Opportunity cost of resident involvement in cataract surgery to attending surgeons

From the 2022 HVPA National Conference

Brittany Tsou BS (Wilmer Eye Institute, Johns Hopkins University School of Medicine), Kerry Smith MS, Rahul Shah MHA, Fasika Woreta MD, MPH, Swaroop Vedula MBBS, PhD, Shameema Sikder MD


The overall opportunity cost of teaching in the operating room in eye surgery has not been quantified. Prior studies on cost of teaching cataract surgery estimated the cost of operating room use. However, estimating cost in terms of work relative value units (wRVUs) captures the time, skill, mental effort and judgment, and stress among attending surgeons. Thus, wRVUs represent the opportunity cost for attending surgeons.


To determine the opportunity cost of intraoperative resident involvement to attending surgeons in cataract surgery.


Operating room records at an academic teaching hospital from July 2016 to July 2020 were analyzed in this cross sectional study. Cases were identified using Current Procedural Terminology (CPT) codes 66982 and 66984 for cataract surgery. Patients who had cataract surgery combined with another procedure were excluded. Outcomes measured include operative time and wRVUs. Cost analysis was performed using the generic 2021 Medicare Conversion Factor.


Of 8,813 cases, 2,906 (33.0%) included resident involvement. For cases logged as CPT 66982, the median (interquartile range) operative time was 47 (22) minutes with resident involvement and 28 (18) minutes without (p<0.001). For cases logged as CPT 66984, the median (interquartile range) operative time was 34 (15) minutes with resident involvement and 20 (11) minutes without (p<0.001). The median wRVUs was 78.5 (20.9) with resident involvement and 61.0 (14.4) without (p<0.001) which converted to an opportunity cost (interquartile range) per case of $1393.72 ($1055.63). Among cases involving residents, the median operative time was significantly higher during the first and second quarters (p<0.001) and for every quarter when compared to cases performed by attendings only (p<0.001).


Cataract surgery cases with resident involvement had longer median operative times and higher median wRVUs compared to cases performed by attending surgeons alone. In addition, the median operative time of cases with resident involvement was significantly higher during the first and second quarters. Our findings emphasize the need for novel approaches to resident training to optimize costs and provide a metric to evaluate their effectiveness.

Clinical Implications

Given the high opportunity cost of teaching cataract surgery in the operating room, it is necessary to develop other ways that residents can gain practice with the procedure outside of the operating room. Targeted training to competence with different steps in the procedure, either through simulation or feedback could lead to development of novel and optimized training curricula. In addition, other ways to compensate and motivate educators are needed, particularly in busy academic environments where faculty have clinical and research responsibilities in addition to teaching responsibilities.

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