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The financial impact of teaching surgical residents in the operating room
The Financial Impact of Teaching Surgical Residents in the Operating Room Matthew Bridges, MD, Daniel L. Diamond, MD, Knoxville, Tennessee
BACKGROUND: There have been no published data regarding the cost of training surgical residents in the operating room. METHODS: At the University of Tennessee Medical Center-Knoxville, in addition to resident-performed teaching cases, some cases are performed without the assistance of residents by the same faculty. RESULTS: Sixty-two case categories involving 14,452 cases were compared for operative times alone. In 46 case categories (10,787 procedures), resident operative times were longer than faculty alone. In 16 case categories, resident operating times were shorter than faculty times. The net incremental operative time cost was 2,050 hours between July 1993 and March 1997. Assuming 4 years of operative training for 11 graduating chief residents, the cost per graduating resident was $47,970. CONCLUSION: Extrapolated to a national annual cost for the 1,014 general surgery residents who completed training in the 1997 academic year, the annual cost of training residents in the operating room is $53 million. This high monetary cost suggests the need for digital skills, selection criteria, the development of training curriculum and resource facilities, the pre-operating room need for suturing and stapling techniques, and perhaps the acquisition of virtual surgery training modules. Am J Surg. 1999;177:28 –32. © 1999 by Excerpta Medica, Inc.
N
ever sine the beginning of an organized residency system in the United States has the future of graduate medical education been more unclear. With the merger of hospitals and hospital systems, not to mention the large shifts in patient base that have affected individual hospitals because of HMO and insurance contracting, the stability of patient base for education has become a major issue for graduate medical education. The emphasis on faculty economic productivity to support medical school budgets and to provide self-support for faculty
From the Department of Surgery, University of Tennessee Medical Center-Knoxville, Knoxville, Tennessee. Requests for reprints should be addressed to Daniel L. Diamond, MD, Department of General and Peripheral Vascular Surgery, 382 W. Chestnut Street, Suite 106, Washington, Pennsylvania 15301. Manuscript submitted August 17, 1998 and accepted in revised form September 28, 1998.
28
© 1999 by Excerpta Medica, Inc. All rights reserved.
whose teaching and research salaries have disappeared threaten the stability of teaching faculty. The declining reimbursement per operative case for attending surgeons and faculty has further assaulted the time commitments required to educate surgical and other trainees. Perhaps most significant of all has been the gradual shift in Medicare reimbursement towards support for primary care fields and away from surgical specialty training. In addition, the change from indemnity, cost-based reimbursement which included hospital expenses for graduate medical education toward a system of managed care, where pricing has not included the cost of graduate medical education, has left the United States Government as the primary monetary support for graduate medical training.1 The Medicare program alone is estimated to have paid $6.8 billion in 1997 for direct medical expense and indirect medical expense. There has been and is no clear consensus and no national vision as to who or what entities should pay for graduate medical education in the future. Unfortunately, there is little knowledge of the true cost of graduate medical education and even less objective data reflective of the true cost of surgical education. At countless meetings in which residency training has been discussed, one may hear such comments as “Surgical residents are the best deal a hospital ever had,” “Surgical residents get paid about thirty cents an hour,” and “Hospitals are making out like bandits on indirect and direct medical education reimbursement from Medicare.” In spite of this plethora of self-righteous opinions, there have been no data indicating the true monetary cost of training a surgical resident. One of the critical pieces of missing data is the cost to a hospital for training residents in the operating room. This study was undertaken to attempt to quantitate the hospital costs incurred as a result of the training of residents in the operating room.
METHODS Since our residency is not large enough to allow resident participation in all operative procedures, surgical faculty perform some cases without resident participation. Since the faculty surgeon is constant, the variable of resident participation was thought to be an adequate means of separating cases into those definitely not done by a resident and those probably done by a resident. Both resident and faculty evaluations have suggested that over 95% of the procedures that involve a resident are performed by the resident with the faculty as teaching assistant. Sixty-two procedures were selected from the University of Tennessee hospital operating room records for their relative frequency and the likelihood that there would be significant numbers of cases performed by 0002-9610/99/$–see front matter PII S0002-9610(98)00289-X
TEACHING SURGICAL RESIDENT IN OPERATING ROOM/BRIDGES AND DIAMOND
TABLE I Forty-Six Categories Where Resident Time Was Longer Without Residents
With Residents
Difference
Procedures
# Cases
Avg. Min.
# Cases
Avg. Min.
Avg. Min.
Total Min.
