World Journal of Surgery

, Volume 41, Issue 8, pp 1950–1960 | Cite as

Tutorial Assistance for Board Certification in Surgery: Frequency, Associated Time and Cost

  • Robert MecheraEmail author
  • Salome Dell-Kuster
  • Marco von Strauss und Torney
  • Igor Langer
  • Markus Furrer
  • Heiner C. Bucher
  • Rachel Rosenthal
Original Scientific Report



Tutorial assistance is related to extra time and cost, and the hospitals’ financial compensation for this activity is under debate. We therefore aimed at quantifying the extra time and resulting cost required to train one surgical resident in the operating theatre for board certification in Switzerland as an example of a training curriculum involving several surgical subspecialties. Additionally, we intended to quantify the percentage of tutorial assistance.


We analysed 200,700 operations carried out between 2008 and 2012. Median duration of procedure categories was calculated according to four different seniority levels. The extra time if the procedure was performed by residents, and resulting cost were analysed. The percentage of procedures carried out by residents as compared to more experienced surgeons was assessed over time.


On average, residents performed about a third of all operations including typical teaching procedures like appendectomies. An increase in duration and cost of well-defined procedures categories, e.g. cholecystectomies was demonstrated if a resident performed the procedure. In less well-defined categories, residents seemed to perform less difficult procedures than senior consultants resulting in shorter durations of surgery.


The financial impact of tutorial assistance is important, and solutions need to be found to compensate for this activity. The low percentage of procedures performed by trainees may make it difficult to fulfil requirements for board certification within a reasonable period of time. This should be addressed within the training curriculum.


Board Certification Major Amputation Laparoscopic Hernia Repair Senior Consultant Tertiary Academic Care Centre 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank Luzi Rageth and the AQC for providing the data set and Eileen Walliser for proofreading.

Compliance with ethical standards

Conflict of interest

Rachel Rosenthal is an employee of F. Hoffmann-La Roche Ltd. since 1 May 2014. The present study was conducted before she joined F. Hoffmann-La Roche Ltd. and has no connection to her employment by the company. Rachel Rosenthal continues to be affiliated to the University of Basel.


