Comparison of knowledge of perioperative care in primary care residents versus anesthesiology residents

Abstract

Primary care physicians (internal medicine and family practice) are often asked to evaluate patients before surgery and prepare them for the procedure. The goal of our study was to examine primary care and anesthesiology resident physicians' knowledge of preoperative evaluation and preparation as well as perioperative changes during anesthesia and surgery. To this end, a questionnaire was sent to primary care resident physicians and anesthesiology resident physicians in our university hospital system. One hundred twenty questionnaires were distributed, and the overall response rate was 50.8%. Although there was agreement between anesthesiology and primary care residents in many of the areas surveyed, differences were observed in questions related to appropriateness of preoperative instructions regarding medications, utility of routine preoperative testing, and identification of expected physiologic changes during anesthesia and surgery. Of the maximum possible 36 points, the mean score for anesthesiology residents (27.55) was higher than the mean scores for primary care residents (21.4 and 20.24 for internal medicine and family practice, respectively), although overall scores were generally lower than expected for both anesthesiology and primary care residents. The level of training of the respondents did not significantly affect the responses. We conclude that primary care resident physicians were knowledgeable about most perioperative care, although some deficiencies were identified when these residents were compared with anesthesiology residents. Surveys such as ours may be used to identify areas of deficiencies that require further education for both groups of residents.

The number of people in the USA older than 65 years is expected to increase by 13.3% by 2010 and 53.2% by 2020, as baby boomers age and life expectancies lengthen (1). This increase in the population of older individuals will result in increased surgical workload (2–4) and a resulting need for preoperative preparation. Furthermore, more complex procedures are being increasingly performed on sicker and older patients in the outpatient setting. There is therefore a need for comprehensive preoperative evaluation and preparation to minimize the occurrence of perioperative complications.

In an outpatient setting, the initial patient encounter with the anesthesiologist often occurs on the day of surgery (5), so that the responsibility for evaluating these patients before surgery often falls to the primary care physician. When pre operative evaluation is done in the inpatient setting, “hospitalists,” a new group of primary care physicians, are likely to be involved in preoperative preparation as many hospitals move to this model of care. Hospitalists work closely with surgeons to care for the medical aspects of preoperative and postoperative management (6). It is therefore important that primary care physicians, including hospitalists, be familiar with optimal preoperative preparation.

Primary care physicians are involved not only in preoperative care but also increasingly in postoperative care (6, 7). The involvement of primary care physicians in preoperative or postoperative care assumes that they have adequate familiarity with the pathophysiologic changes accompanying anesthesia and surgery. Gaps in knowledge and training in this area may lead to inappropriate or inadequate perioperative care(8). To the best of our knowledge, there are no published studies evaluating the knowledge of primary care physicians or anesthesiologists regarding perioperative care.

We hypothesized that there would be no difference in the knowledge of basic perioperative concepts in family medicine and internal medicine residents when compared with anesthesiology residents. Anesthesiology residents were chosen because of their assumed expertise and training in perioperative care. We therefore designed a questionnaire to survey primary care (internal medicine and family practice) resident physicians regarding their knowledge of preoperative evaluation and preparation as well as perioperative changes accompanying anesthesia and surgery when compared with anesthesiology residents.

METHODS

After institutional review board approval, questionnaires were distributed to resident physicians in internal medicine, family medicine, and anesthesiology in our institution. The internal medicine and family medicine residency programs at the University of Texas Southwestern Medical Center comprise 132 residents and 30 residents, respectively, with roughly equal distribution at all levels of training. Internal medicine residents are exposed to and trained in perioperative medicine through a Table 2. Analysis of variance: impact of specialty 4-week rotation on the medicine consult service and continuing on questionnaire score experience throughout training. There is no formal rotation for family medicine residents; however, there is continuing exposure throughout residency training. The anesthesiology residents undergo a formal 4-week rotation in perioperative medicine during the first year of training in addition to continuing exposure throughout training. The general training and experience of the residents in both internal medicine and family medicine programs at our institution are comparable to those of other large US residency programs based on performance on board certification examinations taken at the end of training (9, 10).

Table 2.

Analysis of variance: impact of specialty on questionnaire score

The questionnaire asked about medical specialty and level of training (postgraduate year 1–5) and then listed the five available responses for each question: agree, somewhat agree, neutral, somewhat disagree, and disagree (Likert scale), with an option for comments at the end of each question. Thirty-six questions were included (Table 1), addressing preoperative instructions to patients, preoperative testing, common medical conditions seen in the perioperative period, effects of anesthesia on organ systems, and regional anesthesia. Survey questions were generated after searching MEDLINE and OVID for articles relevant to perioperative care between January 1983 and October 2003. We identified content areas of interest and specific questions. Other questions were developed based on commonly known misconceptions among primary care physicians regarding anesthesia and surgery (8, 11–14). The “correct” answers to the questions asked were obtained from a standard reference textbook of anesthesia (15). Each correct answer received 1 point, for a maximum score of 36 points. Data were collected over 4 months. Reminders were sent 2 months after the initial distribution of questionnaires.

Table 1.

