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26-09-2011 | Article

Surgical patients’ consent falls with greater resident participation

Abstract

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MedWire News: The vast majority of surgical patients support resident training and believe they should be informed of the level of participation, results of a survey published in the Archives of Surgery show.

However, when given this information, patients were much less likely to provide informed consent. Study co-author Matthew Martin (Madigan Army Health System, Tacoma, Washington, USA) and colleagues therefore advise that any disclosure be "carefully planned… to avoid any adverse effects on surgical training."

Central to informed consent is the idea of autonomy, whereby patients make their own decisions after the physician has detailed the nature of the treatment, its possible alternatives, and its potential risks and benefits.

A major component of the informed consent process is that the responsible surgeon or surgeons who will be performing the procedure are identified to the patient. This point is relatively straightforward in a non-teaching or a private practice setting.

However, there are no specific requirements or guidance in terms of disclosure of the extent of participation of surgical trainees.

In fact, the practice of allowing trainees to perform procedures without specific patient consent - termed ghost surgery - is reportedly common in teaching hospitals, based on a detailed investigation in the state of New York.

The purpose of the current study was to examine the general understanding of and willingness to participate in the surgical education process among a group of 316 patients scheduled for a surgical procedure at a tertiary-level US Army hospital.

Patients completed an anonymous questionnaire which included specific scenarios for his or her surgical procedure, with escalating levels of trainee participation and training level (ie, post graduate year [PGY] level), along with corresponding decreases in the level of staff surgeon participation.

Martin and colleagues found that patients overwhelmingly preferred to be informed in terms of resident participation in their surgical procedure, regardless of whether they were undergoing a minor (87.5%) or a major (95.7%) procedure.

Most respondents (68.3%) believed they derived personal benefit from participating in resident training (68.3%), and almost all (87.4%) believed that their participation would benefit other patients.

Notably, most patients consented to having an intern (85.0%) or a resident (94.0%) participate in their surgical procedure.

However, when given specific, realistic scenarios involving trainee participation, major variations in the consent rate were observed. Affirmative consent rates decreased as the level of resident participation increased, from 57.6% for a junior resident assisting a staff surgeon to 18.2% for the junior resident operating unsupervised.

In an accompanying critique Ali Salim (Cedars-Sinai Medical Center, Los Angeles, California, USA) said while adverse effects on surgical training are clearly a concern, specific guidelines will ultimately have to be implemented.

"The consent process and level of disclosure of trainee involvement will become a more prominent issue because it lies at the core of the surgeon-patient relationship," he said.

By Andrew Czyzewski