Keywords
hospital consultation - graduate medical education
Ophthalmology consultation serves an important role for both inpatient and emergency
room-based patient care. It represents an integral component of many tertiary hospital
systems that offer level 1 trauma services. There are a variety of reasons which can
generate an ophthalmology consult including changes in vision, eye pain, periorbital
swelling, trauma, papilledema, and screening for ocular manifestations of disease.[1] The most common medical ocular diagnoses occurring in these settings include refractive
error, conjunctivitis, diabetic retinopathy, corneal abrasion, preseptal or orbital
cellulitis, cranial nerve palsy, optic neuritis, and uveitis.[2]
[3] Traumatic conditions such as orbital wall fractures, periorbital contusions, hyphema,
eyelid laceration, corneal abrasion, traumatic iritis, and corneal/conjunctival foreign
body are also common. Hospital services that request ophthalmology consults include
emergency medicine, internal medicine, neurosurgery, neurology, and pediatrics.[3]
At most teaching hospitals, ophthalmology residents are the primary providers of consultation
services both in the emergency department and inpatient settings. In turn, it offers
an invaluable educational experience for residents by exposing them to a wide variety
of acute clinical pathology including trauma. The hospital is an ideal arena for assessing
key competencies such as communication skill, practice-based learning, systems-based
practice, and professionalism.
The Accreditation Council for Graduated Medical Education (ACGME) requires an appropriate
level of supervision for any clinical care that residents render. The recognized levels
are direct and indirect supervision with an immediately available supervising physician,
either physically on hospital premise or by means of telephone or electronic communication.[4] Because of the 24/7 nature of consultations and physical separation of the hospital
from the outpatient clinics, the provision of timely supervision is not always straight
forward. Staffing models can vary among residency programs in terms of the number,
duration, and clinical background of staffing providers. There is also variability
in terms of how residents are assessed for proficiency specifically related to consult-based
patient care.
This study describes the current state of models used for resident supervision in
these settings. To our knowledge, this is the first paper specifically examining what
methods of supervision are currently being used for hospital-based consultation.
Methods
The study design was approved by the Institutional Review Board at Oregon Health and
Science University. An email containing a description of the study, an invitation
to participate, and a link to an anonymous survey was sent to every program director
at 119 ACGME accredited U.S. ophthalmology programs during the spring of 2018. The
electronic survey was constructed using Survey Monkey (San Mateo, CA).
The survey consisted of 27 binary or multiple-choice questions with the option for
additional comments. Survey questions covered consult volume, rotational schedules
of staffing providers, methods of supervision (direct vs. indirect), and utilization
of consult-dedicated didactics and resident competency assessments. The survey questions
are included in the Appendix.
A single reminder email was sent to nonresponding program directors after 4 weeks.
The survey was closed after 8 weeks. Descriptive statistical analysis was completed
using Microsoft Excel.
Results
Of the 119 programs, 49 (41%) residency directors completed the survey. In terms of
participating program demographics, the most frequently reported number of faculty
at each institution ranged from 11 to 33 (28, 57.1%). The most frequently reported
number of residents ranged from 3 to 4 per year (29, 59.2%).
The majority of programs reported receiving 4 to 6 consults per day from the emergency
room (27, 55.1%) and 4 to 6 consults per day from the inpatient hospital (26, 53.1%).
These patients were typically evaluated by either a postgraduate year one (PGY-1)
or PGY-2 resident (23, 46.9%) who was on a consult-dedicated specific rotation (36,
73.5%) during regular business hours (36, 73.5%). Consults were typically staffed
by a faculty member within a 24-hour period (32, 65.3%). Staffing faculty backgrounds
included neuro-ophthalmology, cornea, comprehensive, or a designated chief of service.
For emergency room consults, faculty staffing tended to rotate on either a daily (20,
40.8%) or weekly (18, 36.7%) basis. A minority of institutions reported longer monthly
(1, 2.04%) or yearly (10, 20.4%) staffing intervals ([Table 1]).
Similar results were reported for inpatient consults where staffing faculty tended
to rotate on either a daily (18, 36.7%) or weekly basis (18, 36.7%). Longer monthly
(1, 2.04%) and yearly (12, 24.5%) intervals were less frequently used.
The percentage of emergency room consults that were personally examined by an attending
ranged from 1 to 30% (22, 44.9%). In contrast, inpatient consults had a higher rate
of direct staffing by an attending provider ranging from 71 to 99% (27, 55.1%).
In terms of surgical involvement, an estimated 1 to 30% of all consults required surgical
intervention (28, 57.1%) for cases such as ruptured globe, eyelid laceration, and
orbital compartment syndrome necessitating an emergent lateral canthotomy and cantholysis.
These surgical consults were often formally staffed with direct supervision by an
attending provider (19, 38.8%). Ruptured globe repairs were typically performed between
the hours of 5 pm to 12 am (26, 53.1%).
Programs most frequently reported that their residents start taking call without direct
supervision after a 6- to 12-week period of supervised call with either a resident
or attending (22, 44.9%). Most programs did not formally assess for competency for
call-related patient care without direct supervision (33, 67.4%) and did not offer
formal consult-specific didactics or consult proficiency evaluation for its residents
(27, 55.1%) ([Table 2]). Of the programs that did offer assessments, orientation lectures, consult-based
conferences, or a formal oral or written consult proficiency examination were reported
methods.
