Dunning Kyle, Liedtke Eric, Toedter Lori, Rohatgi Chand
Department of Surgery, Easton Hospital, Easton, Pennsylvania 18042, USA.
J Surg Educ. 2008 Nov-Dec;65(6):460-4. doi: 10.1016/j.jsurg.2008.07.011.
Across the United States, ambulatory surgery centers (ASCs) are increasing in both number and surgical volume. This trend has been the focus of debate regarding reimbursement and patient safety, as well as surgical productivity and efficiency. However, the impact on surgical resident training caused by this shift toward outpatient surgery in nonhospital settings has not been studied. We reviewed data reported by our hospital and by local surgery centers as well as the case logs of the surgical residents at our institution to determine whether a negative effect on resident case volume has occurred.
We conducted a retrospective review of our PGY-1 through PGY-3 level surgical residents' case logs for 3 consecutive academic years, from July 2004 through June 2007. We evaluated a group of common outpatient procedures that are now also being performed in stand-alone surgical centers in our area, such as breast biopsies, incision and drainage, hernia repair, colonoscopy, and esophagogastroduodenoscopy (EGD). The data were tallied by academic year and compared over time. In addition, we analyzed data reported to state agencies by our hospital and local surgery centers over the last 6 calendar years for any trends in case volume. By evaluating 2 different independent data sets for the same endpoint, we could evaluate our hypothesis twice.
When evaluating state-reported data for the defined cases, a significant decrease was observed in the total number of cases performed at Easton Hospital, Easton, Pennsylvania, each year between 2003 and 2006 (p < 0.0001). When reported cases by procedure category for 2003 versus 2005 only (because of incomplete data from ASCs in 2004 and 2006), a significant decrease was observed as well for certain specific procedures as follows: colonoscopy (p < 0.0001), inguinal/femoral hernia (p = 0.04), excision of skin lesion (p = 0.0022), and incision/drainage (p < 0.0001). When comparing resident reported data, significant decreases were observed in the number of hemorrhoidectomies, breast biopsies, skin grafts, carpal tunnel releases, and excision of skin lesions performed by residents during each academic year from July 2004 to June 2007.
Our residents historically have gained all of their outpatient surgery experience from procedures performed at our home institution. With the recent surge of stand-alone surgical centers, many outpatient procedures are being performed outside of the hospital in centers where our residents do not rotate. Although current residents in our program are performing enough cases to fulfill the ACGME required minimums, the number of cases is significantly decreased because of cases performed by stand-alone surgical centers.
在美国，门诊手术中心（ASC）的数量和手术量都在增加。这一趋势一直是关于报销、患者安全以及手术生产率和效率的争论焦点。然而，这种向非医院环境下门诊手术的转变对外科住院医师培训的影响尚未得到研究。我们回顾了我院和当地手术中心报告的数据以及我院外科住院医师的病例记录，以确定是否对住院医师的病例量产生了负面影响。
我们对2004年7月至2007年6月连续3个学年的我院PGY - 1至PGY - 3级外科住院医师的病例记录进行了回顾性研究。我们评估了一组现在也在我们地区独立手术中心进行的常见门诊手术，如乳房活检、切开引流、疝修补、结肠镜检查和食管胃十二指肠镜检查（EGD）。数据按学年统计并随时间进行比较。此外，我们分析了我院和当地手术中心在过去6个日历年向州机构报告的数据中病例量的任何趋势。通过评估针对同一终点的两个不同独立数据集，我们可以对我们的假设进行两次评估。
在评估州报告的特定病例数据时，观察到宾夕法尼亚州伊斯顿市伊斯顿医院在2003年至2006年期间每年进行的病例总数显著下降（p < 0.0001）。仅比较2003年与2005年按手术类别报告的病例（由于2004年和2006年ASC的数据不完整），某些特定手术也观察到显著下降，如下：结肠镜检查（p < 0.0001）、腹股沟/股疝（p = 0.04）、皮肤病变切除（p = 0.0022）和切开/引流（p < 0.0001）。在比较住院医师报告的数据时，观察到在2004年7月至2007年6月的每个学年中，住院医师进行的痔切除术、乳房活检、皮肤移植、腕管松解术和皮肤病变切除术的数量显著下降。
我们的住院医师以往所有的门诊手术经验都来自于在本院进行的手术。随着独立手术中心的近期激增，许多门诊手术在我们的住院医师不轮转的中心在医院外进行。虽然我们项目中的现任住院医师进行的病例数量足以满足ACGME要求的最低标准，但由于独立手术中心进行的病例，病例数量显著减少。