Appendectomy Appendectomy, laparoscopic AAA AV fistula/graft AV revision Amputation, toe/transmet Anoplasty/endorectal advance Bowel resection, low anterior Breast mass biopsy or removal Breast reconstruction, TRAM Biopsy, node Cystectomy, radical w/ileocon CEA Cholecystectomy, laparoscopic Colostomy Colostomy closure Cysto w/RPG/cystogram Embolectomy UE Embolectomy LE Excision lesion/lipoma Excision cyst Exploratory laparotomy Feeding jejunostomy Femoral–popliteal bypass graft Femoral–tibial bypass graft 1 & D abscess/wound/mass IVC filter Hernia, inguinal, unilateral Hernia, umbilical Hernia, ventral/incisional Hydrocelectomy, unilateral Ing. Laparotomy/LOA Mastectomy, bilateral Mastectomy, modified radical Mastectomy, simple/partial Nephrectomy Parathyroidectomy, total/subtotal PEG tube insertion Prostatectomy, radical Raz/Stamey urethropexy Rectal biopsy STSG Thoracotomy Thyroidectomy Tracheostomy VVSL, unilateral Total
35 26 7 41 29 10 30 4 638 14 77 20 28 294 11 15 361 11 8 284 63 60 7 10 8 84 40 240 75 78 29 11 7 60 56 90 22 19 42 84 3 230 83 47 71 12 3,474
57 72 105 88 65 20 28 113 43 292 43 216 126 80 85 110 24 74 52 46 35 111 47 148 194 26 23 70 45 87 25 75 167 119 69 91 87 37 100 52 12 62 115 99 35 71
125 154 254 290 126 59 12 48 648 12 86 10 609 604 65 59 49 54 118 249 56 723 44 277 111 178 163 420 119 230 9 32 42 252 101 38 90 40 19 28 7 88 151 175 212 77 7,313
78 94 178 105 95 28 54 210 54 453 56 263 128 89 93 118 34 86 117 76 45 121 60 176 206 61 44 81 90 96 39 120 194 141 94 105 120 63 188 78 37 78 152 133 50 86
21 22 73 17 30 8 26 97 11 161 13 47 2 9 8 8 10 12 65 30 10 10 13 28 12 35 21 11 45 9 14 45 27 22 25 14 33 26 88 26 25 16 37 34 15 15
2,625 3,388 18,542 4,930 3,780 472 312 4,656 7,976 1,932 1,118 470 1,218 5,436 520 472 490 648 7,670 7,470 560 7,230 572 7,758 1,332 6,230 3,423 4,620 5,359 2,070 126 1,440 1,134 5,544 2,525 532 2,970 1,040 1,672 728 175 1,408 5,587 5,950 3,180 1,159 148,812
AAA, abdominal aortic aneurysm; AV, arteriovenous; CEA, carotid endarterectomy; IVC, inferior vena cava; LE, lower extremity; LOA, lysis of adhesions; PEG, percutaneous endoscopic gastrostomy; RPG, retrograde pyelogram; STSG, split thickness skin graft; TRAM, transfer rectus abdominis muscle; VVSL, varicose vein stripping and ligation.
residents. Most of the cases were types that a general surgery resident would be expected to complete within an approved residency (Table I, Table II). They were drawn from the fields of general, pediatric, vascular, plastic, urologic, and trauma surgery. Cases that were performed in low numbers or those in which a resident was always present, eg, Whipple procedure, were excluded from the analysis. The cases of surgeons who do
not participate with the surgical residency as teaching faculty were also excluded from the study. A total procedure time was determined from operative records used for hospital billing. The beginning of the procedure time was the incision time and the end of the procedure time was the “left room time,” both recorded by the circulating nurse. A total procedure time for each type of procedure, as well as a mean procedure time and
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TEACHING SURGICAL RESIDENT IN OPERATING ROOM/BRIDGES AND DIAMOND
TABLE II Sixteen Case Categories Where Resident Time Was Shorter Without Residents
With Residents
Difference
Procedures
# Cases
Avg. Min.
# Cases
Avg. Min.
Avg. Min.
Total Min
AV access declot ASD AVR Amputation, LE Axillary dissection Bowel resection, small Cholecystectomy, lap w/chol Colectomy/hemicolectomy Fistulotomy/fistulectomy Hemorrhoidectomy Kidney transplant, cad/LRD Laparoscopy, diagnostic Muscle biopsy Port placement Thoracotomy, lobectomy VSD Total
31 32 50 58 32 22 180 27 44 149 16 32 17 537 7 11 1,245
78 137 228 67 89 125 93 190 28 68 190 105 31 47 152 188
185 18 11 361 103 133 501 223 31 100 108 130 15 478 12 11 2,420
74 131 209 63 76 121 82 158 25 40 189 74 25 45 11 168
24 26 219 24 213 24 211 232 23 228 21 231 26 22 241 220
2740 2108 2209 21,444 21,339 2532 25,511 27,136 293 22,800 2108 24,030 290 2956 2492 2220 25,788
ASD, atrial septic defect; AV, arteriovenous; AVR, aortic valve replacement; LE, lower extremity; LRD, live related donor; VSD, ventricular septic defect.
