Community Health Centers have existed throughout the United States for decades for the purpose of treating underserved populations. These FQHC’s traditionally focused on primary care, obstetrics, and mental care with sub-specialty services often out of reach for many. With the passage of the ACA in 2010, increased funding has allowed these centers to proliferate and expand their capabilities [2]. In 2015, roughly 1300 health centers served 24.3 million people—an increase from 19.5 million in 2010 [1, 2]. Approximately 76% of FQHC patients were insured (49% through Medicaid), up from 65% in 2013 [1, 2]. Nearly 1 in 12 Americans were being seen at these clinics, with 6 in 10 being women, and hundreds of thousands veterans [1, 2]. FQHC facilities have sought to expand their subspecialty medical and surgical care by forming partnerships with nearby hospitals and community mental health organizations [2]. Partnerships between FQHC’s, like the SACHS clinic in San Bernardino, CA, and larger institutions provide unique learning opportunities for residency programs while also providing previously unattainable sub-specialty care to medically underserved population.
Previous studies have shown that resident-directed or resident-run clinics are highly beneficial in developing resident autonomy in a safe, effective manner [3–6]. Currently however, no studies have examined the effectiveness or clinical outcomes of an ENT resident-led clinic. For decades, many plastic surgery programs have incorporated resident-led aesthetic clinics with similar semi-autonomous models into their training in an effort to meet required key indicator cases [7–10]. Many program directors and plastic surgery residents consider these experiences invaluable for their training—particularly in developing autonomous decision making and operative skills—regardless of their final career goals [6].
Additionally, resident led surgery clinics provides an ideal environment to enhance knowledge in systems- based practice, patient care, communication skills, and professionalism [7–10]. Wojcik et al. showed that residents experienced significant improvements in both surgical skills and confidence in surgical ability during a rotation at a resident-run procedure clinic wherein residents were solely responsible for performance of various soft tissue procedures [5]. However, the longitudinal educational value of this resident-run experience was limited by lack of resident involvement in either pre-procedure consultation or post-procedural follow up. Witherspoon et al. similarly showed that a resident-run Urology clinic resulted in high levels of resident confidence in patient management, with low rates of changes in patient management following faculty review [6].
While previous studies have shown resident-run clinic to provide patient care with complication rates and satisfaction scores equivalent to national outcomes—similar to the findings of this paper—the effectiveness of the coordination of patient care in a resident run clinic has not been established [10–12]. This study demonstrates overall comparable outcomes in delivery of Otolaryngology sub-specialty care between the resident-run, SACHS clinic population and the mostly privately insured population of LLUMC faculty clinic. This was evident in time of referral to consultation as well as interval of time between decision for surgery and date of operation, and subsequent post-operative visits. While the overall median interval time to surgery was statistically significantly increased for SACHS patients, analysis by surgery type showed predominantly equivalent times between decision for surgery and the surgery itself. Interval times were only minimally increased for SACHS patients with notable exceptions being markedly—although not statistically significantly—decreased interval times for SACHS patients requiring endoscopic sinus surgery and a nearly doubled interval time to surgery for those requiring thyroid or parathyroid surgery. The latter discrepancy—the only subgroup to reach statistical significance—is likely attributable to the Loma Linda University Thyroid Center—a very high-volume practice of a single faculty surgeon with low participation with the SACHS clinic. On further review of outliers for median time interval were typically due to a variety of patient factors (e.g. preference, need for medical clearance, etc.).
There are noteworthy limitations to the strength of conclusions that can be made from this study. Firstly, surgical scheduling and insurance approval is done separately from the standard electronic medical record and thus the direct contribution of insurance status or provider on time to surgery was unable to be assessed. Additionally, as with any retrospective study, data is limited by the completeness of medical documentation and there exists potential bias in treatment and outcomes due to non-randomization of patients. Lastly, the relatively small sample size with heterogeneous patient populations both introduces potential selection bias as well as limiting the ability to accurately detect statistical significance between groups.