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首页> 外文期刊>The Journal of Graduate Medical Education >Comments: Response to Iannuzzi et al
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Comments: Response to Iannuzzi et al

机译：评论：对Iannuzzi等人的回应

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We read with interest the article by Iannuzzi et al,1 which, in staffing a large academic health center internal medicine service, presents a financial comparison of direct patient care costs and length of stay between the hospitalist-resident teams and the hospitalist-physician assistant (PA) teams. In this letter, we would like to make 3 points. First, the comparison between hospitalist-resident and hospitalist-PA teams may not be fair or rational. Residents are trainees in a formal program of graduate medical education, and there is an educational component to their role. Conversely, a PA employed by an academic health center is a permanent employee of the institution, is not in training, uses fewer resources, and their compensation is at least one-third more than a resident's stipend. As trainees, physician residents are subject to supervision from faculty, and they tend to spend time on the wards for a defined period of time. Hospitalist-PAs are more likely to be permanent workers on wards, bringing greater continuity of care. PAs' supervision entails collaboration with physicians as colleagues. In our own observations, PAs also provide assistance to trainees and maintain continuity of care during periods of trainee turnover. All these variables are not accounted for in the article's analysis and could affect the results. We therefore suggest that these differences make the comparison discussed in the article methodologically inappropriate. Second, the analysis by Iannuzzi and colleagues1 is at odds with findings of similar studies in health services research publications. For example, several recent comparisons have shown not only beneficial effects from the utilization of PAurse practitioner (NP) providers as hospitalists but also have demonstrated cost savings.2–4 One study demonstrated that collaborative physician-NP multidisciplinary care management of hospitalized medical patients reduced length of stay and improved profit without affecting readmissions or mortality.2 Another study found that a service staffed by hospitalists and a PA can provide a safe alternative to a resident service for general medicine inpatients.3 A third study found that hospitalist-PA team-based general medicine inpatient care was associated with a higher length of stay, and had similar charges, readmission rates, and inpatient mortality as compared to traditional resident-based teams.4 Other examples are available if general medicine is to be the standard for comparative studies. We do not think that the 25-year-old data in the Knickman et al5 reference to be a contemporary one, and the citation of neonatal intensive care unit providers to be appropriate for discussion references of an adult medicine ward situation. Third, the authors use the term “midlevel provider” when referring to PAs. This term is considered demeaning to PAs and NPs alike, and suggests that users do not have an understanding of their roles. Does the term presume physicians are at the superior level and nurses at the inferior level of some team arrangement? This type of diminutive collective term is considered pejorative by both health professional associations.6
机译：我们感兴趣地阅读了Iannuzzi等人的文章，1该文章在为大型学术健康中心内部医学服务人员配备时，提供了住院病人团队与住院医生助理之间直接患者护理费用和住院时间的财务比较。 （PA）团队。在这封信中，我们想提出三点。首先，住院医师与住院医师-PA团队之间的比较可能不公平或不合理。居民是接受正规医学研究生教育计划的受训者，他们的角色涉及教育。相反，由学术保健中心雇用的PA是该机构的永久雇员，不在培训中，使用的资源较少，其报酬至少比居民的津贴高出三分之一。作为实习生，医师住院医师需要接受老师的监督，并且他们倾向于在病房中花费一定的时间。住院医生-PA更有可能成为病房的固定工，带来更大的护理连续性。 PA的监督需要与作为同事的医生进行合作。根据我们自己的观察，PA还会为受训人员提供帮助，并在受训人员更替期间保持护理的连续性。本文的分析未考虑所有这些变量，并且可能影响结果。因此，我们建议这些差异使本文中讨论的比较在方法上不适当。第二，Iannuzzi及其同事的分析1与卫生服务研究出版物中类似研究的结果不一致。例如，最近的几次比较显示，不仅利用PA /护士（NP）提供者作为住院医生具有有益效果，而且还显示出成本节省。2–4一项研究表明，住院医生与医生进行NP-多学科协作管理患者缩短了住院时间并提高了利润，而又不影响重新住院或死亡率。2另一项研究发现，由住院医生和PA负责的服务可以为普通医学住院病人提供住院服务的安全替代方案。3第三项研究发现，PA住院医生与传统的以居民为基础的团队相比，以团队为基础的普通药物住院治疗的住院时间更长，收费，再入院率和住院死亡率相近。4比较研究。我们认为，在Knickman等[5]中引用25年的数据并不是当代数据，而引用新生儿重症监护病房提供者来作为讨论成人病房情况的参考文献是适当的。第三，当提到PA时，作者使用术语“中级提供者”。该术语被认为对PA和NP都是贬义的，它表明用户对他们的角色不了解。在某些团队安排中，假定医师是上级还是护士是下级？两个卫生专业协会都认为这种小型的集体名词是贬义的。6

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