How long do we need teaching in the operating room? The true costs of achieving surgical routine

Langenbecks Arch Surg (2004) 389:204 208 DOI 10.1007/s00423-003-0421-3 O R I G I N A L A R T I C L E Thomas Koperna How long do we need teaching in the operating room? The true costs of achieving surgical routine Received: 20 June 2003 Accepted: 25 August 2003 Published online: 14 October 2003 Springer-Verlag 2003 T. Koperna () ) Department of Surgery, Mistelbach Hospital, Liechtensteinstrasse 67, 2130 Mistelbach, Austria e-mail: t.koperna@aon.at Tel.: +43-2572-33419104 Fax: +43-2572-33414692 Abstract Background: Our aim was to quantify the incremental costs of longer operating times of residents and less-experienced junior consultants when compared with senior consultants on the basis of two surgical routine procedures. Methods: We prospectively assessed 246 patients who underwent laparoscopic cholecystectomy and 216 patients who underwent open inguinal hernia repair. Operating times, complication rates and overall costs for these patients were recorded and linked to the attending surgeons. Results: Most importantly, operating times significantly depend on the surgeon (P<0.001) and on proper supervision of junior surgeons (P<0.001 to P=0.003). When compared with those of senior surgeons, incremental costs for the hospital provider were e200 and e54 per laparoscopic cholecystectomy and e153 and e106 per open hernia repair when carried out by junior consultants and residents, respectively. Overall incremental costs per year for these procedures were e8,370 for residents and e22,922 for junior consultants. Conclusion: Owing to longer operating times for junior consultants the costs of achieving surgical routine are considerably higher than previously estimated. These higher costs derive from junior consultants performing operations without proper supervision from senior consultants. We conclude that prolonged supervision in the operating room is highly cost-effective regardless of higher costs for personal resources per operatingminute. Keywords Teaching in the operating room Education Cost-analysis Surgical competence Introduction There are only few studies which aimed to quantify hospital costs incurred as a result of the training of residents in the operating room [1, 2]. Against the background of decreasing reimbursement per operating case due to limited public funds and increasing costs of patient care, we are forced to develop strategies to reduce costs and increase cost-effectiveness. During the past years a continuous reduction in the working hours of surgeons was required by law, which led to a reduction in the acquisition of surgical experience by surgical residents and junior consultants in surgery [3]. A cautious approximation of the costs of the teaching of surgical residents yield costs per graduating resident of approximately e40,775 [2]. This calculation is based on the time lost per operating case performed by a resident. Nevertheless, most surgical routine procedures are performed under supervision of experienced surgeons. In addition, the application of faculty and administrative costs from the viewpoint of a sponsor, but not specifically for surgical residents, leads to costs of approximately e62,810 to e172,682 per graduating resident [1]. From the viewpoint of a hospital provider, our aim was to quantify, also, the costs that occur after surgical residency due to the need of less-experienced surgeons for a

205 longer time to perform routine procedures. The underlying hypothesis was that surgical education might not end with graduation. For that objective we prospectively collected data of patients who underwent two of the most common routine procedures in open and laparoscopic surgery, which were laparoscopic cholecystectomy and open hernia repair, to determine differences in operating times and performance between senior consultants, junior consultants, and residents. Patients and methods From November 2001 to October 2002 we operated on 335 patients for gallstone disease and 266 patients for inguinal hernia. The operations were carried out by three experienced senior consultants (group I), two junior consultants who had finished their surgical residency less than 3 years before (group II), and two surgical residents (group III). The two residents were in their second and forth year of surgical training, respectively, and had both been trained on a simulation model and also on animals. By the beginning of the study they had performed 20 to 50 laparoscopic cholecystectomies and 30 to 70 open inguinal hernia repairs. The two junior consultants had completed formal surgical training and were considered to have finished their learning curve. They had performed 60 to 80 laparoscopic cholecystectomies and 80 to 110 open inguinal hernia repairs by the beginning of the study. Surgical routine was defined as the capability to perform, reproducibly, standard operations without assistance, at low operating times, with associated low complication rates and at reasonable overall costs. According to our quality assurance programme we prospectively collected patient data, co-morbidity scores according to the American Society of Anesthesiologists (ASA), cause and type of surgery, duration of surgery and complications that occurred during and after operation. Duration of surgery was defined as the time from the first incision