To assess knowledge levels, surgery resident physicians take a national examination, the American Board of Surgery In-Training Examination (ABSITE) each year. Resident physicians’ performance is compared to that of their peers nationwide through a percentile score specific for their year of training. Resident physicians who score below a specific threshold are entered into a remediation pathway involving faculty proctors. Consistently low-performing residents are required to have remedial years of training or are dismissed from the program. Each year, every resident physician meets one-on-one with the program director to review evaluations, operative case lists, letters from faculty advisors, and overall progress. Annual resident progress is summarized in each of the General Competencies, and a written assessment is placed in each resident physician's confidential file.
The evaluation process is robust and thorough. Promotion is not automatic; indeed the Residency Evaluation Committee evaluation of the nearly 100 resident physicians in our training program at any given time has resulted in assignment of proctors, remedial years of training, and dismissal from the program when residents are not achieving the mandated level of performance. The number of resident physicians requiring such measures is on par with other programs nationally. To ensure that resident physicians are competent to perform operations, resident physicians are taught surgical skills in a simulated environment before they perform surgery on live patients. The Southwestern Center for Minimally Invasive Surgery is one of the most advanced simulated skills training centers in the United States and includes a large, sophisticated skills laboratory with state-of-the art training models and computer simulation. Resident physicians complete over 30 standardized modules during their 5 years of training and must demonstrate competency in the simulated environment before they are allowed to perform procedures in the operating room. The skills training program is shared with other surgical specialties, especially OB-GYN and Urology, which have robust minimally invasive surgery programs, and it has been accredited (and recently re-accredited) as a Level I (highest level) American College of Surgeons Surgical Education Institute. In fact, UT Southwestern was among the first 7 centers accredited under this program, and our faculty has been actively involved in the development of skills curricula used throughout the nation.
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The UT Southwestern simulation program has always been on the cutting edge of training in the United States. UT Southwestern resident physicians have had laparoscopic training since 1998, and UT Southwestern faculty have set the national standards for simulator training in many areas. Our resident physicians were required to take and pass the national skills course called Fundamentals of Laparoscopic Surgery four years before it became a national requirement for all resident physicians in the United States. In addition to the acquisition of technical skills, UT Southwestern resident physicians are retested every six months after they pass this course and if they do not pass the test, they are retrained to proficiency. Thus, UT Southwestern is ensuring the maintenance of competency with this skill, and is ahead of other programs which are just instituting this course. The success of the UT Southwestern program to train competent general surgeons is assessed in many ways. One objective measure of success is the pass rate on American Board of Surgery Examinations, which is published and reported for all surgery programs in the United States (current report attached). The average 5-year overall pass rate is 75% for all programs nationwide. The 5-year pass rate for UT Southwestern is 98 %, and it has been higher than 96% for more than 25 years. No other program of our size has achieved such results. Also, note the pass rates for other high profile programs, including Duke (see Response No. 3 below). Whatever “model” Duke uses, it is not producing the results that UT Southwestern has had in preparing our residents for board certification and assuring well-trained surgeons to provide care to Dallas and North Texas patients. Another measure of success is the level of accreditation accorded by the Residency Review Committee of the ACGME. At its last accreditation review, the UT Southwestern General Surgery Residency Program was given full continued accreditation without citations and assigned a 5-year cycle for reaccreditation. Of the 246 currently accredited surgery residency programs in the United States, less than 5% are on 5-year cycles without citations. Each UT Southwestern residency program is assessed internally through the UT Southwestern Graduate Medical Education Office, and is also assessed externally through the ACGME. All UT Southwestern residency programs eligible for accreditation by the ACGME are fully accredited. 3. Why does UTSW believe the Parkland tradition of training residents is the better model, as opposed to the so-called Duke model that staff from UTSW and Parkland have cited as comparison?