In terms of overall hospital integration, the majority of programs felt their ophthalmology
consult service was well integrated into the hospital system (40, 81.6%) and many
provided educational content for other hospital services in the format of lectures
or workshops (27, 55.1%).
Billing submission for consult services was inconsistent. Most programs submitted
between 31 and 70% of consults for formal financial reimbursement (18, 36.7%). Many
ophthalmology consults may go financially uncompensated.
Discussion
Hospital-based ophthalmology consultation represents an important aspect of resident
trainee education. Residents are exposed to a wide variety of clinical and surgical
pathology within the emergency room and inpatient setting which are arguably ideal
settings for direct trainee evaluation and competency assessment. Timely patient evaluation
and appropriate staffing support are essential components of a successful service
that can meet the needs of patients who are acutely ill and often medically complex.
Many ophthalmology residency programs reported staffing models that typically involve
a faculty member who rotates on either a daily or weekly basis in both the emergency
room and inpatient setting. A minority of programs reported having faculty rotate
on a longer monthly or yearly interval. The high frequency of short-term rotating
staffing providers could reflect competing clinical obligations in the outpatient
setting, with the reality that the majority of providers also have their own outpatient
clinics. This could also potentially help explain why hospital billing submission
rates for ophthalmology consults are inconsistent since short-term staffing providers
may have less familiarity with billing protocols for the inpatient or emergency room
setting. It implies that many ophthalmology consults may go financially reimbursed.
Despite its less frequent reported use, there are conceivable benefits to having faculty
staff on a longer monthly or yearly interval including improved continuity care and
extended resident assessments by a single faculty provider. An emerging position known
as an “ophthalmic hospitalist” features a single provider who is specifically dedicated
to hospital-based care and staffs inpatient and emergency room consults. This model
is now being utilized by various residency programs with success.[5]
In terms of direct staffing supervision, the emergency room had lower reported rates
of in-person staffing compared with inpatient consults. This could reflect existing
institutional policies that may have stricter direct staffing requirements for inpatient
consults. Hospitalized patients may also have more complex or severe ocular conditions
that require a higher degree of attending supervision. In contrast, patients requiring
surgical interventions such as ruptured globe repair had a high level of direct attending
supervision, presumably because these cases are often managed within a formal operative
room setting.
The low reported rate of formal consult-related didactics or consult proficiency evaluation
among residency programs was a surprising finding. Most programs do not formally assess
for resident competency prior to the initiation of solo call-related activities without
direct supervision. One could argue that urgent and complex ocular conditions often
arise in the emergency room or inpatient setting and require a certain level of knowledge
and skill on part of resident trainees, many of whom begin solo call responsibilities
as early as 6 to 12 weeks. ACGME uses competency-based milestones that require a certain
level of proficiency for all residents who progress through their training. Aspects
of Professionalism, Patient Care and Procedural Skills, Medical Knowledge, Practice-Based
Learning and Improvement, Interpersonal and Communication Skills, and Systems-Based
Practice are required.[4] Staffing providers must carefully navigate the careful balance between trainee supervision
and autonomy, both of which are essential components of resident education.
One program reported the use of a consult syllabus featuring a list of ocular conditions
and landmark studies pertinent to the inpatient or emergency room. Two programs used
a formal consult proficiency examination to help ensure that residents have a certain
level of proficiency before managing patients on call without direct supervision.
Having more standardized measures for consult-specific competencies may encourage
safer practices and increase accountability on part of residency training institutions.
Limitations of this study include an incomplete response rate for the survey. There
may be other models of consultation being used at academic centers which are not included
in this study. Further statistical analysis could also have been performed with a
different survey design allowing for specific integer entry rather than ranges for
available responses.
Conclusion
A variety of models are being used for inpatient and emergency room-based ophthalmology
consultation at academic centers. More emphasis on consult-focused didactics and proficiency
evaluation for residents who evaluate patients without direct attending supervision
could improve resident education and patient safety.
Table 1
Most frequent responses for hospital-based consultation staffing
|
Emergency room
|
Inpatient
|
|
Number of consults
(24-h period)
|
4–6 (27, 55.1%)
|
4–6 (26, 53.1%)
|
|
Resident year in training
|
PGY-1 or PGY-2 (23, 46.9%)
|
PGY-1 or PGY-2 (23, 46.9%)
|
|
Supervising faculty
|
Faculty (43, 87.8%)
|
Faculty (43, 87.8%)
|
|
Staffing rotational duration
|
Daily (20, 40.8%)
Weekly (18, 36.7%)
|
Daily (18, 36.7%)
Weekly (18, 36.7%)
|
|
Direct staffing
|
1–30% (22, 44.9%)
|
71–99% (27, 55.1%)
|
|
Indirect staffing
|
1–30% (18, 36.7%)
30–70% (17, 34.7%)
|
1–30% (24, 49%)
|
Abbreviation: PGY, postgraduate year.
Table 2
Most frequent responses for resident teaching and evaluation on consults
|
Transition to solo call
|
6–12 wk (22, 44.9%)
|
|
Have formal consult didactics
|
No (27, 55.1%); Yes (22, 44.9%)
|
|
Formally assess for resident competency for taking call without direct supervision
|
No (33, 67.4%); Yes (16, 32.7%)
|
