SGO Ethics Series: Discussing Trainees During Surgery with Patients | Claire Hoppenot, MD
Claire Hoppenot, MD
My grand rounds as a fourth-year resident were about consent and teaching during surgery; it is an ethical question dear to my heart. So, I was particularly disappointed recently when a patient asked me, as I had my hand on the door at our postoperative visit, “One more question, Dr.Hoppenot, who did my surgery?”
We had already had differences of opinion, since I had been encouraging her to stop her estrogen replacement while we worked up a uterine mass. She has now undergone a D&C for a pedunculated intracavitary fibroid, so the news was supposed to be only positive that day.
“I looked at the operative report, and your note said you agreed with that other doctor.”
My resident note addendum also states I was present and participated in all parts of the procedure. I could explain that my resident got lost coming to our outpatient clinic and didn’t get a chance to meet her preoperatively, but what matters is that I clearly had not discussed resident involvement as thoroughly as I should have.
As a dedicated resident educator and attending in an academic as well as safety-net hospital without another option for surgical assist, I do worry about patients asking not to having residents be part of the operation. Anecdotally, this has happened only once or twice, but there is some data supporting my concern. Wisner et al asked ophthalmology patients if they would have allowed residents to assist or do the surgery; though 84% agreed to have residents assist, a scary 51% would have refused to have a resident do the surgery.1 Up to a quarter would have even changed providers if they had known residents were involved. (Interestingly, much of the literature comes from ophthalmology, a field that, similar to obstetrics, often operates with awake patients.) A survey in general surgery suggested that over 90% of patients find it important to help in the education of future surgeons, but 32% didn’t want trainees participating in their surgery.2 For many academic institutions, however, talking about trainee involvement is not as much about consent as about disclosure, as trainees are the only assistants available for surgery, which changes some of the timbre of the discussion.3
As in most situations, transparency remains the best option to improve patient comfort with and understanding of trainee involvement. Studies again have supported this. Surveys suggest that patients want to be told about trainee involvement, or even presence in the room, at the time of surgery.1, 3, 4 In another study from ophthalmology, patients who didn’t remember being told about trainees were much more likely to be upset to find out that residents would be part of their surgery than those who remembered the discussion.4 Frustratingly, in this study, despite surgeons reporting that they addressed trainee involvement preoperatively, 17 of 50 patients did not remember the discussion.4
So it again comes back to communication. Surveys are great, but ultimately they take patients out of the clinical environment. One last study in ophthalmologic surgery looked at how we talk about trainee involvement.5 Gan et al trialed three different scripts to see if the uptake of resident involvement differed based on the counseling,5 and not surprisingly, it did. The winning script included factors noted to be reassuring to general surgery patients regarding trainee involvement in a separate qualitative study; these include an explicit statement of trainee involvement, a description of the trainee activities, endorsement that the trainee has experience with the task, a statement of supervision, an expression of teamwork, and reassurance regarding the safety of resident involvement.3, 6, 7
I have always assumed it was my job to have this discussion with patients. Miller et al agree based on research with general surgery patients.3 But a qualitative study in the context of abortion procedures advocates for third-party involvement in the trainee discussion to prevent undo coercion from the trainee or the trainer.8 Their patients also preferred for the discussion to occur while they were fully clothed and outside of the procedure room. As in the context of abortion, our cancer patients are in a difficult situation and often feel that they are stripped of power to make decisions by their diagnosis; coercion is the last thing we aim to do. Yet we are lucky to generally have the time to address trainee involvement in clinic and to build a rapport. In this context, I do feel that I am the best situated to discuss the surgery that I will be performing and the role of others in the room. However these findings have led me to consider whether nursing colleagues who formalize the consent signature in preop should have some more support and training in discussing trainee involvement.
