Does residents' involvement in mastectomy cases increase operative cost? If so, who should bear the cost?

Introduction: 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.

Methods: 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).

Results: 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.

Conclusion: 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.