UT Southwestern is proud of the quality of its residency training programs. After completion, our graduates assume highly responsible positions as practicing surgeons and specialists in Dallas and at many other of the best medical centers in the country. They succeed in part because of their intrinsic skills and dedication, and in part because of the more specialized educational experiences obtained as resident physicians at UT Southwestern. From a
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fundamental perspective, the approach to residency training followed by UT Southwestern and Parkland is the same as followed by other top academic medical centers in the U.S. because all residency training must adhere to the requirements established by the ACGME. Based on a review of the Duke Graduate Medical Education website – http://gsresidency.surgery.duke.edu/modules/gs_res_admin/print.php?id=5 – the “Duke Model” and the “UT Southwestern/Parkland Model” for supervision of general surgery residents (although we do not use this terminology) appear identical. At both institutions the attending physician is required to: (1) exercise control over the care rendered to each patient under the care of a resident physician, either through direct personal care of the patient or through supervision of medical trainees and/or medical personnel; (2) document the degree of participation according to existing hospital policies;
(3) effectively role model safe, effective, efficient and compassionate care and provide timely documentation to program directors required for trainee assessment and evaluation as mandated by the program’s Residency Review Committee, where applicable; (4) participate in educational activities of the training programs, and as appropriate, participate in institutional orientation programs, educational programs, performance improvement teams, institutional and departmental committees; (5) (6) summaries. review and co-sign histories and physicals; and review progress notes and sign procedural and operative notes and discharge
The degree of attending involvement in patient care is commensurate with the type of case, and the level of training, education and experience of the resident physician. The level of supervision varies by specialty, level of training, experience and competency of the resident physician, and the acuity of the clinical situation. Based on the review of the Duke website and observations from the UT Southwestern Medical School Dean and Provost (a graduate of Duke who spent several years as a member of its faculty), UT Southwestern does not attempt to present a definitive comparison of the UT Southwestern general surgery residency training program to Duke’s general surgery residency training program. However, during the period of 2004-2009 Duke’s graduates achieved a respectable 79% pass rate of the American Board of Surgery Examinations, while, as mentioned above, resident physicians completing the UT Southwestern general surgery residency training program achieved a 5-year pass rate of 98%. UT Southwestern believes the success of our graduates on the American Board of Surgery Examinations speaks for itself. Furthermore, Duke
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aside, a comparison of approaches at UT Southwestern to training resident physicians in surgery with those at other preeminent academic centers in this country such as Hopkins, Penn, UC-San Francisco and Harvard will show them to be highly similar since all are structured to be consistent with the “ACGME model.” 4. Recent research studies have found strong correlations between the level of faculty supervision of medical residents and patient injuries or death. What does UTSW do to measure patient errors by residents? Supervision by faculty? Adverse patient outcomes? We would appreciate receiving any metrics that support your conclusions.
UT Southwestern is well aware of these studies, but they have limited applicability to surgery residency programs because most focused on junior resident physicians training in internal medicine rather than surgery. Our general surgery residency program involves close and consistent faculty supervision, with appropriate faculty supervision in the operating room and feedback from resident physicians to ensure adequate supervision in all other areas. Since 1990, faculty attending surgeons have been physically present in Parkland Hospital 24 hours a day, 7 days per week. New admissions, consults, and patients with new problems are evaluated by the faculty physician. Resident physicians report the progress of all patients to the faculty physician on a frequent basis. Thus, every patient has an attending that monitors the treatment and plans of the resident physicians on an ongoing basis. Any assertions of less intensive supervision on a systematic basis are simply inaccurate Each hospital in our training system has an ongoing quality assurance program to measure the errors of all physicians – including both resident physicians and faculty physicians. These programs have objective outcome measures; adverse events are reported and investigated using the root-cause analysis system. Feedback is given to Department Chairs and, when resident physician training issues arise, to the appropriate program director. In addition to the hospitalbased QA programs, UT Southwestern also participates in programs that compare UT Southwestern hospitals with other centers using national benchmarks such as the surgical programs, TQIP (Trauma Quality Improvement) and NSQIP (Surgery Quality Improvement). To ensure that all errors and adverse outcomes are thoroughly evaluated and analyzed, the UT Southwestern surgical department conducts weekly Morbidity and Mortality conferences at all affiliated hospitals. The conferences are attended by faculty surgeons and resident physicians, and medical outcomes of patients are openly discussed. Resident physicians and their supervising faculty are held accountable for their actions. Their resulting self-evaluation, determination of factors leading to the error, and review of the published literature contribute to the improvement of medical care.