TABLE III
TABLE IV
University of Tennessee Medical Center-Knoxville Operating Room 1997 Fiscal Year (July 1 through June 30) Salaries, wages, benefits (OR personnel) Salaries, wages, benefits (20 CRNA) Total Total number of surgical cases (includes nonteaching and surgeons courtesy) Total operating minutes Cost per operating minute Cost per operating hour without anesthesiologist
$6,384,075 $2,196,814 $8,580,889 18,330 2,001,180 $ 4.29 $ 257.27
a mean difference in the length of the procedure with or without a resident were determined using regression and analysis of means. The mean time lost or gained was calculated in each case category. The total time lost was generated by subtracting the total net time difference in categories when resident cases were shorter from the total net time difference in categories where resident cases were longer. During the course of the study (July 1993 through March 1997), there were 11 surgical trainees who completed training. This number was divided into the total “lost” time to yield the lost time per graduated resident. Thus, the lost time is an averaged figure that includes time lost by both junior and senior residents over a 4-year period. The cost per hour of operating time was determined by dividing the total minutes of all operations in 1 year into the non-supply cost associated with running the operating room for that year. The cost per minute was then multiplied by 60 to generate an hourly cost. The non-supply costs include administrative salaries, hourly wages, overtime, on-call pay, longevity pay, and the cost of all benefits (including retirement) of all operating room personnel and 20 CRNAs (Table III). For purposes of this calculation, the cost of surgeon and anesthesiologist time was not 30
University of Tenessee Medical Center-Knoxville Surgical Teaching Case Data (July 1993–March 1997) Total cases for analysis Cases with resident Cases with no resident Forty-six categories where resident time was longer 7,313 cases with a resident 3,474 cases with no resident Sixteen categories where resident time was shorter 2,420 cases with a resident 1,245 cases with no resident
14,452 9,733 4,719
considered, since this is not a hospital expense in most systems. The 1997 fiscal year (July 1 to June 30) was selected as the index year for purposes of cost calculation formula.
RESULTS There were 14,452 total cases for analysis, 9,733 with a resident and 4,719 with no resident (Table IV). There were 46 operative case categories (10,787 cases) in which procedures performed with a resident required longer operative times (103 minutes average time) when compared with cases done without a resident (61 minutes average time). This resulted in a total of 148,812 more minutes (2,480 hours), of operating time than would have been expected if the case times had been the same as those which were performed without residents in these 46 categories (Table V). In the 16 categories (3,665 cases) in which operating time of cases performed with residents was actually shorter than cases performed without a resident, the total time difference was 25,788 minutes (430 hours). Analysis of all of the 62 categories yields a net incremental operative time “cost” of 123,024 minutes (2,050 hours). Given a cost figure of $4.29 per minute (excludes supplies,
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 JANUARY 1999
TEACHING SURGICAL RESIDENT IN OPERATING ROOM/BRIDGES AND DIAMOND
TABLE V University of Tennessee Medical Center-Knoxville Net Operating Time Gain or Loss Analysis Net time loss (46 categories) Net time gained (16 categories) “Net of nets” time ‘lost’ to resident training Net cost @ $4.29/minutes (11 graduating residents over 4 years)
148,812 min (2,480 hr) 25,788 min (430 hr) 123,024 min
$527,772.96
TABLE VI University of Tennessee Medical Center-Knoxville FourYear Operating Room Training Cost per Graduating Resident Cases with residents Cases per graduating resident Net time lost per case Net lost time per resident Cost per graduating resident
9,733 885 12.64 min 11,816 min $47.797
indirect costs, anesthesiologist fees or costs, and surgeons fees), the total cost for this “lost time” was $527,772.96. Within the 62 case categories that were analyzed for this report, there were 9,733 operative cases performed with residents or 885 per graduating chief resident (Table VI). Given a total lost or extra minute figure of 123,024 minutes generated by 9,733 cases performed with residents, the 4-year training figure is 11,184 lost minutes of operative time, or $47,979 of cost per graduating resident.
