Assessing the Value of Work Done by an Orthopedic Resident During Call

摘要

Introduction Resident physicians are a critical part of the medical workforce. They are important to the care for medically underserved patients and improve access to care by working at academic medical centers with a high volume of these patients. Most resident education is funded by the Medicare system, with national funding totaling $9.5 billion in 2010.1 To reduce the federal deficit, Medicare funding of graduate medical education (GME) has been targeted for cuts.1 Simultaneously, numerous reports project coming physician shortages and decreased resident duty hours despite increased demand with the Affordable Care Act.1 In this context, it is important to demonstrate the value residents provide to the health care system during training to justify preservation or even increases in funding for GME. Studies that quantify the amount and type of work done by residents are difficult to perform and interpret. Some have attempted to calculate the amount of work lost under duty hour reductions, resulting in estimates of as much as $1.6 billion/y.2,3 Two studies4,5 tracked the types of duties that residents perform on call, whereas 2 others6,7 examined theoretical relative value unit (RVU) generation by residents and fellows. To date, no study, to our knowledge, has measured the number of RVUs generated by a single orthopedic resident while on call. The purpose of our study was to quantify the amount and type of work performed by a junior orthopedic surgery resident during a 2-year experience of in-hospital call at a level-1 trauma center, and its calculated Medicare value. In our hospital, on-call work outside the operating room is performed without the attending physician being physically present, and thus, no bills are submitted for the care provided by the on-call resident. We compare the value of that work to the funding received from Medicare to support GME to determine whether the government investment in our orthopedic residency program is cost-effective.;Methods We collected a single orthopedic resident's on-call emergency department and inpatient consults during a 2-year (postgraduate year [PGY]–2 and PGY-3) call period at a large, tertiary, level-1 trauma center hospital. Patient charts were reviewed for demographic data, admission data, orthopedic diagnoses, and procedures performed without the presence of the attending surgeon. Each patient's radiographs were reviewed and converted into International Classification of Disease, 9th Revision, codes. Procedural treatments provided acutely were reviewed and coded according to the Current Procedural Terminology (CPT) guidelines.8 Additional care for injury, such as a sling for a clavicle or scapula fracture or a cast for a distal radius fracture, was coded with the corresponding CPT code. If the CPT code included 90?days worth of follow-up care, then the ?54 modifier was used to decrease the monetary value of the code by 30% to exclude follow-up care that the resident would not provide. The history and physical examination for either outpatient or inpatient consultation was also converted into an evaluation and management code. The CPT and evaluation and management codes were then converted into work relative value units (wRVUs) using the 2012 Medicare wRVU crosswalk and then multiplying by the $34.03 rate per Medicare wRVU for a total monetary value of work performed.9 The study was approved by the institution's Institutional Review Board.;Results There were 6 first-call junior (PGY-2 and PGY-3) residents in the call pool, which resulted in 120 calls per resident during a 2-year period. A call shift was defined as initially evaluating all orthopedic consults at a level-1, tertiary care hospital. Requests for consultation were from the adult or pediatric emergency departments or from current inpatients in the adult or children's hospital. Call periods and frequencies are detailed in table?1. In addition to orthopedics, our service covers hand consults 30 of 30?d/mo and spine