to completed skin closure, and all surgeons were aware of being timed for quality control. Regardless of the fact that systemic complications were recorded for all organ systems, only cardio-pulmonary complications and one case of sepsis were found. As local complications, haematoma and wound infection were recorded. Re-operative surgery was necessary in two patients after laparoscopic cholecystectomy but in no patient after hernia repair. The causes of re-laparoscopy were infected haematoma and biliary leak from an aberrant bile duct, while another patient had to undergo postoperative endoscopic retrograde cholangio-pancreaticography (ERCP) for a retained choledochal stone. From the 335 patients who underwent cholecystectomy, 64 were excluded because they were operated on during other major surgery or because they had had primarily open surgery. A further 25 patients had to be excluded because of lack of data. Therefore, 246 patients were intended to undergo laparoscopic cholecystectomy and represented the primary focus of our study. Conversion to open surgery was necessary in 34 patients, and cause of conversion and distribution between the groups were recorded. Acute cholecystitis has to be described clinically, by sonography, and histologically. Only patients on whom cholecystectomy was performed laparoscopically served as the basis for evaluation of duration of surgery. The distribution of patients between the groups of surgeons, conversion rate, cause of conversion, and complications are given in Table 1. Senior consultants scheduled the surgeon to operate on a specific patient, which explains a pre-selection of patients such as a higher rate of patients with acute cholecystitis in group I. Table 1 Clinical data of 246 patients, who were intended to undergo laparoscopic cholecystectomy Postoperative ERCP Re-laparoscopy Wound infection Sepsis Cardio-pulmonary complications Bile-duct injury Conversion Acute cholecystitis Group Operating time Median (range) I. Senior consultants 37 min (18 115) 40 (28.8) 22 (15.8) 0 4 (2.9) 0 2 (1.4) 0 0 (n=139) II. Junior consultants 63.5 min (34 133) 11 (19.0) 10 (17.2) 1 (1.7) 1 (1.7) 1 (1.7) 1 (1.7) 1 (1.7) 1 (1.7) (n=58) III. Residents (n=49) 46 min (24 74) 6 (12.2) 2 (4.1) 0 0 0 0 1 (2.0) 0

206 Table 2 Clinical data of 216 patients who underwent open hernia repair Group Operating time Median (range) Operation for recurrent hernia Wound haematoma Cardio-pulmonary complications I. Senior consultants 26 min (11 103) 15 (17) 6 (6.8) 3 (3.4) (n=88) II. Junior consultants 55 min (31 208) 5 (9.3) 2 (3.7) 2 (3.7) (n=74) III. Residents (n=54) 44.5 min (21 103) 2 (2.7) 2 (2.7) 0 Table 3 Cost analysis in euros for laparoscopic cholecystectomy and open hernia repair and incremental costs per unit of groups II and III when compared with group I. Costs for personnel per operating minute are given in parentheses Group Costs for personnel Costs for capital resources Overhead costs Overall costs Laparoscopic cholecystectomy I. Senior consultants (n=139) 336 (9.1) 389 171 896 0 II. Junior consultants (n=58) 467 (7.4) 389 240 1.096 200 III. Residents (n=49) 366 (8.0) 389 195 950 54 Open hernia repair I. Senior consultants (n=88) 266 (10.2) 228 126 620 0 II. Junior consultants (n=74) 358 (6.5) 228 187 773 153 III. Residents (n=54) 332 (7.5) 228 166 726 106 Incremental costs related to group I From the 266 patients who underwent hernia repair, patients with laparoscopic procedures (n=27) and those providing insufficient data (n=23) were excluded. Laparoscopic hernia repair was unevenly distributed between the groups and was performed by, or under guidance of, only one experienced surgeon. The remaining 216 patients were evaluated for duration of operation and complications. Reconstruction type was the Lichtenstein operation for 121 patients, while primary closure such as Bassini and Shouldice repair was used for 95 patients. The distribution of patients between the groups of surgeons, proportion of recurrent hernia, and complications are given in Table 2. For calculation of the costs for capital resources such as laboratory resources, supplies, and drugs, mean costs were determined for all patients who underwent laparoscopic cholecystectomy and open hernia repair. Costs for personnel were calculated for each operation, including costs for surgeons, anaesthesiologists, nurses and any additional personnel. For the calculation of the time spent for an operation, overall time of the attending personnel at the operating theatre was measured. Therefore, overall costs for personnel per minute of operating time were the higher the shorter an operation was. Overhead costs and operating-room costs were allocated according to usage of the overhead item, which was e2.6 per operating minute for laparoscopic cholecystectomy and e2.1 for hernia repair. Additional overhead costs in the operating room which had to be calculated for the duration of anaesthesiological preparation were e1.51 and e1.45, respectively. Anaesthesiologists, nurses and surgeons fees were also included, the different remuneration of senior and junior surgeons being taking into consideration (e0.7 to e0.4 per minute; Table 3). Referring to cost data from the literature, which was given in US dollars, we used a currency conversion rate of 0.85 euros to the dollar. The viewpoint of the present cost analysis was that of the hospital provider, using