COMMENTS One can certainly take exception to the methodologies used in this analysis. Some of the cases listed with the resident may actually have been done by faculty, but our internal analysis seems to indicate that cases done with a resident listed by operating room personnel as assistant serves as a reasonable proxy for “case done by resident with faculty in attendance.” If anything, the potential to have some resident cases actually done by faculty would minimize the effect of lost time rather than to magnify it, since there are more cases that were prolonged than shortened by resident participation. The operative times may not be totally accurate, but they serve as the basis for hospital billing. One may reasonably assume that there are the same inaccuracies whether a resident is scrubbed or not scrubbed. Some case categories have a high percentage of resident participation whereas others have a low resident participation, thus creating a nonrandom distribution. There is also the possibly of faculty or resident selection bias because of resident participation in more difficult or index type cases. While all of these are valid potential criticisms, the large number of cases should tend to nullify the potentially confounding effects of some of these concerns. It would have been easier and neater to use 5 years of data, but our hospital operating room information system had slightly less than 4 years of data that could substantiate resident participation and length of procedure. Unfortunately, the hospital information system does not use the same 277 case categories that exist in the Surgical Operative Log of the Residency Review Committee for Surgery,
thus partially explaining the disparity between the 885 cases per graduating resident generated by our data and the average 938 reported to the RRC for the 11 graduating residents. The reasons for some case categories in which residents seemingly operated faster than their teaching faculty are of obvious interest. Some, such as laparoscopic cholecystectomy with cholangiogram, colectomy, or kidney transplant, are cases in which the individual resident has as high a volume of experience as the operating surgeon or is more accustomed to doing that case with the teaching faculty as an assistant than the teaching faculty is without a resident. In addition, cases that are performed by teaching faculty with no resident participation are often performed with significantly less assistance, as it is rare for faculty surgeons to assist each other and there are no paid surgical assistants at University of Tennessee Medical Center at Knoxville. Whatever assistance is provided, if any, is usually an additional scrub technician. The cost figures are thought to represent easily measurable costs in most institutions. There are undoubtedly local issues in each hospital that would make an analysis of the costs somewhat different. By defining the costs that we used in the analysis, other institutions should be able to arrive at a comparison. Most discussions of indirect medical expense payments to hospitals list such things as additional diagnostic tests and lower hospital staff productivity as one of the rationales for indirect medical expense payment from Medicare. To our knowledge, there has never been a financial analysis of incremental cost associated with training a resident in the operating room. Given the fact that there are approximately 21,000 residents enrolled in core surgical programs in the United States,2 it would seem prudent to study this issue in more detail since there is a direct financial cost over and above that paid from the patients and income of teaching surgeons. When and if there is a national consensus regarding graduate medical education funding, the cost of operative training should be factored in. If one attempts to extrapolate from this study to a national annual cost figure for general surgery alone, the cost is somewhere in the $53 million range. This assumes a per-case loss of $54.23 for the 11 residents who finished the program involved in this study, 961 average cases reported in the Surgical Operative Log for 1,014 general surgery residents who completed training in the 1997 academic year.3 If the dictates of optimal patient care and the stresses imposed on faculty surgeons did not already demand it, the direct economic cost of training residents on patients would suggest that we need to look for ways to make this a more productive and efficient process. Perhaps there is a need for an articulated technical training curriculum that includes the setting and achievement of goals and standards. There is a need for development of technical resource facilities where residents can practice and can compete in technical exercises. There is a need for animal or cadaver laboratories in which residents are taught suturing and stapling techniques. There is a need for the promise of virtual surgery to be realized for the benefit of training
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 JANUARY 1999
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TEACHING SURGICAL RESIDENT IN OPERATING ROOM/BRIDGES AND DIAMOND
surgical residents. While these alternatives may be expensive, they are one-time costs that do not recur each time a resident steps in the operating room. And finally, perhaps it is not too early for us to recognize that surgery is and always has been a technical exercise at which some people are more adept than others and to reflect this recognition in our selection processes. Although the figures generated by this analysis are likely to be different in each institution, it is hoped that all will reflect a net time cost to training residents in the operating room. If that is not the case, perhaps those of us who are
32
responsible for that training are in need of some remedial technical training.