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Dr. Valentine is quoted in university records and sworn testimony as saying in a 2007 faculty meeting that it was OK for residents to make mistakes that could have been prevented by closer faculty supervision. Is that UTSW’s position? Is it a reality of teaching hospitals that patients must accept the possibility of mistakes when treated by doctors in training?
The statement attributed to Dr. Valentine is inaccurate, taken out of context, and fundamentally mis-characterizes discussions from a faculty meeting held in March of 2007. This was a meeting devoted to consideration of faculty supervision. Dr. Valentine made specific and definitive statements regarding the published ACGME guidelines that resident physicians are expected to have graded and progressive responsibility as they advance through training. Dr. Valentine specifically noted that all resident physicians are to be supervised by an attending physician at all times, and that resident physicians are to be given supervised autonomy on the basis of their training level, ability, and demonstrated competence. He specifically discussed the supervision policies outlined in departmental Goals and Objectives and Supervisory Lines of Responsibility documents and reminded the faculty how to access them. As stated in the preamble above, the ACGME has recently reiterated its position on resident supervision and autonomy in its 2010 Common Program Requirements: “The specialty education of physicians to practice independently is experiential, and necessarily occurs within the context of the health care delivery system. Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the resident physician to assume personal responsibility for the care of individual patients. For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty who give value, context, and meaning to those interactions. As residents gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence. This concept--graded and progressive responsibility-is one of the core tenets of American graduate medical education. Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to the individual patient; assuring the development of the skills, knowledge, and attitudes in the resident required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth.” Consistent with this program requirement, resident physicians are permitted to develop skills and knowledge within the primacy of the imperative of patient safety. Resident physician mistakes are recognized and corrected before they translate into patient care errors - which are preferable to mistakes made after the resident physician has completed training, when they cannot be recognized by a supervisor before they affect a patient. At no time did Dr. Valentine state or
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imply that it is acceptable for resident physicians to make mistakes, and at no time did he suggest that the resident physicians should not be supervised. Dr. Valentine has been a program director for 14 years and is a recognized national authority in resident education. In fact, he is a recipient of the highest national honor bestowed on a program director, the ACGME's 2009 Courage to Teach Award. He has been president of the Association of Program Directors in Surgery and is a board member of the American Board of Surgery. He is well versed in the ACGME requirements and responsible for ensuring that resident physicians and faculty follow the supervisory expectations. Moreover, he personally practices medicine with the highest moral and ethical standards, is superb at supervising and teaching resident physicians and medical students, and is an expert vascular surgeon who provides high quality care to and obtains excellent outcomes for his patients, whether operating himself or supervising surgery conducted by resident physicians and fellows without regard to the venue in which they are treated, the patient’s race or national background, or economic status. He trained at UT Southwestern and his dedication to Parkland patients, patients at Children’s Medical Center, and University Hospital, and to education at UT Southwestern is unquestioned. He is a pillar of the Southwestern community. He would never have made, and did not make, the statements attributed to him in this question or those attributed to him recently in other media. His statements must have been misrepresented or mischaracterized to the DMN. Dr. Valentine’s explanations concerning guidelines and requirements of the ACGME and Residency Review Committee were clear, precise, and accurate. Most importantly, UT Southwestern faculty physicians have consistently fulfilled these ACGME standards. 6. When mistakes are made by residents working on their own or under the supervision of other residents, what steps does UTSW take to review and correct the causes? What does UTSW do for patients harmed by such errors?
As noted above, resident physicians are under the supervision of attending faculty. The policies for supervision of resident physicians have been clearly defined in the recent 2010 ACGME Common Program Requirements: “Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced resident. Other portions of care provided by the resident can be adequately supervised by the immediate availability of the supervising faculty member or resident physician, either in the institution, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of resident-delivered care with feedback as to the appropriateness of that care.”