I was again thrown for a loop when my institution just recently added a new part of the standard consent forms specifically regarding “examinations or invasive procedures for educational and training purposes” including pelvic exams. While I include “exam under anesthesia” to most procedures that I do, I did not explicitly bring up the educational nature until now. I generally try to get trainees involved in parts of the procedure that are medically necessary (finding the cervix before placing a manipulator or a pelvic exam prior to cervical dilation to assess the orientation of the uterus), but I also use portions of the procedure for education, for example to practice considerations of route of surgery and physical exam skills. I have had calls from emergency room physicians and hospitalists that have made me wish they had done more physical exams in the past, so I do believe it is an important part of training for medical students planning to enter other specialties as well.
A commentary in Obstetrics and Gynecology reviews why an EUA by a trainee requires explicit consent.9 The argument for explicit consent lies in two parts. First, the educational, rather than therapeutic, purpose of the examination. Educational procedures by trainees are not covered by the general trainee consent. Second, and perhaps more important, is respect for a patient’s autonomy as well as working within a framework of trauma-informed care, acknowledging that pelvic examinations are intrusive for many patients even when fully awake. I was struck by the emphasis that training future generations of doctors is our responsibility, not a burden to place on
patients. I also recommend reading their recommended sample language on how to discuss exam under anesthesia with patients.9
In conclusion, I am constantly trying to improve, and here are some of what my experiences and research for this post are leading me to consider adjusting.
- My consent process includes written information for the patient (outside of the official consent document). I am adding a section about who will participate on the surgical team, in part to trigger the discussion during a busy preoperative visit
- Incorporating aspects of the scripts in the studies above to better describe what residents will do
- Considering a separate/second preop visit, especially if the surgery is further out, due to difficulty with retention of the deluge of information
- Patients sign consents in preop, but these are conversations that I first have in the office. Maybe I can leverage the two-part discussion to prevent coercion for trainee involvement in educational procedures (such as exam under anesthesia).
- Practicing how to address patient refusals of trainee involvement, especially as I don’t have another option for surgical assistant.
References
1. Wisner DM, Quillen DA, Benderson DM, Green MJ. Patient attitudes toward resident involvement in cataract surgery. Arch Ophthalmol. 2008;126(9):1235-9.
2. Cowles RA, Moyer CA, Sonnad SS, Simeone DM, Knol JA, Eckhauser FE, Mulhollan MW, Colletti LM. Doctor-patient communication in surgery: attitudes and expectations of general surgery patients about the involvement of education and surgical residents. J Am Coll Surg 2001;193(1): 73-80.
3. Miller A, Prasad K, Quach WT, Lin GT, Smetak M, Langerman A. Talking with Patients about Surgical Trainees. J Clin Ethics. 2023 Spring;34(1):98-102. doi: 10.1086/723315. PMID: 36940349.
4. Vallance JH, Ahmed M, Dhillon B. Cataract surgery and consent: recall, anxiety, and attitude toward trainee surgeons preoperatively and postoepratively. J Cataract Refract Surg 2004;30:1479-85.
5. Gan KD, Rudnisky CJ, Weis E. Discussing resident participation in cataract surgery. Can J Ophthalmol 2009;44:651-4
6. A. Arambula, K. Bonnet, D.G. Schlundt, and A.J. Langerman, “Patient Opinions Regarding Surgeon Presence, Trainee Participation, and Overlapping Surgery,” Laryngoscope 129, no. 6 (2019): 1337–46.
7. M.M Naguib et al., “Patient Perceptions of Resident Involvement in Surgery: A Qualitative Study Using Surgical Video,” Journal of Surgical Education 79, no. 4 (2022): 974–82.
8. Crystal-Ornelas L, Sarnaik S, Dianat S, Dehlendorf C, Holt K. Consent for trainee participation in abortion care: A qualitative study of patient experiences and preferences in the United States. Contraception. 2023 May;121:109974. doi: 10.1016/j.contraception.2023.109974. Epub 2023 Feb 8. PMID: 36758737.
9. Cundall, H. , MacPhedran, S. & Arora, K. (2019). Consent for Pelvic Examinations Under Anesthesia by Medical Students. Obstetrics & Gynecology, 134 (6), 1298-1302. doi: 10.1097/AOG.0000000000003509.
Claire Hoppenot, MD, is a gynecologic oncologist at Baylor College of Medicine in Houston, TX.