REFERENCES 1. Fishman LE. Medicare payments with an education label: fundamentals and the future. Association of American Medical Colleges; 1996. 2. Kwakwa F, Jonasson O. The longitudinal study of surgical residents, 1993 to 1994. J Am Coll Surg. 1996;183:425– 433. 3. Residency Review Committee for Surgery. Program National Data. Reporting period 7/1/96 – 6/3/97. Accreditation Council for Graduate Medical Education, Chicago, IL; 1997.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 JANUARY 1999
BACKGROUND: There have been no published data regarding the cost of training surgical residents in the operating room. METHODS: At the University of Tennessee Medical Center-Knoxville, in addition to resident-performed teaching cases, some cases are performed without the assistance of residents by the same faculty. RESULTS: Sixty-two case categories involving 14,452 cases were compared for operative times alone. In 46 case categories (10,787 procedures), resident operative times were longer than faculty alone. In 16 case categories, resident operating times were shorter than faculty times. The net incremental operative time cost was 2,050 hours between July 1993 and March 1997. Assuming 4 years of operative training for 11 graduating chief residents, the cost per graduating resident was $47,970. CONCLUSION: Extrapolated to a national annual cost for the 1,014 general surgery residents who completed training in the 1997 academic year, the annual cost of training residents in the operating room is $53 million. This high monetary cost suggests the need for digital skills, selection criteria, the development of training curriculum and resource facilities, the pre-operating room need for suturing and stapling techniques, and perhaps the acquisition of virtual surgery training modules. Am J Surg. 1999;177:28 –32. © 1999 by Excerpta Medica, Inc.
N
ever sine the beginning of an organized residency system in the United States has the future of graduate medical education been more unclear. With the merger of hospitals and hospital systems, not to mention the large shifts in patient base that have affected individual hospitals because of HMO and insurance contracting, the stability of patient base for education has become a major issue for graduate medical education. The emphasis on faculty economic productivity to support medical school budgets and to provide self-support for faculty
From the Department of Surgery, University of Tennessee Medical Center-Knoxville, Knoxville, Tennessee. Requests for reprints should be addressed to Daniel L. Diamond, MD, Department of General and Peripheral Vascular Surgery, 382 W. Chestnut Street, Suite 106, Washington, Pennsylvania 15301. Manuscript submitted August 17, 1998 and accepted in revised form September 28, 1998.
28
© 1999 by Excerpta Medica, Inc. All rights reserved.
whose teaching and research salaries have disappeared threaten the stability of teaching faculty. The declining reimbursement per operative case for attending surgeons and faculty has further assaulted the time commitments required to educate surgical and other trainees. Perhaps most significant of all has been the gradual shift in Medicare reimbursement towards support for primary care fields and away from surgical specialty training. In addition, the change from indemnity, cost-based reimbursement which included hospital expenses for graduate medical education toward a system of managed care, where pricing has not included the cost of graduate medical education, has left the United States Government as the primary monetary support for graduate medical training.1 The Medicare program alone is estimated to have paid $6.8 billion in 1997 for direct medical expense and indirect medical expense. There has been and is no clear consensus and no national vision as to who or what entities should pay for graduate medical education in the future. Unfortunately, there is little knowledge of the true cost of graduate medical education and even less objective data reflective of the true cost of surgical education. At countless meetings in which residency training has been discussed, one may hear such comments as “Surgical residents are the best deal a hospital ever had,” “Surgical residents get paid about thirty cents an hour,” and “Hospitals are making out like bandits on indirect and direct medical education reimbursement from Medicare.” In spite of this plethora of self-righteous opinions, there have been no data indicating the true monetary cost of training a surgical resident. One of the critical pieces of missing data is the cost to a hospital for training residents in the operating room. This study was undertaken to attempt to quantitate the hospital costs incurred as a result of the training of residents in the operating room.
METHODS Since our residency is not large enough to allow resident participation in all operative procedures, surgical faculty perform some cases without resident participation. Since the faculty surgeon is constant, the variable of resident participation was thought to be an adequate means of separating cases into those definitely not done by a resident and those probably done by a resident. Both resident and faculty evaluations have suggested that over 95% of the procedures that involve a resident are performed by the resident with the faculty as teaching assistant. Sixty-two procedures were selected from the University of Tennessee hospital operating room records for their relative frequency and the likelihood that there would be significant numbers of cases performed by 0002-9610/99/$–see front matter PII S0002-9610(98)00289-X
TEACHING SURGICAL RESIDENT IN OPERATING ROOM/BRIDGES AND DIAMOND
TABLE I Forty-Six Categories Where Resident Time Was Longer Without Residents
With Residents
Difference
Procedures
# Cases
Avg. Min.
# Cases
Avg. Min.
Avg. Min.
Total Min.