Perioperative medicine questionnaire with answers from Miller's Anesthesia, 6th edition

The data were analyzed using SAS Version 9.1 (SAS Inc, Cary, NC). For the purpose of analysis, the “agree” and “somewhat agree” responses were combined, and the “disagree” and “somewhat disagree” responses were also combined. Questionnaire responses were evaluated utilizing the Fisher exact test since expected cell values were often low, therefore not satisfying the assumptions for valid chi-square contingency table analysis. Additionally, overall scores were calculated for each participant. A two-way analysis of variance was used to detect the influence of specialty and level of training on questionnaire score. The Student-Newman-Keuls multiple comparisons test was applied for pairwise comparisons of questionnaire scores between the given specialties. A P value <0.05 was considered statistically significant.

RESULTS

We distributed 120 questionnaires, and the overall response rate was 50.8%. The response rate for anesthesiology residents was 57.1%, while that for internal medicine and family practice residents was 52% and 48%, respectively. Two questionnaires were only partially answered and were not included in the analysis. Overall, mean questionnaire scores were significantly higher for the anesthesiology residents (27.55) than for the internal medicine residents (21.40) and family medicine residents (20.24) (P < 0.001) (Table 2). Questionnaire scores between family medicine and internal medicine residents were not significantly different (P = 0.391). No statistically significant difference could be detected for the impact of level of training on questionnaire score (P = 0.054) (Table 3).

Table 3.

Analysis of variance: impact of level of training on questionnaire score

Individual questions were examined for differences in response for the three specialty areas. Significant differences in responses were detected when comparing anesthesiology, internal medicine, and family medicine residents. When internal medicine and family medicine residents were grouped as primary care residents, most of the differences persisted. Finally, there were no significant differences in responses when comparing internal medicine and family medicine residents (Table 4).

Table 4.

Response to questionnaire by specialty∗

DISCUSSION

Since primary care physicians are increasingly involved in perioperative patient care (16, 17), it is important for them to be familiar with perioperative pathophysiology. Our findings indicate that primary care residents were knowledgeable about preoperative preparation, except in areas involving preoperative instructions and preoperative testing, in which the primary care physicians favored the preoperative ordering of routine blood tests, urinalysis, and electrocardiograms (P = 0.001) (18). This is in contrast to the recommendations of the practice guidelines of the American Society of Anesthesiologists (19), which state that preoperative tests should be performed selectively to guide or optimize perioperative management. The guidelines also recommend that indications for such testing should be based on information obtained from the medical records, patient interview, and physical examination, as well as the type and invasiveness of the planned procedure.

Many primary care residents did not correctly identify the physiologic changes that accompany induction of anesthesia and subsequent laryngoscopy and tracheal intubation. Presumably, the understanding of anticipated hemodynamic changes during the perioperative period will result in better patient preparation.

There were also knowledge gaps concerning the safety and effect of regional anesthesia on organ systems and disease states. The perception that “neuraxial blockade” does not affect the cardiovascular system may in part be responsible for recommendations favoring regional anesthesia in patients with significant cardiovascular comorbidities.

It is remarkable that the anesthesiology residents did not perform as well as would be expected on the survey (average score, 27.5 [± 3.8]; maximum possible, 36 points), even though nearly all the residents that participated in our survey had completed their perioperative care rotation. The lower-than-expected scores may reflect the content of the anesthesia perioperative medicine rotation in our institution and represent an opportunity for improvement in the quality of the rotation.

The limitations of our study include a relatively low response rate from our subjects. The reasons for this are unclear. Possible reasons include lack of interest in perioperative care, a perception that perioperative medicine is outside the scope of their specialty, or a perception that physician extenders could be better utilized in this role. It is likely that responders may have been more likely than nonresponders to feel that they had adequate knowledge of preoperative care. It is also possible that physicians who have completed training, rather than the residents surveyed, would have different responses to the questions asked, although we did not find a significant difference when responses were analyzed based on level of training. Another limitation may be related to the way questions were framed. The questions with negative answers may have led to some confusion and resulted in conflicting responses.

In conclusion, our study showed that although primary care physicians are knowledgeable about preoperative preparation, there is a need for a better-defined perioperative medicine curriculum in primary care training programs and for continuing education among primary care physicians. This training would provide relevant information about perioperative events to which primary care physicians are typically not exposed but which are important for adequate preoperative preparation. Perioperative medicine is not a subspecialty of internal medicine or family medicine but rather a body of medical knowledge that enables physicians to manage medical illness during the perioperative period, assess operative risk, and respond to complications.

As hospitalists continue to play a more significant role in the care of perioperative patients, other physician groups with interest in perioperative care (anesthesiologists, cardiologists, etc.) will need to work closely with hospitalists to further improve perioperative care. Cooperation between these groups to update existing guidelines and formulate new guidelines represents an opportunity to standardize teaching about peri-operative medicine. Finally, surveys such as ours may be used to detect deficiencies in knowledge and to identify areas requiring more education.

Acknowledgments

The authors would like to thank Michael H. Wall, MD, for support towards statistical analysis and overall review of the manuscript. Shiv Sharma, MD, April Gorman, MS, and Joan Reisch, PhD, at the University of Texas Southwestern Medical Center at Dallas provided statistical analysis.