Friday, September 23, 2011

Training Surgeons and Informed Consent

A rather bold new survey reveals that patients are willing to let residents operate as long as they operate on someone else. The study, published on line in Archives of Surgery, queried 316 patients at a tertiary care US Army hospital.

There were some positives. When given generic questions on resident participation in their surgery, 94% of all respondents said they would “consent to the involvement” of a resident in their operation. Of those respondents who had a preference, 91% felt that their care would be as good or better in a teaching vs. a non-teaching hospital. 

However, when presented with specific descriptions of the degree of resident participation in an operation, patients’ enthusiasm waned significantly. Just over half (57%) said they would consent to a junior resident assisting the staff surgeon; 32% would agree to having the staff surgeon assist the resident; 25% would consent to having the resident perform the surgery with the staff surgeon observing; only 18% would allow the resident to operate without the staff surgeon in the room. This survey clearly shows that if given a choice, most patients would not allow surgical residents to perform any part of their surgery.

This research is bold because it addresses a topic that most surgeons in teaching hospitals would rather not talk about.

You see, to learn how to be a surgeon, one must actually perform surgery. It can’t be learned by watching and regardless of what you may have read or heard, it can’t be learned on simulators alone.

With the pressure on to reduce work hours and alleged fatigue, surgical residents already are grappling with their levels of confidence upon graduation from training. The American College of Surgeons is so concerned about this that it is surveying its members to assess their opinions on whether today’s residents are adequately trained [Survey Regarding Competency and Confidence of Current General Surgical Trainees, link not available].


Since everyone likes the surgeons/pilots analogy, are you aware that co-pilots, some with far less experience than senior pilots, often are at the controls during take-offs and landings without the knowledge or consent of the passengers? The airline industry knows that flying is another skill that has to be learned by doing.

In the old days, surgeons learned by doing. Yes, we made some mistakes. And we still do. We are human. But how is the next generation of surgeons to be trained if they cannot operate under supervision?

1 comment:

plumtree said...

This has been a problem for years. I used to work at a medical school and we frequently fielded complaints that "I got a bill for Dr C (often a chief resident, although they didn't know that) when all he did was stand in the room while some !@#$ did the work." This was ophthalmology so many procedures were done without GA.
Having talked at length to older doctors, people in the their 70s & older, many have said that in the "old days" the tradeoff was clear. You went to a teaching hospital, care was free or at minimal cost, and you knew that part of the reason was that you'd be cared for by people in various stages of training. Now fee for service effectively applies across the board.
One of our biggest problems in the med school was getting our associates to operate at the teaching hospital--they had to meet a minimum quota. They preferred the suburban hospitals for many reasons, but one was that the patients were vociferous about not wanting residents or students to assist. (Another biggie was the quality of the nurses...)

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