Appendectomy Appendectomy, laparoscopic AAA AV fistula/graft AV revision Amputation, toe/transmet Anoplasty/endorectal advance Bowel resection, low anterior Breast mass biopsy or removal Breast reconstruction, TRAM Biopsy, node Cystectomy, radical w/ileocon CEA Cholecystectomy, laparoscopic Colostomy Colostomy closure Cysto w/RPG/cystogram Embolectomy UE Embolectomy LE Excision lesion/lipoma Excision cyst Exploratory laparotomy Feeding jejunostomy Femoral–popliteal bypass graft Femoral–tibial bypass graft 1 & D abscess/wound/mass IVC filter Hernia, inguinal, unilateral Hernia, umbilical Hernia, ventral/incisional Hydrocelectomy, unilateral Ing. Laparotomy/LOA Mastectomy, bilateral Mastectomy, modified radical Mastectomy, simple/partial Nephrectomy Parathyroidectomy, total/subtotal PEG tube insertion Prostatectomy, radical Raz/Stamey urethropexy Rectal biopsy STSG Thoracotomy Thyroidectomy Tracheostomy VVSL, unilateral Total
35 26 7 41 29 10 30 4 638 14 77 20 28 294 11 15 361 11 8 284 63 60 7 10 8 84 40 240 75 78 29 11 7 60 56 90 22 19 42 84 3 230 83 47 71 12 3,474
57 72 105 88 65 20 28 113 43 292 43 216 126 80 85 110 24 74 52 46 35 111 47 148 194 26 23 70 45 87 25 75 167 119 69 91 87 37 100 52 12 62 115 99 35 71
125 154 254 290 126 59 12 48 648 12 86 10 609 604 65 59 49 54 118 249 56 723 44 277 111 178 163 420 119 230 9 32 42 252 101 38 90 40 19 28 7 88 151 175 212 77 7,313
78 94 178 105 95 28 54 210 54 453 56 263 128 89 93 118 34 86 117 76 45 121 60 176 206 61 44 81 90 96 39 120 194 141 94 105 120 63 188 78 37 78 152 133 50 86
21 22 73 17 30 8 26 97 11 161 13 47 2 9 8 8 10 12 65 30 10 10 13 28 12 35 21 11 45 9 14 45 27 22 25 14 33 26 88 26 25 16 37 34 15 15
2,625 3,388 18,542 4,930 3,780 472 312 4,656 7,976 1,932 1,118 470 1,218 5,436 520 472 490 648 7,670 7,470 560 7,230 572 7,758 1,332 6,230 3,423 4,620 5,359 2,070 126 1,440 1,134 5,544 2,525 532 2,970 1,040 1,672 728 175 1,408 5,587 5,950 3,180 1,159 148,812
AAA, abdominal aortic aneurysm; AV, arteriovenous; CEA, carotid endarterectomy; IVC, inferior vena cava; LE, lower extremity; LOA, lysis of adhesions; PEG, percutaneous endoscopic gastrostomy; RPG, retrograde pyelogram; STSG, split thickness skin graft; TRAM, transfer rectus abdominis muscle; VVSL, varicose vein stripping and ligation.
residents. Most of the cases were types that a general surgery resident would be expected to complete within an approved residency (Table I, Table II). They were drawn from the fields of general, pediatric, vascular, plastic, urologic, and trauma surgery. Cases that were performed in low numbers or those in which a resident was always present, eg, Whipple procedure, were excluded from the analysis. The cases of surgeons who do
not participate with the surgical residency as teaching faculty were also excluded from the study. A total procedure time was determined from operative records used for hospital billing. The beginning of the procedure time was the incision time and the end of the procedure time was the “left room time,” both recorded by the circulating nurse. A total procedure time for each type of procedure, as well as a mean procedure time and
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 JANUARY 1999
29
TEACHING SURGICAL RESIDENT IN OPERATING ROOM/BRIDGES AND DIAMOND
TABLE II Sixteen Case Categories Where Resident Time Was Shorter Without Residents
With Residents
Difference
Procedures
# Cases
Avg. Min.
# Cases
Avg. Min.
Avg. Min.
Total Min
AV access declot ASD AVR Amputation, LE Axillary dissection Bowel resection, small Cholecystectomy, lap w/chol Colectomy/hemicolectomy Fistulotomy/fistulectomy Hemorrhoidectomy Kidney transplant, cad/LRD Laparoscopy, diagnostic Muscle biopsy Port placement Thoracotomy, lobectomy VSD Total
31 32 50 58 32 22 180 27 44 149 16 32 17 537 7 11 1,245
78 137 228 67 89 125 93 190 28 68 190 105 31 47 152 188
185 18 11 361 103 133 501 223 31 100 108 130 15 478 12 11 2,420
74 131 209 63 76 121 82 158 25 40 189 74 25 45 11 168
24 26 219 24 213 24 211 232 23 228 21 231 26 22 241 220
2740 2108 2209 21,444 21,339 2532 25,511 27,136 293 22,800 2108 24,030 290 2956 2492 2220 25,788
ASD, atrial septic defect; AV, arteriovenous; AVR, aortic valve replacement; LE, lower extremity; LRD, live related donor; VSD, ventricular septic defect.
