Task Shifting and Task Sharing in Surgical Care

The United States surgeon workforce shortage is expected to worsen in coming years, exacerbated by burnout, surgeon aging, and retirement.1 As residency training positions have been slow in expanding, one natural response has been to grow an advanced practice provider (APP) workforce within surgical specialties. Limited early data suggest rapid expansion of APPs involved in surgical care and potential benefits including improved access and clinical outcomes.2 However, APP integration into surgical specialty care across the country is not well understood. Despite widespread surgical workforce expansion, significant knowledge gaps remain concerning the real-world division of labor among surgeons and APPs, and their implications for surgical patient care and outcomes. One way to conceptualize, implement, and study this newfound division of labor as APPs integrate into surgical care delivery can be found in existing implementation science literature. Specifically, there is a growing body of research on task shifting and task sharing within health care teams that could be applied, framing APP integration into surgical care teams as a strategic redistribution of duties related to the care of surgical patients. This can mean surgeons and APPs sharing tasks (eg, new patient visits, closing surgical wounds, and endoscopy) or shifting certain tasks altogether from surgeons to APPs (eg, certain established care or postoperative visits, inpatient rounding, and drain management). Traditionally, task sharing has been studied and implemented in low- and middle-income countries to address the shortage in the availability of evidence-based care in areas such as education and delivery of contraception and HIV care using a less specialized, less trained workforce. Recently, task sharing of surgical care in such settings has also been examined, providing evidence that nonsurgeons can be trained to perform elective inguinal hernia repair, cesarean section, and circumcision, among others.3,4 Emerging studies in high-income countries have examined nonphysicians performing tube thoracostomy, external ventricular drain placement, circumcision, and cesarean delivery.3 While evidence is emerging, we propose conceptualizing the current integration of APPs into surgical care teams would benefit from adopting lessons from the task sharing literature. Task shifting and sharing has been recommended by the World Health Organization as a public health initiative supporting its validity.5 The recommendations also highlight the need to ensure quality of care when implementing task shifting and sharing given potential harms arising from a less expert workforce, such as defining roles and associated competencies required for various tasks as well as establishing supervision and quality assurance mechanisms. While these competencies have not been fully defined or endorsed in surgical care, an opportunity rests in the evolving approach to entrustable professional activities providing a path forward for surgical task shifting and sharing.6 Furthermore, supervision and clinical mentoring are essential to task sharing and task shifting when APPs are integrated into surgical care teams. While these roles are common and well understood in academic health centers, APPs are rapidly entering the workforce across the landscape of American surgery, including in practices where supervisory and mentorship roles are new and may be unfamiliar. The Concepts and Opportunities to Advance Task Shifting and Task Sharing Framework outlines opportunities, conditions, and considerations for task sharing (Fig. 1).7 Surgical care in the US appears to meet the necessary criteria for task shifting and sharing. Specifically, there are large new cadres of providers willing to be trained to deliver interventions in surgical care teams. We have, and are expected to continue to have, a shortage of health human resources (ie, surgeons). Several interventions that are clinically effective in the context of surgical care are also able to be delivered by healthcare providers with less training as highlighted in the examples above—however, high-quality, generalizable evidence for this is lacking at present. Indeed, important considerations for implementation remain. First, the resources needed to develop and scale task shifting and sharing programs have not been developed. Robust training and supervision standards, credentialing, protocols and algorithms are needed to ensure task shifting and sharing implementation maintains high quality standards. Second, we have extremely limited knowledge regarding the social acceptability of task shifting and sharing in the context of surgical care in high-income countries like the US. Future work will need to elicit patient and provider perspectives in specific contexts and for varied tasks. Finally, the implications of rapid integration of APPs into surgical care teams are already playing out in surgical care delivery across the US. We need to prioritize understanding the tradeoffs inherent in this new division of labor. While specialization and division of labor may improve access, there may be costs related to care coordination and a potential impact on the physician-patient relationship.FIGURE 1.: The COATS Framework for task shifting and task sharing outlines the definitions and purpose of task shifting and sharing as well as opportunities and necessary conditions and important considerations for its use.7 COATS indicates concepts and opportunities to advance task shifting and task sharing. The figure is used from an open access paper available at https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-021-00605-z.Given ongoing trends in the surgical care workforce expansion, the question is not whether we should engage in task sharing with APPs—this is already happening. Instead, the question is to what extent is task sharing evidence-driven and effective versus variable and haphazard.