The Accreditation Council for Graduate Medical Education (ACGME) is an
independent accrediting organization that works in conjunction with each
medical specialty's governing body to provide quality education for resident
physicians. In 1999, the ACGME identified six core competencies that are
important to the practice of medicine. They are: (1) patient care, (2) medical
knowledge, (3) interpersonal and communication skills, (4) professionalism,
(5) practice-based learning and improvement, and (6) systems-based
practice.
One of the core competencies, systems-based practice, enables a physician
to interact effectively with the health care system, utilizing resources
properly without compromising care. This competency is not well delineated;
thus, the specific skills needed are not well understood. The systems-based
competency does, however, incorporate practice management. Practice management
skills are becoming increasingly important in navigating the health care
system. A physician can no longer be concerned only with the clinical aspects
of his or her practice but must also be able to interact with multiple
health-care entities such as insurance companies and hospitals. Additionally,
physicians must develop the skills needed to run a business (a practice) as
well as know how to code and bill correctly for their services.
The purpose of this article was to review the current trends in practice
management training during graduate medical education that have been reported
in the literature. Furthermore, we wanted to gain a better understanding of
how graduating orthopaedic residents are educated with regard to one aspect of
practice management, coding and billing issues, during their residency
training program. Coding and billing issues are largely overlooked in
residency training programs, and it is often left to the institution's
graduate medical education office to provide training in this area.
Unfortunately, this education is often inadequate because it is not reinforced
with practice activities. Finally, we wanted to compare our practice
management education program with what is being done at other academic
institutions.
First, a literature search for practice management curricula and coding
and/or billing education during graduate medical training across all medical
specialties was performed with use of PubMed. Second, an informal survey was
developed and sent to all senior orthopaedic residents graduating in 2006 to
further delineate the current trends among orthopaedic residency programs with
regard to how coding and billing issues are being taught.
Past and Current Trends in Resident Education in Practice
Management
Practice management issues are perceived to be an area in which an
orthopaedic resident's education is lacking. There are many facets to practice
management, and all become important when a resident begins his or her
practice. This education deficiency does not start with residency, as a survey
of medical students showed that >70% thought that their training in
practice management skills was inadequate during medical
school1. It has been
postulated that resident training programs can benefit from a resident who is
more educated in practice management through increases in productivity and
reimbursement. Patterson initiated a practice management curriculum in a
family practice residency and saw an increase in collections and
productivity2. Also,
graduates of this program reported that they were able to operate their
practices profitably. Additionally, potential employers sought the program's
graduates because of their practice management background.
The majority of the available data on resident education in practice
management comes from the family medicine specialty, which was the first to
require practice management training during
residency3.
Currently, at least sixty hours are required in the areas of personal finance,
office and personnel management, business planning, use of computers, managed
care, alternative practice models, professional liability, and risk
management4.
Although this educational requirement exists, subsequent follow-up studies
have shown that residents still do not believe that they can manage their
practice well on completion of their
training5-12.
A recent survey of family medicine residents and graduates found a discrepancy
between current residents and recent graduates with regard to their confidence
levels in select practice management
topics4. Despite
this discrepancy, the authors concluded that the programs surveyed are
adequately educating their residents in practice management. An explanation
for the difference was that graduates may have obtained additional training
after residency as well as overall experience from establishing their
respective
practices4. That
study suggests that, although practice management education is important,
perhaps actual experience is more valuable.
The Patterson study is an exception to the norm. Most studies have shown
that residents are not being taught the business skills needed to manage a
medical practice effectively. For example, a survey of general surgery program
directors showed that 87% of the respondents thought that residents should be
trained in business and practice
management13.
Seventy percent of the program directors also thought that their current
residents were inadequately trained in these areas. The authors agreed with
previous reports on the core competencies that emphasis needs to be placed on
education in practice management. An earlier study of general surgery training
programs mirrored these results, with 100% stating that their residents were
not prepared in practice management and that none of the faculty had had
training in practice
management1.
Other studies have pointed out the dilemma that training programs are
facing with regard to how to educate residents in practice management. A
survey of emergency-medicine residents showed that the majority received less
than two hours of training on coding and billing issues, only 4% of the
residents felt extremely confident in their coding abilities, and over 80% of
the residents did not know how to correctly code a visit or
procedure14. A
study of pediatric residents in an outpatient clinic showed that 62% had
miscoded visits, resulting in 19.1% less
reimbursement15.
Those residents also tended to assign lower coding levels to visits although
they had documentation to support higher coding levels. None of these
residents had had formal training in coding and billing issues. A survey of
obstetrical residencies showed that 87% offered no formal training in practice
management16.
Interestingly, that study also contacted former residents of whom 62% stated
that residency training programs should implement practice management
training.
