Is a resident going to perform most of a surgical procedure? If so, many patients probably would expect to learn this fact before the procedure. However, many urologists do not disclose it, according to a group of researchers.1
Investigators surveyed 49 urology residency program directors in 2021 about informed consent processes. About half reported their hospitals do not explicitly discuss trainee involvement in surgery. Most (87.8%) do not explicitly discuss when a resident is going to perform most of the procedure.
About three-fourths of respondents reported a patient declined to allow the trainee to participate in the surgery after the trainee’s role was explained. Confusion over the role of residents is a contributing factor, says Juliana Kim, the study’s lead author and a medical student at Rutgers Robert Wood Johnson Medical School. For example, some patients assume the terms “resident” or “trainee” mean the individual lacks an MD.
“Further efforts are required to improve communication and education regarding resident involvement in surgery, and address patient concerns and preferences more effectively to protect the physician-patient relationship,” Kim says.
Who is ethically obligated to explain the resident’s involvement? “The lead surgeon or the resident should explain the resident’s role in the procedure,” according to Robert S. Olick, JD, PhD, associate professor emeritus of bioethics and humanities at SUNY Upstate Medical University in Syracuse, NY.
Medical students often are told they should inform the patient about their role and seek express consent for their participation. “But, ultimately, it is the responsibility of the lead surgeon to have this conversation with the patient and family,” Olick asserts.
When choosing a surgeon, patients often want to know about the surgeon’s experience and outcomes. Surgeons are ethically obligated to volunteer this information, or at least ask if patients would like it, according to Olick. “This ethical responsibility extends to residents and medical students who will be involved in the patient’s care,” he adds.
Surgical training is necessary for residents to become good surgeons; that benefits future patients. “Some may argue that the greater good of having well-trained, competent surgeons to serve the greater community of patients outweighs the interests of any particular patient,” Olick offers.
Often, patients consent to the resident’s role. “Willingness to consent varies with the nature of the procedure, its risks, and the resident’s role,” Olick says.
For example, most patients would be more apprehensive about heart surgery than intubation, and are less concerned about suturing. “Concerns about consent to the resident’s role may be exaggerated, especially when the attending surgeon is present and supervising the procedure,” Olick suggests.
As a pediatric surgeon, Catherine Hunter, MD, FACS, FAAP, has been conflicted between a professional obligation to provide residents with a strong educational experience and an ethical duty to provide the safest, best care to patients. Hunter and colleagues surveyed 51 attending surgeons and 55 residents about ethical principles that guide surgical training.2
“It is helpful for residents to understand the ethical considerations that are at play for an attending surgeon,” says Hunter, division chief of pediatric surgery at the University of Oklahoma College of Medicine.
Residents were more likely to be involved in less complex cases and cases with perceived lower error margins. Surgeons used intraoperative supervision to mitigate the risk of resident participation and to uphold the principles of beneficence and nonmaleficence. “The attending surgeon must maintain a balance between providing the best, transparent surgical care to patients — while still allowing residents to participate in a broad range of cases on a wide spectrum of patients,” Hunter says.
Respondents indicated they used transparent consent practices to uphold the ethical principle of patient autonomy. This gives patients a fuller understanding of the role residents play in their care. “Many cases are quite complex and require an additional set of hands or eyes,” Hunter says.
The consent discussion should specify who will be participating in the surgical case, and who will be involved in the postoperative care. “Although a resident may be inexperienced with a procedure, they are still highly educated and skilled individuals who provide real benefits to procedures and patient care when supervised appropriately,” Hunter says.
REFERENCES
1. Kim JE, Khizir L, Srivastava A, et al. Survey of informed consent procedures in urology: Disclosing resident participation to patients. J Clin Ethics 2023;34:190-195.
2. Golubkova A, Liebe H, Leiva T, et al. Ethics of resident involvement in surgical training. J Clin Ethics 2023;34:175-189.
Further efforts are required to improve communication and education regarding resident involvement in surgery, and address patient concerns and preferences more effectively to protect the physician-patient relationship.
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