only costs and not charges. The price year for the present study was 2002. For statistical analysis, the c 2 test was used for qualitative variables, while for continuous risk factors, the Mann Whitney-U test and the t-test were applied when appropriate. For the comparison of the three groups of patients, the Kruskal Wallis test and one-way ANOVA were applied. We used multiple linear regression analysis to predict the correlation between operating time and case-mix features. Differences were considered statistically significant at P<0.05. Results Laparoscopic cholecystectomy During the observation period senior consultants performed more laparoscopic cholecystectomies than did groups II and III together (Table 1). Junior consultants needed a significantly longer time for successfully performing laparoscopic cholecystectomy, than did senior consultants and residents (P<0.05). However, residents did not need a significantly longer time for laparoscopic cholecystectomy than senior consultants, which can be explained by the fact that a significantly higher proportion of operations were performed under supervision of senior consultants in group III than in group II (78.7% vs 14.6%; P<0.001). Overall, consultants had a significantly higher conversion rate than residents (16.3% vs 4.1%; P=0.048). This was due to there being a higher proportion of patients with acute cholecystitis, who were intended to undergo laparoscopic cholecystectomy in group I than in groups II and III (28.8% vs 15.9%; P=0.026). Acute cholecystitis (56%) and choledochal stones (20.6%) accounted for most conversions to open surgery, which illustrates the rather high conversion rates in groups I and II and an obvious pre-selection of patients in group III. When multiple linear regression analysis was performed, dura-

207 tion of operation was significantly correlated with the surgeon, supervision by a senior surgeon for younger surgeons, and the presence of acute cholecystitis (all P<0.001). All systemic complications occurred in patients in groups I and II (Table 1). One bile-duct injury occurred in group II and was repaired after conversion to open surgery. Re-laparoscopy was successfully carried out on one patient with an infected haematoma in group III and in one patient with a bile leak in group II. Postoperative ERCP was carried out on one patient with a retained choledochal stone in group II. There was no major difference in mean pre-operative ASA scores between the groups (1.56 in group I; 1.52 in group II; 1.51 in group III). Hernia repair The duration of operation significantly differed between all groups of surgeons (P<0.05), and for open hernia repair the longest mean duration of operation was found in group II, followed by group III and group I (Table 2). Again a pre-selection was recorded in favour of group III when compared with groups I and II in terms of operations for recurrent hernia (2.7% vs 14.1%; P=0.017). Open hernia repair was less likely to be carried out under the supervision of a senior consultant in group II when compared with group III (5.8% vs 47.3%; P<0.001), which led to a longer duration of operations in group II. Performing multiple linear regression analysis, we found that the duration of operation was significantly correlated with the surgeon (P<0.001), supervision by a senior surgeon for younger surgeons (P=0.003), operation for recurrent hernia (P=0.018), and ASA score (P=0.011). Local haematoma occurred more often in group I patients than in groups II and III patients, while no systemic complication was recorded in group III (Table 2). Cost analysis Incremental costs for the hospital provider for laparoscopic cholecystectomy and open hernia repair carried out by junior surgeons when compared with senior consultants were e31,292 per year. Additional costs for these procedures were e8,370 for residents and e22,922 for junior consultants per year (Table 3). Regardless of the fact that costs per operating minute were lowest for junior consultants and highest for senior consultants, overall costs showed an inverse proportion. The incremental costs for junior consultants performing laparoscopic cholecystectomies were nearly fourtimes higher and for performing open hernia repair nearly 50% higher than those for residents. That analysis shows that further guidance in the operating room for junior consultants should be strongly recommended because of a major impact on overall costs for a hospital provider. These higher costs may derive from the performance of standard operations without proper supervision. Therefore, prolonged assistance by senior consultants seems to be highly cost-effective, regardless of the higher costs for personal resources. Discussion When compared with open surgery, a more standardized graduate medical education for laparoscopic surgery, with short courses to introduce technical innovation and simulated tasks on a video trainer, enables residents to acquire laparoscopic surgical skills during 3 years of training [4, 5, 6]. Unfortunately, most residents do not perform enough operations to gain surgical competence [7]. In accord with the fact that performance of laparoscopic cholecystectomy cannot be related only to surgical experience [8, 9], we found a less pronounced difference in operating times for laparoscopic cholecystectomy than for open hernia surgery. With proper supervision, surgical residents do not