title: The cost of intraoperative plastic surgery education.
abstract: OBJECTIVE
  Within the surgical community, it is commonly accepted that the length and cost of a surgical case increase when a resident physician participates. Many accountable care organizations, however, believe the opposite, that is, resident assistance enhances efficiency and diminishes operative time. The purpose of this study is to determine the opportunity cost to the attending surgeon for intraoperative teaching during index plastic surgery cases.
  
  
  METHODS
  A single senior surgeon's experience over a 7-year period was evaluated retrospectively for Current Procedural Terminology codes 40700 (repair of primary, unilateral cleft lip) and 42200 (palatoplasty). Variables collected include operative time, the presence or absence of a physician learner, and postgraduate year level. Statistical analysis was performed with the Kruskal-Wallis test using the S+ programming language. A cost analysis was performed to quantify the effect of longer operative times in terms of relative value units (RVUs) lost.
  
  
  RESULTS
  During the study period, a total of 45 patients had primary, unilateral cleft lip repair; 70 patients had cleft palate repair. Of those cases, 39 (87%) cleft lip repairs and 60 (86%) cleft palate repairs were performed with a resident or fellow present. There was a statistically significant difference in the amount of time required to perform either surgery with a physician learner than without, with operative times being 60% (p = 0.020) longer for cleft lip repair and 65% (p = 0.0016) longer for cleft palate repair. The results were further stratified based on level of training, with craniofacial fellows and plastic surgery residents (independent and integrated) compared separately. Cases where a craniofacial fellow was present required the longest operative times: 103% (p = 0.0012) longer for cleft lip repairs and 104% (p < 0.0001) longer for cleft palate repairs when compared with the senior surgeon operating alone. Using the 2011 physician work RVUs for these surgeries and the 2011 Medicare conversion factor for RVUs to dollars, the opportunity cost is over $275 per case per trainee for any physician learner. When craniofacial fellows are analyzed separately, over $440 is invested in intraoperative teaching per case per fellow.
  
  
  CONCLUSIONS
  Resident involvement in the operating room is crucial to the education of independent surgeons. This involvement, however, comes at a significant opportunity cost to the attending surgeon. As an incentive to retain academic surgeons and uphold a quality academic environment in the OR, compensation should be offered for intraoperative teaching.
authors.affiliation: Division of Plastic Surgery, Riley Hospital for Children, Indiana University Medical Center, Indianapolis, Indiana. Electronic address: ssasor@gmail.com.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Sasor
authors.forename: Roberto L
authors.initials: RL
authors.lastname: Flores
authors.forename: William A
authors.initials: WA
authors.lastname: Wooden
authors.forename: Sunil
authors.initials: S
authors.lastname: Tholpady
mesh_terms: D000328:Adult; D002971:Cleft Lip / Q000601:surgery*; D003365:Costs and Cost Analysis; D005260:Female; D006801:Humans; D007196:Indiana; D007396:Internship and Residency; D007432:Intraoperative Period; D008297:Male; D008505:Medical Staff, Hospital / Q000191:economics / Q000458:organization & administration; D061646:Operative Time; D010036:Otolaryngology / Q000191:economics; D010819:Physician's Role; D015895:Relative Value Scales; D013518:Surgery, Plastic / Q000191:economics / Q000193:education*; D013663:Teaching / Q000458:organization & administration*
keywords: Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; cleft lip; cleft palate; craniofacial; operative time; opportunity cost; resident education