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Regardless of complexity or acuity, procedures in the operating rooms at Parkland as well as at other training sites are performed under the supervision of a faculty surgeon who is physically present in the operating room for the key and critical portions of the procedure and immediately available at all other times. To more directly respond to the question, the situation in which the error occurs necessarily dictates how it is reviewed and corrected. Along the continuum of procedures requiring the least-to-most supervision, a missed finding on a physical examination should be detected at some time after the physical examination was performed (normally within 24 hours of admission) and corrected by writing an addendum in the medical record, planning for appropriate follow-up, and instructing the resident physician involved. On the other end of the spectrum, a resident physician error in the operating room on complex procedures with faculty presence will be detected immediately by the attending faculty physician who takes the decision-making or the case over as the operating surgeon. It is also the responsibility of the attending surgeon to discuss and counsel the resident physician about the error and to document any deficiencies using the formal evaluation process. Resident physician errors occur within the context of the attending surgeon’s credentials and assigned hospital privileges. Errors committed by resident physicians are therefore also attributed to the attending faculty surgeon. Patient outcomes are the ultimate responsibility of the faculty physician. 7. Several doctors proposed changes within the UTSW surgery department that would have required faculty physicians to be notified before residents operated on patients, among other things. Were these changes instituted? If not, why not?
This question makes an entirely erroneous presumption. UT Southwestern has always required resident physicians to notify faculty physicians before operating on patients. Resident physicians operate on the basis of the faculty surgeon’s credentials and are directly responsible to the faculty surgeon. As noted above, surgeons must also be present for the critical portions of the case and immediately available during the entire case. It is also the responsibility of the supervising surgeon to be available and to respond to resident physician pages and calls in a timely manner. This issue was raised by a small group (comprising a tiny fraction of the faculty) who claimed that they were not called by the resident physicians in time to come to the operating room to supervise specific cases. Each of the alleged circumstances has been thoroughly investigated and addressed. To ensure that pages are delivered in a timely fashion, resident physicians and nursing staff were asked to clearly document that attending surgeons were notified and that they responded.
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In order to ensure appropriate supervision in any eventuality, “safety net” policies are in place. If a faculty physician does not respond appropriately, a back-up faculty surgeon is always on call whom operating room staff and resident physicians are directed to call. 8. Several UT Southwestern doctors have said in interviews and in sworn testimony that resident physicians have vast autonomy to care for patients but are closely supervised by faculty physicians when they rotate through Zale Lipshy and St. Paul hospitals. Some have said that has resulted in a two-tier level of patient care between Parkland and University hospitals. What would you say to that?
First, we note that these “several doctors” represent a tiny minority of the nearly 2,000 clinical faculty at UT Southwestern who would not agree with this characterization. More importantly, UT Southwestern categorically rejects the notion that UT Southwestern provides different standards of care at the different sites in which its physician’s work. We note that staffing and duties on services vary considerably depending on the manner of patient presentation to the hospital, the type of service being provided, the level and number of resident physicians assigned to the service, and the needs of the patients. Several training paradigms are used in our training program to achieve the educational goals that are specific for each surgical service while assuring excellence in the care provided to all patients. Surgical rotations on trauma and emergency surgical services at Parkland are fashioned to work as teams composed of supervising faculty with several senior and junior resident physicians who take call in the hospital for a 24-hour period. This arrangement is particularly suited to the highvolume, urgent/emergent care at Parkland because medical duties can be divided according to resident physician level of competence. In this way, as many as 35 patients with acute problems can be rapidly evaluated, triaged, and treated each night. Under this paradigm, the faculty supervisor oversees the work performed by resident physicians at each level and is intimately involved in the planning and treatment of all patients. University Hospital has no trauma, burn service, or acute general surgery service. Therefore, there is much less emergency surgical care, and a higher percentage of elective surgery, provided to patients. The staffing and functioning of services are comparable to elective services at Parkland, and in each of these settings resident-physicians function in an apprenticeship model. Parkland Memorial Hospital, the Dallas VA Medical Center, and the University Hospitals are very different hospitals involving discreet and complex medical systems that are not comparable. Care on the Parkland emergency services is team-based and different from other surgical services. For the historical reasons described in the accompanying Overview, University Hospital-St. Paul does not have residents in its non-Level 1 emergency department (though it is the long-term goal of UT Southwestern to do so). However, care on Parkland elective general surgery services, the Dallas VA services, and the University Hospitals is similar, and the supervision paradigm is the same. However, because the complement of resident physicians at
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the institutions differ, an attending surgeon at University Hospital is likely to have a lower level resident physician assisting him/her in the care of their patients and will have to appropriately limit the resident physician’s responsibility for the care of the patient to match the year of training (that is, the attending will be more directly involved). This is consistent with the guidelines of the RRC and ACGME. 9. Medicare mortality data indicate that on a risk-adjusted basis, patients at Parkland consistently fare worse than those at other UTSW hospitals. The mortality rate differential for pneumonia exceeds two standard deviations. Does that difference concern UTSW? Does UTSW wish to offer alternative explanations for these differences? Does UTSW have other mortality data that it could share with us?
