Preoperative Disclosure of Surgical Trainee Involvement: Pandora's Box or an Opportunity for Enlightenment?

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In its landmark 2001 report, Crossing the Quality Chasm, the Institute of Medicine named patient-centered care as 1 of the 6 fundamental aims of the United States health care system.1 They define patient-centered care as “health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.” In the field of surgery, where the patient is particularly vulnerable as they are often sedated during an operation, nowhere is shared decision-making between patient and surgeon more evident than in the process of informed consent. Informed consent includes 3 elements: (1) disclosure by the surgeon of pertinent information regarding the diagnosis and an explanation of the operation, alternative therapies, and the risks and benefits associated with each; (2) assessing that the patient fully understands the information by providing them the opportunity to ask questions and clarifying misunderstandings; and (3) allowing the patient to synthesize the information they have received from both the surgeon and other sources until they have reached their own decision.2 However, an often undiscussed—yet ethically imperative—aspect of the informed consent process is the disclosure to the patient of the fact that (and of the extent to which) trainees will participate in their care.3
Whether the dialogue is initiated by the patient or the surgeon, the issue of trainee involvement is sensitive. Indeed, prior studies have found that surgeons often avoid disclosing the extent of resident support in patient care for a variety of reasons, including the fear of provoking anxiety and of lengthening the informed consent discussion.4 Despite these fears, however, patients are actually more receptive to trainee involvement than attending surgeons perceive. A survey of the general public found that 96% of respondents welcomed resident participation.5 In this study, the vast majority of residents, faculty, and administrators felt that the inclusion of residents improved the quality of patient care, and only 3% of patients disagreed. These sentiments are likely reflective of patient views of resident assistance in the postoperative phase of care, as they are more likely to express concerns when the topic of trainee participation in an operation is approached.5,6
This is a challenging time for us all in the field of surgery. We must make good on our promise to deliver high-quality, patient-centered care, in which patient autonomy is not only respected but also encouraged. This requires surgeons to respect a patient's right to refuse resident involvement in their operation. At the same time, we must also make good on our pledge to society, and to our resident trainees, to deliver high-quality, resident-centered education, in which resident autonomy is respected and encouraged by both patients and faculty. This requires patients to respect a surgeon's right to refuse to perform their operation without a trainee in elective situations. In an effort to deliver on our obligations to both patients and trainees, surgical departments must fully embrace several implicit responsibilities that will help to ensure that everyone benefits from a highly skilled surgical workforce.
First, we must be transparent during every preoperative patient encounter in our disclosure of the resident's role in the operation and also the postoperative phase of care. This exchange should convey the degree of autonomy that the resident will have during key portions of the operation and how the attending surgeon will supervise their work. An early and direct conversation with the attending surgeon is the most effective strategy.
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