TABLE III
TABLE IV
University of Tennessee Medical Center-Knoxville Operating Room 1997 Fiscal Year (July 1 through June 30) Salaries, wages, benefits (OR personnel) Salaries, wages, benefits (20 CRNA) Total Total number of surgical cases (includes nonteaching and surgeons courtesy) Total operating minutes Cost per operating minute Cost per operating hour without anesthesiologist
$6,384,075 $2,196,814 $8,580,889 18,330 2,001,180 $ 4.29 $ 257.27
a mean difference in the length of the procedure with or without a resident were determined using regression and analysis of means. The mean time lost or gained was calculated in each case category. The total time lost was generated by subtracting the total net time difference in categories when resident cases were shorter from the total net time difference in categories where resident cases were longer. During the course of the study (July 1993 through March 1997), there were 11 surgical trainees who completed training. This number was divided into the total “lost” time to yield the lost time per graduated resident. Thus, the lost time is an averaged figure that includes time lost by both junior and senior residents over a 4-year period. The cost per hour of operating time was determined by dividing the total minutes of all operations in 1 year into the non-supply cost associated with running the operating room for that year. The cost per minute was then multiplied by 60 to generate an hourly cost. The non-supply costs include administrative salaries, hourly wages, overtime, on-call pay, longevity pay, and the cost of all benefits (including retirement) of all operating room personnel and 20 CRNAs (Table III). For purposes of this calculation, the cost of surgeon and anesthesiologist time was not 30
University of Tenessee Medical Center-Knoxville Surgical Teaching Case Data (July 1993–March 1997) Total cases for analysis Cases with resident Cases with no resident Forty-six categories where resident time was longer 7,313 cases with a resident 3,474 cases with no resident Sixteen categories where resident time was shorter 2,420 cases with a resident 1,245 cases with no resident
14,452 9,733 4,719
considered, since this is not a hospital expense in most systems. The 1997 fiscal year (July 1 to June 30) was selected as the index year for purposes of cost calculation formula.
RESULTS There were 14,452 total cases for analysis, 9,733 with a resident and 4,719 with no resident (Table IV). There were 46 operative case categories (10,787 cases) in which procedures performed with a resident required longer operative times (103 minutes average time) when compared with cases done without a resident (61 minutes average time). This resulted in a total of 148,812 more minutes (2,480 hours), of operating time than would have been expected if the case times had been the same as those which were performed without residents in these 46 categories (Table V). In the 16 categories (3,665 cases) in which operating time of cases performed with residents was actually shorter than cases performed without a resident, the total time difference was 25,788 minutes (430 hours). Analysis of all of the 62 categories yields a net incremental operative time “cost” of 123,024 minutes (2,050 hours). Given a cost figure of $4.29 per minute (excludes supplies,
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 JANUARY 1999
TEACHING SURGICAL RESIDENT IN OPERATING ROOM/BRIDGES AND DIAMOND
TABLE V University of Tennessee Medical Center-Knoxville Net Operating Time Gain or Loss Analysis Net time loss (46 categories) Net time gained (16 categories) “Net of nets” time ‘lost’ to resident training Net cost @ $4.29/minutes (11 graduating residents over 4 years)
148,812 min (2,480 hr) 25,788 min (430 hr) 123,024 min
$527,772.96
TABLE VI University of Tennessee Medical Center-Knoxville FourYear Operating Room Training Cost per Graduating Resident Cases with residents Cases per graduating resident Net time lost per case Net lost time per resident Cost per graduating resident
9,733 885 12.64 min 11,816 min $47.797
indirect costs, anesthesiologist fees or costs, and surgeons fees), the total cost for this “lost time” was $527,772.96. Within the 62 case categories that were analyzed for this report, there were 9,733 operative cases performed with residents or 885 per graduating chief resident (Table VI). Given a total lost or extra minute figure of 123,024 minutes generated by 9,733 cases performed with residents, the 4-year training figure is 11,184 lost minutes of operative time, or $47,979 of cost per graduating resident.
