An Old Idea is a Novel Concept for Supplemental Funding of Surgical Residency Programs.

Background In July 2014, the Institute of Medicine released a review of the governance of Graduate Medical Education (GME), concluding that changes to GME financing were needed to reward desired performance and to reshape the workforce to meet the nation's needs. In light of the rapid emergence of alternative payment systems, we evaluated the financial value of resident participation in operative surgical care.  Methods The Department of Surgery provided Current Procedural Terminology (CPT) codes for procedures performed by the general surgical service at our institution for the 2011 academic year. For each code, the charge and total instances were provided. CPTs allowing an assistant fee were identified using the Searchable Medicare Physician Fee Schedule. This approach enabled calculation of the potential resident contribution to GME funding. Results A total of 515 unique CPTs were potentially billable for a total of 6,578 procedures, of which 2,552 (39%) were reimbursable. These CPTs would have generated $1,882,854 in assistant charges. The top 50 most frequent CPTs resulted in 4,247 procedures. Within the top 50, 1362 procedures (32% of the top 50, 21% of the total) were reimbursable. Of the total assistant charges, $963,227 (51%) occurred in the top 50 most frequent CPTs. Conclusions Credit for resident participation in operative care as co-surgeon would average $67,244 per resident, compared to our current funding of $142,635 per resident. This type of alternative funding could provide 47% of current educational support. The skew in distribution of procedures also suggests that such a system could provide guidance to a more balanced operative experience. Such performance-based credentialing could be used to ensure appropriate housestaff for a given case; these reimbursements could also be adjusted based on quality metrics to provide for transformational change in patient outcomes.

Continuous retroflexion cystoscopy during prostate cryoablation.

During cryotherapy of the prostate, identification of probe tips that are misplaced into the bladder is often not readily apparent via transrectal ultrasonography. Ultimately, cystoscopy is needed to ensure this has not occurred before initiating a freeze. We describe the innovative use of continuous flexible cystoscopy in retroflexion for visualization of the bladder neck during insertion and manipulation of cryoprobes. Using this technique, it is possible to identify probes errantly placed into the bladder lumen in real time, thereby facilitating safe and accurate placement and eliminating an unnecessary step in the cryotherapy procedure. Instead of placing a Foley catheter at the beginning of the cryotherapy procedure, a flexible cystoscope is advanced into the bladder lumen and retroflexed at the onset of the procedure. The cystoscope is maintained in this position during cryoprobe placement. This real-time observation of the bladder neck allows for immediate withdrawal and repositioning of cryoprobes inadvertently advanced into the bladder. This technique also obviates the need for Foley catheter placement at the beginning of the procedure and subsequent removal after cryoprobe insertion to allow for cystoscopic evaluation for inadvertent cryoprobe insertion into the bladder or urethral lumen.