For the response to question #9, UTSW assumes that the CMS data to which the DMN refers are the publically available data which report mortality by hospital for acute myocardial infarction (AMI), congestive heart failure (CHF) and pneumonia by hospital with comparison to the national rates. We note that updated data were just released on the Hospital Compare website on July 7, 2010. Those data are the source of the responses below. If another source of data was used, we would appreciate the DMN providing us a copy of the subject data, so that we have the opportunity to review, analyze and comment on the accuracy of the DMN's interpretation. Before commenting on the specifics, it is important to note that the CMS data was developed to compare hospital performance to national mortality rates. CMS cautions against using the data to compare rates between individual hospitals since the number of patients in such comparisons is frequently too small to make the comparison valid. The data set was designed to determine which hospitals are better, worse or not significantly different than the national rates. The data analysis was not constructed to compare individual hospitals to each other, a point that has been made by many national organizations, e.g., the American Heart Association. The assertion that, on a risk-adjusted basis, patients at Parkland consistently fare worse than those at other UTSW hospitals is incorrect. Data from CMS show that indicate mortality rates for AMI, CHF and pneumonia at all UT Southwestern hospitals (and Parkland) are not statistically different from the national rate. In addition, mortality rates for both Parkland and University Hospital are at or below the national rates for AMI and CHF. The data also indicate that the mortality rate for AMI is lower at Parkland than at University Hospital, although again the difference is not statistically significant. While the mortality data for pneumonia show a rate of 13.2% at Parkland versus 9.7% at University Hospital, it would be inaccurate to infer any greater likelihood of death from pneumonia at one hospital or another based on the patient size that comprised those percentages – 86 patients at Parkland and 266 patients at University Hospital. CMS explains on its website that the patient volume differences place the risk-adjusted interval estimated percentages for both
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hospitals at “no different” than the national 30-day death rate for pneumonia of 11.6 percent. However, we want to emphasize that UT Southwestern is concerned with mortality rates for all conditions at all of our hospitals, and we specifically focus quality improvement efforts on those conditions identified as having excessive risk-adjusted mortality. Even if standard statistical principles are ignored, the implication that differences between Parkland and the University Hospitals exist is incorrect, given the broader perspective of the Dallas area as a whole or other university hospitals nationally. For example, the reported mortality rate for Parkland for AMI is better than Medical City Dallas, Baylor University Medical Center (BUMC), Presbyterian Dallas and Duke University, a nationally known hospital for cardiac care. Also, the mortality rate at Parkland for CHF is better than Presbyterian Dallas, Medical City Dallas and Methodist Dallas. Finally, BUMC had a pneumonia mortality differential that fell outside two standard deviations when compared to UT Southwestern, indicating there are reasons for variances in mortality rates that are outside of UT Southwestern control and not recognized by the risk-adjustment methodology of CMS. 10. The 2004 consultants’ study also noted that insured patients who were initially admitted to Parkland were quickly transferred to Zale Lipshy and St. Paul, more often than uninsured patients with the same medical conditions. If so, why would that be the case?