COMMENTS One can certainly take exception to the methodologies used in this analysis. Some of the cases listed with the resident may actually have been done by faculty, but our internal analysis seems to indicate that cases done with a resident listed by operating room personnel as assistant serves as a reasonable proxy for “case done by resident with faculty in attendance.” If anything, the potential to have some resident cases actually done by faculty would minimize the effect of lost time rather than to magnify it, since there are more cases that were prolonged than shortened by resident participation. The operative times may not be totally accurate, but they serve as the basis for hospital billing. One may reasonably assume that there are the same inaccuracies whether a resident is scrubbed or not scrubbed. Some case categories have a high percentage of resident participation whereas others have a low resident participation, thus creating a nonrandom distribution. There is also the possibly of faculty or resident selection bias because of resident participation in more difficult or index type cases. While all of these are valid potential criticisms, the large number of cases should tend to nullify the potentially confounding effects of some of these concerns. It would have been easier and neater to use 5 years of data, but our hospital operating room information system had slightly less than 4 years of data that could substantiate resident participation and length of procedure. Unfortunately, the hospital information system does not use the same 277 case categories that exist in the Surgical Operative Log of the Residency Review Committee for Surgery,
thus partially explaining the disparity between the 885 cases per graduating resident generated by our data and the average 938 reported to the RRC for the 11 graduating residents. The reasons for some case categories in which residents seemingly operated faster than their teaching faculty are of obvious interest. Some, such as laparoscopic cholecystectomy with cholangiogram, colectomy, or kidney transplant, are cases in which the individual resident has as high a volume of experience as the operating surgeon or is more accustomed to doing that case with the teaching faculty as an assistant than the teaching faculty is without a resident. In addition, cases that are performed by teaching faculty with no resident participation are often performed with significantly less assistance, as it is rare for faculty surgeons to assist each other and there are no paid surgical assistants at University of Tennessee Medical Center at Knoxville. Whatever assistance is provided, if any, is usually an additional scrub technician. The cost figures are thought to represent easily measurable costs in most institutions. There are undoubtedly local issues in each hospital that would make an analysis of the costs somewhat different. By defining the costs that we used in the analysis, other institutions should be able to arrive at a comparison. Most discussions of indirect medical expense payments to hospitals list such things as additional diagnostic tests and lower hospital staff productivity as one of the rationales for indirect medical expense payment from Medicare. To our knowledge, there has never been a financial analysis of incremental cost associated with training a resident in the operating room. Given the fact that there are approximately 21,000 residents enrolled in core surgical programs in the United States,2 it would seem prudent to study this issue in more detail since there is a direct financial cost over and above that paid from the patients and income of teaching surgeons. When and if there is a national consensus regarding graduate medical education funding, the cost of operative training should be factored in. If one attempts to extrapolate from this study to a national annual cost figure for general surgery alone, the cost is somewhere in the $53 million range. This assumes a per-case loss of $54.23 for the 11 residents who finished the program involved in this study, 961 average cases reported in the Surgical Operative Log for 1,014 general surgery residents who completed training in the 1997 academic year.3 If the dictates of optimal patient care and the stresses imposed on faculty surgeons did not already demand it, the direct economic cost of training residents on patients would suggest that we need to look for ways to make this a more productive and efficient process. Perhaps there is a need for an articulated technical training curriculum that includes the setting and achievement of goals and standards. There is a need for development of technical resource facilities where residents can practice and can compete in technical exercises. There is a need for animal or cadaver laboratories in which residents are taught suturing and stapling techniques. There is a need for the promise of virtual surgery to be realized for the benefit of training
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TEACHING SURGICAL RESIDENT IN OPERATING ROOM/BRIDGES AND DIAMOND
surgical residents. While these alternatives may be expensive, they are one-time costs that do not recur each time a resident steps in the operating room. And finally, perhaps it is not too early for us to recognize that surgery is and always has been a technical exercise at which some people are more adept than others and to reflect this recognition in our selection processes. Although the figures generated by this analysis are likely to be different in each institution, it is hoped that all will reflect a net time cost to training residents in the operating room. If that is not the case, perhaps those of us who are
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responsible for that training are in need of some remedial technical training.
REFERENCES 1. Fishman LE. Medicare payments with an education label: fundamentals and the future. Association of American Medical Colleges; 1996. 2. Kwakwa F, Jonasson O. The longitudinal study of surgical residents, 1993 to 1994. J Am Coll Surg. 1996;183:425– 433. 3. Residency Review Committee for Surgery. Program National Data. Reporting period 7/1/96 – 6/3/97. Accreditation Council for Graduate Medical Education, Chicago, IL; 1997.
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