Impact of fellow compared to resident assistance on outcomes of minimally invasive surgery

The RVU Compensation Model and Head and Neck Surgical Education

BACKGROUND

The present study aims to quantify the opportunity cost of training residents and fellows for head and neck surgery.

METHODS

A 2005-2015 review of ablative head and neck surgical procedures was performed using the National Surgical Quality Improvement Program (NSQIP). Work relative value units (wRVU) generated per hour were compared among procedures performed by attendings alone, attendings with residents, and attendings with fellows.

RESULTS

Among 34,078 ablative procedures, the rate of wRVU generation per hour was greatest for attendings alone (10.3), followed by attendings with residents (8.9) and attendings with fellows (7.0, p < 0.001). Resident and fellow involvement was associated with opportunity costs of $60.44 per hour (95% CI: $50.21-$70.66/h) and $78.98 per hour ($63.10-$94.87/h, 95% CI), respectively.

CONCLUSION

wRVU-based physician reimbursement does not consider or adjust for the extra effort involved in training future head and neck surgeons.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:113-119, 2024.

Development of a prospective biliary dashboard to compare performance and surgical cost

BACKGROUND

Transparency around surgeon level data may align healthcare delivery with quality care for patients. Biliary surgery includes numerous procedures performed by both general surgeons and subspecialists alike. Cholecystectomy is a common surgical procedure and an optimal cohort to measure quality outcomes within a healthcare system.

METHODS

Data were collected for 5084 biliary operations performed by 68 surgeons in 11 surgical divisions in a health system including a tertiary academic hospital, two regional community hospitals, and two ambulatory surgery centers. A privacy protected dashboard was developed to compare surgeon performance and cost between July 2018 and June 2022. A sample cohort of patients ≥ 18 years who underwent cholecystectomy were compared by operative time, cost, and 30-day outcomes.

RESULTS

Over 4 years, 4568 cholecystectomy procedures were performed by 57 surgeons. Operations were done by 57 surgeons in four divisions and included 3846 (84.2%) laparoscopic cholecystectomies, 601 (13.2%) laparoscopic cholecystectomies with cholangiogram, and 121 (2.6%) open cholecystectomies. Patients were admitted from the emergency room in 2179 (47.7%) cases while 2389 (52.3%) cases were performed in the ambulatory setting. Individual surgeons were compared to peers for volume, intraoperative data, cost, and outcomes. Cost was lowest at ambulatory surgery centers, yet only 4.2% of elective procedures were performed at these facilities. Prepackaged kits with indocyanine green were more expensive than cholangiograms that used iodinated contrast. The rate of emergency department visits was lowest when cases were performed at ambulatory surgery centers.

CONCLUSION

Data generated from clinical dashboards can inform surgeons as to how they compare to peers regarding quality metrics such as cost, time, and complications. In turn, this may guide strategies to standardize care, optimize efficiency, provide cost savings, and improve outcomes for cholecystectomy procedures. Future application of clinical dashboards can assist surgeons and administrators to define value-based care.

Outcomes in Minimally Invasive Sleeve Gastrectomy and Implications for Surgical Resident Education

Introduction: Resident participation in advanced minimally invasive and bariatric surgeries is controversial. The aim of this study is to evaluate the safety of resident participation in robotic and laparoscopic sleeve gastrectomy (SG). Methods: Prospectively maintained institutional Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database was used to identify patients who underwent SG, which was performed at our institution between January, 2018, and December, 2021. Operative notes were reviewed to determine the training level of the assistant. These were then classified into 7 groups: postgraduate years 1-5 residents, bariatric fellow (6), and attending surgeons (7). Each group was stratified and their outcomes, which included duration of surgery, length of stay (LOS), postoperative complications, readmissions, and reoperations, were compared. Results: Out of 2571 cases, the assistants for the procedures were minimally invasive surgery (MIS) fellows (n = 863, 58.8%), fifth- and fourth-year residents (n = 228, 15.5%), third- and second-year residents (n = 164, 11.2%), no assistants (n = 212, 14.5%), and 134 robotic SG. Mean body mass index was higher in cases wherein the attending surgeon performed by himself (47.1, standard deviation 7.7) when compared with other groups. There were no conversions to open. Mean LOS was 1.3 days, and there was no difference between groups (P = .242). Postoperative complications were low, with 11 reoperations in 30 days (3.3%) and no difference between groups. There was no mortality in 30 or 90 days. Conclusion: Postoperative outcomes were similar for patients who underwent SG regardless of the assistant's level of training. Including residents in bariatric procedures is safe and does not affect patient safety. Encouraging residents to participate in complex MIS procedures is recommended as part of their training.

A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology

BACKGROUND

Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. This study investigates whether participation of a senior resident versus a fellow has an impact on outcomes of patients undergoing complex cancer surgery.

METHODS

Patients who underwent esophagectomy, gastrectomy, hepatectomy, or pancreatectomy between 2007 and 2012 with assistance from a senior resident (post-graduate years 4-5) or a fellow (post-graduate years 6-8) were identified from the ACS NSQIP. Based on age, sex, body mass index, ASA classification, diagnosis of diabetes mellitus, and smoking status, propensity-scores were created for odds of undergoing the operation assisted by a fellow. Patients were matched 1:1 based on propensity score. Postoperative outcomes including risk of major complication were compared after matching.

RESULTS

In total, 6934 esophagectomies, 13,152 gastrectomies, 4927 hepatectomies, and 8040 pancreatectomies were performed with assistance of a senior resident or fellow. After matching, overall rates of major complications were equivalent across all four anatomic locations between cases performed with the participation of a senior resident versus a surgical fellow: esophagectomy (37.0%% vs 31.6%, p = 0.10), gastrectomy (22.6% vs 22.3%, p = 0.93), hepatectomy (15.8% v 16.0%, p = 0.91), and pancreatectomy (23.9% vs 25.2%, p = 0.48). Operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.004) involving a resident compared to a fellow, but comparable for esophagectomy (330 vs. 336 min; p = 0.41), hepatectomy (217 vs. 219 min; p = 0.85), and pancreatectomy (320 vs. 330 min; p = 0.43).

CONCLUSIONS

Senior resident participation in complex cancer operations does not appear to negatively impact operative time or postoperative outcomes. Future research is needed to further assess this domain of surgical practice and education, particularly with regard to case selection and operative complexity.

The silver lining of the pandemic in surgical education: virtual surgical education and recommendations for best practices

Virtual education is an evolving field within the realm of surgical training. Since the onset of the COVID-19 pandemic, the application of virtual technologies in surgical education has undergone significant exploration and advancement. While originally developed to supplement in-person curricula for the development of clinical decision-making, virtual surgical education has expanded into the realms of clinical decision-making, surgical, and non-surgical skills acquisition. This manuscript aims to discuss the various applications of virtual surgical education as well as the advantages and disadvantages associated with each education modality, while offering recommendations on best practices and future directions.