The institution assures that appropriate support services, personnel, and facilities are available for its trainees. For example neurosurgery has a suite of call rooms within the NICU consisting of 2 bedrooms each with bunk beds, computer, and a private bathroom connected to both rooms. YNHH has three cafeterias, located throughout the hospital complex. Residents are provided monthly with meal coupons valued at $6.50 each, to be used at any of the cafeterias for breakfast and dinner when on call. In addition, the hospital makes available a free late night meal to all resident on call in the House Staff Lounge. Finally, 24-hour/day canteens are available in a number of locations throughout the institution, including one in the House Staff Lounge, which provide an assortment of sandwiches, fruits, snacks and beverages and a microwave oven.
Neurosurgery residents share a conference room in the intensive care unit. The conference room is used for rounds, small teaching conferences, and has imaging workstation, view boxes, TV, and VCR. THE NICU also has an office that is shared by the Chief Residents and the lead PA. The office in the ICU has computers with internet and data base access. Additionally, the junior resident is provided with a laptop computer for conference presentations. The resident have a private lounge/conference room adjacent to the NICU and patient care area with computer terminals, printers, conference space, and The Louis Kaplow Neurosurgery Residents Library which as been endowed by one of our former patient’s families.. Additionally, residents are provided with a personal set of lead protection from radiation and surgical loupes. They attend 2 to 3 national meeting per year. In PGY 2 or 3 they attend the Woods Hole course in basic neuroscience and in PGY 3 or 4 the AFIP short course in neuroradiology and neuropathology.
A patient care associate (PCA) is assigned on all shifts to every patient care unit. This PCA performs almost all phlebotomy, electrocardiograms, patient transport, as well as several other patient support services. Nurses insert and maintain all peripheral intravenous catheters. All specimens, excluding cerebral spinal fluid are transported to the appropriate laboratory by a pneumatic tube system. Requests for laboratory, radiological, and consultation services are entered into the hospital computer system. Results of all laboratory tests are available immediately after completion on the same hospital computer system. Terminals are located throughout the hospital on all patient care units as well as in the Emergency Department, operating rooms, on call rooms, clinics, etc. Medical records are available in a timely fashion and can be requested 24 hours/day. Discharge summaries are now available on the hospital-wide computer network. Radiology tests are done in a timely fashion and are prioritized according to the urgency of the case. An attending level radiologist is available in the hospital 24 hours/day to review films. In addition, once the radiology study has been evaluated, a dictated report is entered in the RTAS radiology service which is available 24 hours/day by phone. Computerized images including CT, MRI and plain films are available on-site at selected Autorad terminals and via PC in conference rooms, resident offices, and off-site via Synapse.
In order to assure that the above-described support is adequate to meet the needs of the residents, the GMEC and OGME receive continuous feedback from program directors as well as through specific question in the Annual report monitoring whether work conditions are adequate and what improvements might be implemented.
Role of the Physician Associates on the Neurosurgical Service:
The Physician Associates on the neurosurgical service are an integral part of the neurosurgical team. They provide a wide spectrum of services including high quality direct patient care while enhancing resident education. The role of the physician associates is complex, comprehensive and flexible. The primary responsibility is the provision of direct patient care, with an emphasis on detail and continuity. Working collaboratively with the attending staff and residents, daily work rounds are conducted (twice daily with residents) and (once daily with attending neurosurgeons) with plans for patient management formulated and implemented. Throughout the day, the physician associates serve as a “readily available” conduit for communication between attending physicians and residents (who may be obligated in the operating room, etc) and help provide high quality, efficient, patient care with a focus on continuity of care.
The development and maintenance of an ongoing relationship that occurs with ongoing employment as a physician associate with the attending neurosurgeons provides opportunity for resident education in their earlier phases of training, as well as continuity of care for the patients. This has become a more important issue in order to maintain compliance with residency work hour limitations. The physician associates are also able to assist with clinical research projects and some of the administrative tasks in collaboration with the Chief Resident, (such as maintaining daily Operating room and morbidity and mortality data). The Lead physician associate shares office space with the Chief Resident which provides opportunity for frequent communication in order to address any concerns or issues. Physician associate work schedules are generated in collaboration with the Chief Resident in order to improve work flow and general needs of the service.
The number of physician associate positions has been increased over the past 2 years to five full-time positions, including a “Lead Physician Associate”. The areas of coverage include: the neurosurgical intensive care unit, adult step-down floor, pediatric intensive care unit, pediatric step-down floors, adult and pediatric emergency departments, inpatient adult and pediatric consults, outpatient adult and pediatric clinics, and the operating room. In-house physician associate coverage is provided Monday-Friday (6am - 4pm) in the neurosurgical intensive care unit, Monday-Friday (7am - 5pm) on the adult neurosurgical step-down floor. A rotating schedule has been developed which allows for “off-loading” the on-call neurosurgical resident with a “short-call PA” scheduled five evenings a week (Monday-Friday 2pm - 12am). A physician associate is teamed up with the on-call neurosurgical resident with the result of more available manpower to cover the service in the “off hours”. This design allows for more efficient patient care, improved documentation, and a collaborative working environment with opportunity for education of both the physician associates and residents. Over time, the continuity and familiarity with the unique aspects and attending preferences of the service is conveyed by the physician associate to the neurosurgery residents. In exchange, the neurosurgical resident is available for assistance, education and “back up” for the physician associates in many clinical experiences (egg. Central line placement, ventriculostomy, emergency/trauma consults, etc). Communication with ancillary and nursing staff is greatly enhanced as is team morale with the result of a more positive work environment.
With the full complement of 5 physician associates weekend coverage is provided to include Saturdays and Sundays (from 7am - 5pm) with the exception of 5 major holiday weekends. This additional coverage allows for more expeditious discharges and more efficient patient management in timely fashion. It also allows further opportunity for formal teaching rounds by the attending physicians and/or Chairman without adversely affecting patient care. It has improved patient satisfaction and the working relationship with the nursing staff.
We anticipate planning for several additional physician associate positions in the future in order to provide 24/7 in-house coverage and meet any additional department needs.