Lost Relative Value Units: The Opportunity Cost of Training Surgical Residents

Abstract

The private-academic surgeon salary gap is particularly large in the field of vascular surgery, with full professors earning 16% less than private practitioners. Despite institutional benefits and nonclinical sources of funding, relative value unit (RVU) targets are still pertinent in determining compensation for academic surgeons. The RVU system does not account for the additional time and effort required during teaching cases. A retrospective observational study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Five common vascular surgery procedures were identified using unique Current Procedural Terminology codes. All cases missing pertinent data were dropped. Resident cases were defined as those with resident plus attending available or present. One-to-one propensity score matching was performed to compare resident cases with nonresident (attending only) cases, controlling for patient age, race, ethnicity, body mass index, sex, comorbidities, American Society of Anesthesiologists class, and case classification. The national Medicare conversion factor was used to assign the dollar value per RVU for each year and was divided by the operative time to calculate RVUs per hour and dollars per hour. The t-test and χ2 test were used for statistical analysis. P < .05 was considered significant. There were 57,610 cases analyzed after matching for the following procedures: above-knee amputation (4526), below-knee amputation (5140), carotid endarterectomy (CEA; 37,542), endovascular aneurysm repair (5660), and femoral-distal bypass (4742). The average difference in operative time for all procedures combined was 25.13 minutes longer for resident cases, which translates to 2.727 lost RVUs per hour and $96.22 less per hour compared with nonresident cases (all P < .00). The average difference in length of stay was 0.47 day longer for resident cases (all P < .05 except CEA, which was not significantly different). There was no difference in mortality. More patients required reoperation when a resident was involved for above-knee amputation (7.47% vs 9.46%; P < .016), below-knee amputation (11.79% vs 14.32%; P < .007) and CEA (4.52% vs 5.04%; P < .018). Fewer patients had strokes after CEA cases if a resident was involved (331/18,771 vs 286/18,771); however, the difference was not statistically significant. The current system of RVUs does not adequately compensate surgeons for additional time spent teaching residents. A Current Procedural Terminology code for “teaching case” could compensate academic surgeons more appropriately within the RVU system. Narrowing the compensation gap between private and academic vascular surgeons may incentivize residents to consider a career in academic surgery.