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The Patient Protection and Affordable Care Act, also known as the House of Representatives Bill HR 3590, was created to improve the quality of patient care and access to health care for American citizens. Provisions of this bill are likely to have both intended and unintended consequences on surgical education. The purpose of this article is to explore the ways in which HR 3590 may affect the educational experience of surgical house officers at teaching hospitals.

Objective: To compare risk- and volume-adjusted outcomes of colon resections performed at teaching hospitals (THs) vs non-THs to assess whether benign disease may influence the volume-outcome effect., Design: Retrospective data analysis examining colon resections determined by International Classification of Diseases, Ninth Revision, Clinical Modification classification performed in the United States from 2001 through 2005 using the Nationwide Inpatient Sample (NIS) and the Area Resource File (2004). Patient covariates used in adjustment included age, sex, race, Charlson Index comorbidity score, and insurance status. Hospital covariates included TH status, presence of a colorectal surgery fellowship approved by the Accreditation Council for Graduate Medical Education, geographical region, institutional volume, and urban vs rural location. County-specific surgeon characteristics used in adjustment included average age of surgeons and proportion of colorectal board-certified surgeons within each county. Environmental or county covariates included median income and percentage of county residents living below the federal poverty level., Setting: A total of 1045 hospitals located in 38 states in the United States that were included in the NIS., Patients: All patients older than 18 years who had colon resection and were discharged from a hospital included in the NIS., Main Outcome Measures: Operative mortality, length of stay (LOS), and total charges., Results: A total of 115 250 patients were identified, of whom 4371 died (3.8%). The mean LOS was 10 days. Fewer patients underwent surgical resection in THs than in non-THs (46 656 vs 68 589). Teaching hospitals were associated with increased odds of death (odds ratio, 1.14) (P = .03), increased LOS (P = .003), and a nonsignificant trend toward an increase in total charges (P = .36)., Conclusions: With the inclusion of benign disease, colon surgery displays a volume-outcome relationship in favor of non-THs. Inclusion of benign disease may represent a tipping point.

Hypothesis: The mechanism by which trauma systems improve mortality is unknown. Outcomes may be influenced by experienced trauma surgeons treating more patients (surgeon effect) or improving the overall system of care (system effect). We hypothesized that mortality is lower in patients treated by a fellowship-trained senior trauma program director (experienced) vs first-year general surgery attending surgeon (novice) and that patient mortality for novice surgeons would improve after adding a new senior trauma director., Design: Retrospective cohort study., Setting: Academic level I trauma center., Patients: Individuals who had experienced trauma., Main Outcome Measures: We concurrently compared mortality in trauma patients treated by an experienced trauma surgeon with those admitted by novice surgeons during 5(1/2) years. We also compared mortality in patients treated by novice surgeons before vs after implementation of a more structured trauma program. The chi(2) test and multiple logistic regression analysis were used to compare the groups. Odds ratios (95% confidence intervals) for death were examined., Results: Concurrent comparison of patients treated by novice surgeons vs experienced trauma surgeons demonstrated no difference in mortality (odds ratio, 1.33; 95% confidence interval, 0.82-2.15). At unadjusted univariate analysis, mortality in patients treated by novice surgeons significantly improved over time in the blunt trauma group and all emergency department survivor subgroups. Multivariate analysis demonstrated significantly improved mortality over time in patients treated by novice surgeons (odds ratio, 0.56; 95% confidence interval, 0.37-0.85)., Conclusions: In a structured trauma program, there is no mortality difference between novice surgeons and their experienced trauma director. The organized trauma program and senior surgical mentoring overpower any influence of individual surgeon inexperience.

Background: Minority groups have poor access to quality health care services. This is true of colorectal cancer care and may be related to both geographical proximity and use of surgical, gastroenterology, and radiation oncology services. Without suitable access, many minority patients may present with advanced colorectal cancer and be less likely to receive appropriate adjuvant therapies. We sought to examine the variations in geographical access among minorities at a county level., Design: A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists., Setting: All counties in the United States., Participants: Prevalence rate of African Americans and Asian Americans within a county., Main Outcome Measure: Rate of colorectal surgeons, gastroenterologists, and radiation oncologists., Results: Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13)., Conclusion: Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.