  1. 1.
    Sutherland LM, Middleton PF, Anthony A et al (2006) Surgical Simulation. Ann Surg 243:291–300. doi: 10.1097/01.sla.0000200839.93965.26 CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Von Strauss Und Torney M, Dell-Kuster S, Mechera R et al (2012) The cost of surgical training: analysis of operative time for laparoscopic cholecystectomy. Surg Endosc 26:2579–2586CrossRefGoogle Scholar
  3. 3.
    Webb TP, Brasel KJ, Redlich PN, Weigelt JA (2010) Putting a price on education: hours and dollars for a general surgery curriculum. Am J Surg 199:126–130. doi: 10.1016/j.amjsurg.2009.09.004 CrossRefPubMedGoogle Scholar
  4. 4.
    Bridges M, Diamond DL (1999) The financial impact of teaching surgical residents in the operating room. Am J Surg 177:28–32. doi: 10.1016/S0002-9610(98)00289-X CrossRefPubMedGoogle Scholar
  5. 5.
    Margolin DA (2012) The impact of health care economics on surgical education. Clin Colon Rectal Surg 25:177–180. doi: 10.1055/s-0032-1322547 CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Bartkowski R (2009) Problem DRG: does medical training fall by the wayside? Swiss knife 3:8–10Google Scholar
  7. 7.
    Swiss Association for Quality Assurance in Surgery (AQC). Accessed 20 July 2016
  8. 8.
  9. 9.
    Newson R (2006) Confidence intervals for rank statistics: percentile slopes, differences, and ratios. Stata J 6(4):497–520Google Scholar
  10. 10.
    Meara MP, Schlitzkus LL, Witherington M et al (2010) Surgical resident education: what is the department’s price for commitment? J Surg Educ 67:427–431. doi: 10.1016/j.jsurg.2010.06.008 CrossRefPubMedGoogle Scholar
  11. 11.
    Babineau TJ, Becker J, Gibbons G et al (2014) The “cost” of operative training for surgical residents. Arch Surg 139:366–370CrossRefGoogle Scholar
  12. 12.
    Harrington DT, Roye GD, Ryder BA et al (2007) A time-cost analysis of teaching a laparoscopic entero-enterostomy. J Surg Educ 64:342–345. doi: 10.1016/j.jsurg.2007.06.009 CrossRefPubMedGoogle Scholar
  13. 13.
    Koperna T (2004) How long do we need teaching in the operating room? The true costs of achieving surgical routine. Langenbecks Arch Surg 389:204–208. doi: 10.1007/s00423-003-0421-3 CrossRefPubMedGoogle Scholar
  14. 14.
    Hosler MR, Scott IU, Kunselman AR et al (2012) Impact of resident participation in cataract surgery on operative time and cost. Ophthalmology 119:95–98. doi: 10.1016/j.ophtha.2011.06.026 CrossRefPubMedGoogle Scholar
  15. 15.
    Sasor SE, Flores RL, Wooden WA, Tholpady S (2013) The cost of intraoperative plastic surgery education. J Surg Educ 70:655–659. doi: 10.1016/j.jsurg.2013.04.008 CrossRefPubMedGoogle Scholar
  16. 16.
    Chamberlain RS, Patil S, Minja EJ, Kordears K IV (2012) Does residents’ involvement in mastectomy cases increase operative cost? if so, who should bear the cost? J Surg Res 178:18–27. doi: 10.1016/j.jss.2012.08.027 CrossRefPubMedGoogle Scholar
  17. 17.
    Hwang CS, Pagano CR, Wichterman KA et al (2008) Resident versus no resident: a single institutional study on operative complications, mortality, and cost. Surgery 144:339–344. doi: 10.1016/j.surg.2008.03.031 CrossRefPubMedGoogle Scholar
  18. 18.
    Hwang CS, Wichterman KA, Alfrey EJ (2010) The cost of resident education. J Surg Res 163:18–23. doi: 10.1016/j.jss.2010.03.013 CrossRefPubMedGoogle Scholar
  19. 19.
    Droeser RA, Dell-Kuster S, Kurmann A et al (2014) Long-term follow-up of a randomized controlled trial of Lichtenstein’s operation versus mesh plug repair for inguinal hernia. Ann Surg 259:966–972. doi: 10.1097/SLA.0000000000000297 CrossRefPubMedGoogle Scholar
  20. 20.
    Singh P, Aggarwal R, Hashimoto DA et al (2014) A comparative study of contrasting surgical residency programs. World J Surg 38:2495–2501. doi: 10.1007/s00268-014-2575-2 CrossRefPubMedGoogle Scholar
  21. 21.
    Moonesinghe SR, Lowery J, Shahi N et al (2011) Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review. BMJ 342:d1580. doi: 10.1136/bmj.d1580 CrossRefPubMedGoogle Scholar
  22. 22.
    Joint Committee on Surgical training. JCST quality indicatiors. Accessed 28 Dec 2015
  23. 23.
    ACGME Program Requirements for Graduate Medical Education in General Surgery (2016) Accessed 21 July 2016
  24. 24.
    Carayon P, Weinger MB, Brown R et al (2015) How do residents spend their time in the intensive care unit? Am J Med Sci 350:403–408. doi: 10.1097/MAJ.0000000000000520 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  • Robert Mechera
    • 1
    Email author
  • Salome Dell-Kuster
    • 1
    • 2
  • Marco von Strauss und Torney
    • 1
    • 3
  • Igor Langer
    • 4
    • 5
  • Markus Furrer
    • 6
  • Heiner C. Bucher
    • 2
  • Rachel Rosenthal
    • 1
  1. 1.Department of SurgeryUniversity Hospital of BaselBaselSwitzerland
  2. 2.Basel Institute for Clinical Epidemiology and BiostatisticsUniversity Hospital of BaselBaselSwitzerland
  3. 3.Department of SurgeryCantonal Hospital AarauAarauSwitzerland
  4. 4.Department of SurgeryLindenhof Hospital BernBernSwitzerland
  5. 5.Swiss Association for Quality Assurance in Surgery (AQC)ZurichSwitzerland
  6. 6.Department of SurgeryCantonal Hospital GraubündenChurSwitzerland

Personalised recommendations