The survey that we sent to the 2006 graduating orthopaedic residents
yielded only a 22% response rate, which is too low to have validity. However,
the survey did reveal some interesting data that merit further investigation.
From an educational standpoint, >90% of the responding orthopaedic
residents indicated that formal training in coding and billing issues during
residency is essential, and they thought that their training would be more
complete if these concepts were taught during the residency. When they were
asked how confident they were in their coding abilities if they were to start
their practice tomorrow, only 13% stated that they were confident.
Interestingly, 96% of the residents thought that surgeons who did their own
coding had a direct impact on their practice revenue. The survey results,
while not scientifically valid, support our perception that orthopaedic
residents are lacking sufficient education in coding and billing and desire
education in this
area2,13-16.
A recent study showed that program directors and recent graduates of a
residency training program thought that coding correctly was the most
important business topic for residents to
learn17.
Implementing Practice Management Training
Educational models should address practice management topics to provide a
fundamentally sound business background for residents. Topics within practice
management that have been identified as important for residents can be found
in Table
I17.
The American Board of Orthopaedic Surgery has yet to mandate practice
management education for residents, and the responsibility rests with each
training program. Each program will have unique characteristics varying from
one region of the country to another. Thus, an educational model should be
tailored to meet the specific needs of each program.
Several modalities can be used to achieve systems-based practice objectives
through the introduction of practice management topics. The most common
educational method, and the one most familiar to residents, is through
lectures. A recent study involving internal medicine and pediatric residents
showed that use of a lecture format spanning a twelve-month time-period was
consistently well received by the residents, and the residents' knowledge on
practice management topics increased from 74% to 91% on the basis of test
results. The authors concluded that this curriculum design was effective in
educating residents in practice
management18. Other
studies have used workshops entailing small group discussions, self-learning
slide presentations, written material, and mentoring relationships with
faculty to discuss and learn practice management skills. These studies
concluded that each was an effective method for residents' education in
practice
management19,20.
Finally, Patel et al. developed an interactive practice management curriculum
on CD-ROM for
residents17. Those
authors are currently evaluating the effectiveness of this curriculum.
A residency training program in family medicine evaluated its practice
management training, which consisted of a two-day didactic workshop and then
informal monthly sessions with faculty discussing various issues related to
managing a medical
practice21.
Internal reviews of this educational model showed that the format was not
adequately preparing the residents to manage a practice. Over a two-year
period, the residency program revamped their educational model. The major
changes included modifying the educational format into monthly half-day
workshops with a combination of lectures and discussions from faculty and
invited experts for each topic. The most important change was the formulation
of a mock practice for the residents. The residents were able to apply the
information learned in the didactic sessions to the mock practice, providing
hands-on experience with the development and management of a practice. After
finishing the program, the residents completed a self-assessment questionnaire
based on the American Academy of Family Physicians educational guidelines for
practice management, and the results demonstrated great improvement in all
areas.
The literature on this subject indicates that there is no one method that
is an established standard in educating residents on practice management
issues. Each department should evaluate its respective resources (i.e., time,
money, personnel, and faculty) and formulate a curriculum that uses these
resources most effectively and efficiently to educate residents. At our
institution, residents are first exposed to coding and/or billing issues
during their initial orientation. Then, throughout the year, the residents
receive lectures on a quarterly basis about the different facets of practice
management. The faculty members mentor the residents, giving them insights
into various aspects of practice management. Perhaps the most substantial
educational element, with regard to coding and billing issues, is that the
residents are responsible for assigning codes through an electronic medical
record for encounters with patients (in the clinic, hospital, and emergency
room) and for procedures performed on patients. This is done on a continual
basis throughout each year of the resident's training. The faculty member
checks the resident's coding each time a procedure or encounter is billed. The
faculty is responsible for pointing out any errors or discrepancies seen with
the coding. This provides continual feedback for the residents so that future
errors can be minimized. Additionally, our department's certified coders
review the codes and provide at least monthly feedback to the residents and
faculty members as codes change with Medicare and private insurers' policy
updates. In addition, our program encourages the residents to participate in
practice management courses sponsored by the state orthopaedic society and
national organizations. Thus, our program uses a combination of educational
tools to teach the practice management skills needed in today's complex
practice environment.
In conclusion, practice management education should be an integral part of
a resident's education. The ACGME has recognized its importance by
categorizing practice management as a systems-based competency. Orthopaedic
surgery training programs need to embrace this concept and educate their
residents. To our knowledge, this is the first report to review the literature
pertaining to practice management training during graduate medical education.
Our informal survey of senior orthopaedic residents suggests that orthopaedic
residents currently are not receiving adequate education in practice
management. Although further studies need to be done with validated surveys to
better evaluate the present educational programs, a variety of educational
models should be developed to ensure effective training in this critical area
of orthopaedic practice.