The balance between increasing learner autonomy and ensuring patient safety is a fundamental difficulty in surgical education. While a great deal of literature continues to be published on the optimization of this interaction, much less is known about the perspectives of the other stakeholders in this equation: the patients. While the ethical considerations of allowing trainees to be involved in patient care are largely deemed to be both permissible and necessary, the process of informing the patient of this aspect and ensuring their permission is less clear, especially in surgical fields.1-5
Studies have demonstrated remarkable variation in the understanding and expectations of patients during a surgical hospitalization.3,6,7 Specifically, even when presenting to a university hospital, 46–79% of patients did not expect that trainees (including medical students, residents, and fellows) would be involved in their care.3,4 There is also confusion among patients about common medical terms that indicate overall physician rank. Of those surveyed about typical medical teams, 27–29% of patients did not know the term “attending” referred to a physician who is done with formal training, and 26–36% did not know resident physicians have already graduated from medical school.6,8
While the literature reports varying outcomes when trainees are involved, there are some notable consistencies of involving trainees, including increased procedural time.9-15 However, many of these large studies are limited as they draw from data that were not originally collected to answer this question of trainee involvement. These databases, like the ACS National Surgical Quality Improvement Program (ACS NSQIP®), often report time and involvement of trainees (and even trainee level) but are unable to quantify the level of involvement of the trainees.9,11-15 This is why, paradoxically, many operations involving junior residents are of a shorter duration than senior residents, as the attending surgeon presumably plays a much larger role in the case.
Aside from increased operating room time, there is no clear effect of trainee involvement on patient outcomes. Both benefits and consequences have been identified within individual studies.9,11-16 These results tend to follow an overall logical expectation. For example, some gaps in procedural knowledge or ability of trainees can lead to higher rates of postoperative complications and re-operation, but close monitoring by trainees may be responsible for a lower rate of failure-to-rescue in sick patients.11-13,16 This dynamic should be an important part of a conversation with patients, as one study demonstrated that more than 90% of patients would agree to resident involvement if they could be assured of equal or better outcomes.17 As with the consent for the surgery itself, a realistic review of alternative options is warranted, especially if the patient indicates they may not want trainees to be involved in their care. In some institutions, there may be infrastructure in place (PAs, RNFAs, or NPs) that allow for a viable alternative to resident involvement. However, patients should be made aware they may receive less than the standard of care if residents and/or fellows are not involved in their operative and postoperative course. For example, Castleberry and colleagues noted that patients undergoing complex surgery for oncological disease had significantly lower mortality and failure-to-rescue rates when residents were involved in their care.12
While the field of simulation continues to develop to provide trainees with higher-fidelity learning experiences and a greater number of safe training repetitions, the majority of surgical learning is still with actual patients. Although residents must advocate for their own autonomy, it is the attending’s responsibility to ensure this is done safely, and ultimately with respect to the patient’s stated wishes. These differences in opinions on how much autonomy trainees should have vary greatly between patients, trainees, surgical faculty, and administrators.17 Perhaps surprisingly, one study demonstrated that patients actually had a higher degree of receptiveness to resident involvement than was expected by faculty and administrators.17
However, these general discussions on graduated trainee autonomy require pretraining or they are unlikely to be helpful when consenting a patient and their family in a preop area or discussing surgical options in clinic. A universal part of the surgical training experience is learning to navigate these sometimes-challenging preoperative conversations, which will often include questions like: “Will the doctor be doing the whole procedure?”, “Will you be in the surgery?”, and “They’re not going to let someone practice on me, right?” Typically, residents’ responses must be honest but measured. Lying about or intentionally obfuscating the resident’s involvement is obviously unethical, but the way in which it is introduced can have a significant impact on patient’s perceptions.
These ad hoc bedside discussions are unlikely the most reliable means of promoting patient permission for resident participation. For example, it is not uncommon for the attending to be the only physician the patient meets from the surgical team preoperatively. This may actually not be a significant drawback, as 78% of patients would prefer the conversation of resident participation to come from the attending physician.5 Other possible methods to increase patient acceptance of resident involvement include patient education techniques. While informative videos and pamphlets have demonstrated some improvement in patient buy-in of resident involvement at the senior level, there are some mixed results for participation of junior residents.2-4 Notably, while a majority (65–80%) of patients want to be asked permission for a resident to be involved in their care, 85% of patients agreed to resident participation before having a conversation with the team or viewing educational materials about the function of a resident.2,4,5 This likely indicates that most patients’ desire to consent to resident involvement is not an issue of being able to decline, but more a matter of respect for their personal autonomy. Therefore, it appears early transparency in care is the most reliable method of assuring patients of the quality of their care while promoting their approval of trainee involvement.5
Our recommendations follow common principles for surgical consent, namely respect for patient autonomy, education and verification of understanding, and disclosure of risks, benefits, and alternatives.18,19 We recommend appropriately setting the stage (preferably by the attending) and directly addressing the plan for trainee involvement. The physician holding this conversation with the patient should discuss average outcome statistics of resident involvement (mentioned and cited above), as well as any relevant statistics with respect to the attending or hospital. This discussion of risks and benefits may include commentary on the feasibility, or lack thereof, of performing the procedure without trainee involvement and should inform the patient of what the major roles of each team member will be in the procedure, as well as the level of supervision intended throughout the case. If the patient states that they would not like trainees to be involved, then it may also be prudent to pursue the reasoning behind their concerns if time allows. Finally, patient conversations around trainee involvement should permit enough time for the patient to think about this information, demonstrate understanding, ask questions, and provide or decline consent.
In conclusion, the current education literature indicates that patients primarily want to be well informed of their surgical team’s roles, rather than assigning the roles themselves. We recommend early and clear discussions with surgical patients of the expected members and roles of their surgical team. Further investigation is warranted on optimizing patient and family permission to involve trainees, especially as there is no one-size-fits-all solution given the diverse patient population and practice environments.