In 2004 when HMA issued its report, UT Southwestern took great exception to it for several reasons. The suggestion by HMA that Parkland was negatively impacted by Zale Lipshy, St. Paul and UT Southwestern’s private practice because of inappropriate transfers of privately funded patients and competition for Parkland’s Medicare, Medicaid, and private patients was incorrect. Data to the contrary was provided to HMA, but ignored. In the 1980's, a decision was made that UT Southwestern needed to construct outpatient and inpatient facilities for patients referred to its faculty, in order to stop the “revolving door” of clinical specialists that had prevailed at the Medical School and Parkland for decades. Experience had made clear that it was impossible to retain specialists in fields requiring a large number of elective referrals to attain a critical mass of cases (for example, heart surgery, transplants, brain surgery, aneurysms, ophthalmology, cancer, neuro-degenerative diseases, etc.) when Parkland was their only practice site. Capable doctors in these fields soon began to leave UT Southwestern and Parkland because of their inability to develop adequate referral practices. This was exemplified in 1974 when half of the surgery department left Dallas for Seattle to join the University of Washington because it provided the opportunity to practice both at the public King County Hospital and at a University Hospital and Clinic where faculty specialists could attract referral patients. It took UT Southwestern and Parkland over half a decade before being
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able to replace most of those who departed, while the revolving door in many areas continued unabated. Parkland agreed that UT Southwestern needed to build a private hospital and clinic in order to recruit and retain specialists (whom Parkland needed). Parkland insisted, however, that UT Southwestern’s private hospital and clinic must be constructed immediately adjacent to Parkland and connected floor by floor; Parkland wished to ensure that the doctors practicing in the University’s private referral facilities would also remain closely involved in the care of Parkland’s patients, avoiding separate groups of doctors who were dedicated principally to one or the other site, and instead maintaining “integrated” practices between the two sites. UT Southwestern agreed to Parkland’s condition that the new hospital and clinic be built immediately adjacent and connected to Parkland. The number of privately funded patients at Parkland actually increased after Zale Lipshy opened, not decreased, because the specialty faculty recruited by UT Southwestern also attracted more paying patients to Parkland. The presence of private facilities for referral patients enabled Parkland to realize the benefits of specialists who otherwise could not be recruited or afforded, and has prevented a recurrence of the periodic mass defections of specialists seen in the past. The HMA report mentioned none of this. During Calendar Year 2003, data demonstrated that 244 patients were transferred from Parkland to Zale Lipshy; 210 were Psychiatry and Physical Medicine & Rehabilitation patients who were transferred according to pre-established Parkland protocols because these Parkland services were full; and 31 transfers [Neurosurgery (15); Orthopedic Surgery (1); Surgery (7); Neurology (4); and Internal Medicine (4)] were determined to be for well-explained reasons (patient request; could not be safely operated at Parkland; OR/ICU or Psychiatry bed availability). During the same period there were several dozen transfers of insured patients from Zale Lipshy to Parkland. The data did not support the assertions made in the HMA report. Furthermore, it should be noted that in those instances in which patients were transferred to Zale-Lipshy, initial admission was made through the Parkland emergency room as the only emergency facility then available. 11. Some faculty members at UTSW said that the culture there valued research -- and the funding that accompanies research -- far more highly than patient care. Is that a fair statement? Have priorities changed in recent years?
UT Southwestern does not believe this to be an accurate characterization of institutional priorities but individual faculty members may have voiced personal opinions to this effect. Our president has been unequivocal in emphasizing the importance of excellence in patient care at UT Southwestern. UT Southwestern’s institutional mission consists of four equally important goals:
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(1) To improve the health care in our community, Texas, our nation, and the world through innovation and education; (2) To deliver patient care that brings UT Southwestern’s scientific advances to the bedside – focusing on quality, safety and service. (3) To conduct high-impact, internationally recognized research;
(4) To educate the next generation of leaders in patient care, biomedical science and disease prevention; Each of these is critically dependent on the others and we believe that underperformance on any one of these missions diminishes success in the others. 12. Is there anything you would like to say about UT Southwestern faculty supervision of medical resident physicians that we have not asked?
More than half of the physicians in North Texas have been trained, at least in part, by UT Southwestern. UT Southwestern has been and remains an outstanding asset for healthcare in this region. UT Southwestern with its affiliates provides the greatest amount of indigent care of any medical school in the nation, and in doing so in conjunction with its partners, has achieved remarkable quality in the outcome of that care, as recognized nationally in such diverse areas as obstetrics, trauma and burn care.