need longer operation times to perform laparoscopic cholecystectomies, which is not true for more challenging cases such as acute cholecystitis [10]. We also recorded shorter operating times associated with supervision by experienced surgeons in groups II and III. Operative selection is known to affect conversion rates significantly [8], which we have also shown for our residents. A structured assessment of technical skills in open surgery reveals a significant difference between junior and senior residents [11]. Therefore, our analysis contained laparoscopic cholecystectomy and open hernia repair for each of these entirely different operating techniques. Prolonged supervision of residents for open hernia repair should lead to lower recurrence rates and better performance [12, 13]. According to our experience, tension-free hernia repair is easier to perform and suitable especially for surgeons in training [14, 15]. The surgeon can best learn open hernia repair by assisting at those operations before operating under the supervision of a senior surgeon and, after that, through reinforcement by further work with senior surgeons [16]. By a significantly longer operating time we demonstrated that, even with relatively simple open surgical procedures, it is more difficult for competence to be gained than with more standardized laparoscopic procedures that allow faster learning through more standardized graduate medical education. The published average difference for operation times performed by experienced surgeons and residents is 9 minutes for laparoscopic cholecystectomy and 11

208 minutes for open inguinal hernia repair [2], whereas we recorded a difference of 5 and 18.5 minutes respectively. If, for cost analysis, the cost of supplies, indirect costs, and anaesthesiologists and surgeons fees are excluded, the cost per graduating resident is approximately e40,775, with a given number of 885 operations during residency [2]. If all costs per operating minute were included, it would lead to costs at least three-times higher [1]. However, graduation does not solve the problem of a longer duration of operations. Younger surgeons who have finished their training are now forced to perform significantly more operations without the supervision of an experienced surgeon. The importance of supervision for more difficult operations is corroborated by a major difference in operating times for laparoscopic cholecystectomy and also open hernia repair between junior consultants and residents. Nevertheless, these operations are thought to be routine procedures after 2 years of surgical residency. We have shown that surgical education may not be finished after graduation. From our experience, we expect 4 years of postgraduate supervision to be necessary for younger surgeons to acquire the competence for routine general surgery. References 1. Blewett LA, Smith MA, Caldis TG (2001) Measuring the direct costs of graduate medical education training in Minnesota. Acad Med 76:446 452 2. Bridges M, Diamond DL (1999) The financial impact of teaching surgical residents in the operating room. Am J Surg 177:28 32 3. Whang EE, Mello MM, Ashley SW, Zinner MJ (2003) Implementing resident work hour limitations. Lessons learned from the New York State experience. Ann Surg 237:449 455 4. Rogers DA, Elstein AS, Bordage G (2001) Improving continuing medical education for surgical techniques: applying the lessons learned in the first decade of minimal access surgery. Ann Surg 233:159 166 5. Rosen J, Solazzo M, Hannaford B, Sinanan M (2002) Task decomposition of laparoscopic surgery for objective evaluation of surgical residents learning curve using hidden Markov model. Comput Aided Surg 7:49 61 6. Scott DJ, Bergen PC, Rege RV, Laycock R, Tesfay ST, Valentine RJ, Euhus DM, Jeyarajah DR, Thompson WM, Jones DB (2000) Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg 191:272 283 7. Park A, Witzke D, Donelly M (2002) Ongoing deficits in resident training for minimally invasive surgery. J Gastrointest Surg 6:501 507 8. Bartlett A, Parry B (2001) Cusum analysis of trends in operative selection and conversion rates for laparoscopic cholecystectomy. Aust N Z J Surg 71:453 456 9. Lekawa M, Shapiro SJ, Gordon LA, Rothbart J, Hiatt JR (1995) The laparoscopic learning curve. Surg Laparosc Endosc 5:455 458 10. Wang WN, Melkonian MG, Marshall R, Haluck RS (2001) Postgraduate year does not influence operating time in laparoscopic cholecystectomy. J Surg Res 101:1 3 11. Winckel CP, Reznick RK, Cohen R, Taylor B (1994) Reliability and construct validity of a structured technical skills assessment form. Am J Surg 167:423 427 12. Decurtins M, Buchmann P (1984) Ist die Behandlung von Leistenhernien eine Operation für Anfänger? Chirurg 55:589 592 13. Yamamoto S, Maeda T, Uchida Y, Yabe S, Nakano M, Sakano S, Yamamoto M (2002) Open tension-free mesh repair for adult inguinal hernia: eight years of experience in a community hospital. Asian J Surg 25:121 125 14. Danielsson P, Isacson S, Hansen MV (1999) Randomised study of Lichtenstein compared with Shouldice inguinal hernia repair by surgeons in training. Eur J Surg 165:49 53 15. Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund G (2002) Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice. Br J Surg 89:45 49 16. Davies BW, Campbell WB (1995) Inguinal hernia repair: see one, do one, teach one? Ann R Coll Surg Engl 77:299 301