Resident and Fellow Participation Associated with Potential Opportunity Costs for Attending Head and Neck Surgeons

by Linda Kossoff •

CLINICAL QUESTION

What is the opportunity cost of training residents and fellows for head and neck surgery?

BOTTOM LINE

Work relative value unit (wRVU)-based physician reimbursement does not consider or adjust for the extra effort involved in training future head and neck surgeons.

COMMENT: wRVU aims to capture the time, work, skill, judgment, and stress associated with a given service. In many employed-physician models, wRVUs have been utilized to define baseline productivity goals and bonus incentive targets. Yet, this may not be appropriate in academic settings and particularly with complex cases such as those performed by head and neck oncologists. This novel study provides initial evidence of the opportunity cost borne by teaching residents and fellows. Additional studies exploring compensation models that take into account the time necessary for education, research, leadership, and citizenship behaviors with a goal to achieve fair and equitable pay should be encouraged. —Sarah Bowe, MD, EdM

BACKGROUND: The RVU was created to quantify the economic value of medical care. Critics assert that RVU-based care leads to a “volume over value system” that incentivizes procedures over non-procedural activities. There are additional considerations in teaching institutions, where those practicing with trainees have significant responsibilities in addition to direct patient care.

STUDY DESIGN: Data study.

SETTING: Department of Otolaryngology, Head and Neck Surgery, New York University, New York.

SYNOPSIS: Researchers mined data from the American College of Surgeons National Surgery Quality Improvement Project for ablative head and neck surgical procedures performed by otolaryngologists between 2005 and 2015. The team identified 34,078 patients (64.6% female, median age 49 years) who underwent procedures. Procedures were grouped into five categories: thyroid/parathyroid (63.2%), salivary gland (20.3%), oral cavity (8.8%), lymph node dissection (5.7%), and larynx/pharynx (2.0%). Median procedure length was 114 minutes. Researchers compared the wRVUs generated per hour among procedures performed by attendings alone (n = 3,645), attendings with residents (highest post-graduate year [PGY] level 5 or lower / n = 29,453), and attendings with fellows (PGY 6 or greater / n = 980). 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). Resident and fellow involvement was associated with opportunity costs of $60.44 per hour and $78.98 per hour, respectively, and decreases in the number of wRVU generated per hour of 1.8 and 2.3, respectively. Findings showed that the education of residents and fellows was associated with significant opportunity costs to attending head and neck surgeons. Study limitations included lack of trainee participation information post-2015.

CITATION: Chow MS, Gordon AJ, Talwar A, et al. The RVU compensation model and head and neck surgical education. Laryngoscope. 2024;134:113–119.