Department of Surgery, Saint Barnabas Medical Center, University of Medicine and Dentistry of New Jersey, 94 Old Short Hills Road, Livingston, NJ 07039, USA.
J Surg Res. 2012 Nov;178(1):18-27. doi: 10.1016/j.jss.2012.08.027. Epub 2012 Aug 30.
It is a widely held belief that surgical residents' involvement in operative cases increases operative time and costs. However, there is little published data regarding the veracity of this belief, and there is poor documentation of the actual costs associated with involving surgical residents in operative cases. This report represents a retrospective analysis of the additional cost associated with involving surgical residents of all training years in mastectomy cases over a 6-y period.
A total of 1063 mastectomy cases (with and without reconstruction) were performed over a 6-y period (2004-2010) at the Saint Barnabas Medical Center, Livingston, NJ. Data relating to the type of mastectomy performed, operative times, training level of residents involved, and the surgical attendings' case volume were collected. Two major groups (attendings-only and attendings with residents) and 19 mastectomy subcategories were formed. Differences in operating room (OR) times between the attendings-only and attendings with residents groups were multiplied by the hospital OR charges per minute of time ($15/min after the initial 30 min) to determine the additional operative costs associated with residents' involvement. The impact of postgraduate training year and the attendings' case volume on operative time was analyzed separately. Statistical analysis was conducted using IBM SPSS 18.0.1 Windows version (PASW Statistics for Windows, SPSS Inc, Chicago).
Twenty-six surgeons and 97 residents were involved in 1063 mastectomy cases. Eight hundred ninety-five cases involved residents, of which 405 cases had reconstruction and 490 cases did not. Among 168 cases involving residents, 107 cases had reconstruction and 61 cases did not. The mean OR time was increased in nearly all cases involving surgical residents but statistically significant in only nine of the 19 mastectomy subcategories. Postgraduate year (PGY) 1 or PGY2 residents increased OR time for unilateral mastectomy, whereas the involvement of PGY1 through PGY3 residents increased OR time for bilateral mastectomy+reconstruction (P<0.05). No significant difference was observed when PGY4 and PGY5 were involved in mastectomy cases. The additional calculated time required to perform mastectomies involving surgical residents was 41,366 min, which corresponded to an increase in OR costs of $620,340 over 6 y.
The involvement of surgical residents in mastectomy cases significantly increases operative times and cost. This difference is most apparent when junior-level residents are involved and disappears by the PGY4-PGY5. Increased operative costs and the lost opportunity costs for surgical attendings are significant issues associated with residency education. Center for Medicare and Medicaid Services and Accreditation Council on Graduate Medical Education should consider such data when establishing appropriate reimbursements for graduate training programs.
人们普遍认为，外科住院医师参与手术会增加手术时间和成本。然而，关于这一观点的真实性，几乎没有发表的数据，而且与外科住院医师参与手术相关的实际成本也记录不佳。本报告代表了对过去 6 年期间所有培训年限的外科住院医师参与乳房切除术病例相关的额外成本的回顾性分析。
在新泽西州利文斯顿的圣巴纳巴斯医疗中心，2004 年至 2010 年期间共进行了 1063 例乳房切除术（包括重建和不包括重建）。收集了与手术类型、手术时间、参与的住院医师培训水平以及外科主治医生手术量相关的数据。形成了两个主要组（主治医生组和主治医生加住院医师组）和 19 个乳房切除术亚组。主治医生组和主治医生加住院医师组之间手术时间的差异乘以医院每手术分钟的手术费用（30 分钟后每 15 分钟$15 美元），以确定与住院医师参与相关的额外手术费用。分别分析了研究生培训年限和主治医生手术量对手术时间的影响。使用 IBM SPSS 18.0.1 Windows 版本（Windows 版的 PASW Statistics for SPSS Inc，芝加哥）进行统计分析。
26 名外科医生和 97 名住院医师参与了 1063 例乳房切除术。895 例涉及住院医师，其中 405 例有重建，490 例没有。在 168 例涉及住院医师的病例中，107 例有重建，61 例没有。几乎所有涉及住院医师的病例的手术室时间都延长了，但在 19 个乳房切除术亚组中只有 9 个具有统计学意义。PGY1 或 PGY2 住院医师增加了单侧乳房切除术的手术时间，而 PGY1 至 PGY3 住院医师的参与增加了双侧乳房切除术+重建的手术时间（P<0.05）。PGY4 和 PGY5 参与乳房切除术时，未观察到显著差异。执行涉及住院医师的乳房切除术所需的额外计算时间为 41366 分钟，这对应于过去 6 年手术室费用增加了 620340 美元。
外科住院医师参与乳房切除术显著增加了手术时间和成本。当涉及初级住院医师时，这种差异最为明显，而当涉及到 PGY4-PGY5 住院医师时，这种差异就消失了。手术住院医师的教育成本增加和手术主治医生的机会成本损失是与住院医师教育相关的重要问题。医疗保险和医疗补助服务中心以及研究生医学教育认证委员会在为研究生培训计划确定适当的报销时应考虑此类数据。
