Is There a Paradigm Shift Affecting Resident Training?

In response to the special focus section on patient safety and quality improvement, I am writing to introduce a potentially new area of focus for quality improvement regarding resident education. I am a resident physician in a program that depends on a consortium of 4 hospital systems for training, 3 of which are private hospitals. I have no background in economics, but I have been perceptive enough during my training to recognize that economics drives the health care system and that administrative decisions are often based on costs. One recent trend as a means to improve efficiency and save costs is the ambulatory surgery center (ASC). Many procedures within otolaryngology are outpatient but currently occur within the hospital. As Meltzer et al demonstrate, even thyroid and parathyroid surgery can be safe as an outpatient procedure. As such, our specialty is primed to function within ASCs. I have experienced this firsthand, as 2 hospitals within our consortium have opened ASCs and a third is scheduled to do so. Unfortunately for me, this means that cases may go uncovered as residents tend to hospital-based procedures. I cannot help but wonder how ASCs affect the resident training experience. One of the challenges of working with residents is balancing efficiency with education. We are, after all, inherently inefficient. I like to think that the desires of hospitals to improve efficiency and costs through ASCs account for resident education, but I am not naïve to the fact that they likely do not. Residents seem to be caught in the middle of a virtual tug-of-war between education and health care economics. The increase in ASCs nationwide is a good indication of who is winning. So how can education and economics be effectively balanced? Ishii et al demonstrated that ASCs can be integrated into an academic health system, but not all academic health systems have the resources to easily integrate ASCs. The literature is lacking in its evaluation of the effects of ASCs on resident training, and this trend is still too new to get any quality data. The question of how resident training is affected by ASCs is a prospective study waiting to happen. As a trainee who aspires for a career in academics, I hope that the future tips the scales of hospital priorities back toward resident education. While ASCs may improve the economics of a hospital in the short term, poorly trained residents will certainly not.