The impact of emergency medicine residents on clinical productivity

Faculty productivity is of interest for hospital and university administrators as pressure is placed on them by government and private payors. Further, the effect of trainees on clinical productivity is of personal interest to physicians because their performance evaluations and earning potential are often tied to their productivity. Several groups have utilized creative methodology to study the effect of learners on emergency department (ED) productivity, but they were faced with multiple confounding variables for which it was difficult to adjust. In this study, we utilize relative value unit (RVU)/h to study the effect of resident physicians and medical students on the productivity of academic emergency physicians (EPs) during the implementation of a new residency program. Each physician's productivity on shifts with distinct types of learners present is compared to their shifts worked without any learners during the same time frame. Each attending physician serves as their own control while the confounding variables introduced by comparing over multiple years are minimized.

The objective of this study is to measure the influence of emergency medicine (EM) residents on the clinical productivity of attending EPs.

We conducted an observational study of a single ED during implementation of a new residency program. The productivity of each EP was measured by RVU/h billed. Trainees' schedules and end-of-shift evaluations were utilized to determine what learners (if any) were working with the EP on each shift. RVU/h calculations were performed for each EP (overall, when working without learners, and when working with each of the four learner categories). The primary outcome (determined a priori) was the difference in RVU/h for the attending EPs when they worked without learners compared to when they worked a majority of their shift with at least one learner. The secondary outcome (also determined a priori) was determining the influence of the learners of each type on EP RVU/h for the subgrouped shifts in which a learner was present for the majority of the shift.

There was no significant difference in mean EP RVU/h when attendings worked with a medical student or non-EM R1 in comparison to working without learners in the 1761 ED encounters analyzed (12.95 RVU/h vs. 12.52 RVU/h; p=0.125). Although there was variability among individual physicians, EP RVU/h increased significantly for the overall group when one or more EM R1s were present (15.19 RVU/h with one EM R1 present, 15.25 RVU/h with two, 24.75 RVU/h with three; p<0.001). Similarly, mean EP productivity increased significantly with the addition of an EM R2 (17.96 RVU/h vs. 16.84 RVU/h; p=0.001).

The presence of EM residents was positively associated with the clinical productivity of EM faculty as measured by RVU/h. There was also a positive association between productivity and the number of EM residents present as well as their training level. Non-EM residents and medical students had no effect on EP productivity.