The quandary of resident involvement in surgical procedures

The quandary of resident involvement in surgical procedures

Skill to do comes of doing.
-Ralph Waldo Emerson

We are in the last steps of getting surgery arranged; the counseling is complete and the consent is on the clipboard. Just as the patient is putting pen to paper, she asks, “When I’m asleep, you’re not going to let some trainee practice on me, are you? I mean, I wouldn’t let the brand new stylist cut my hair, right? I don’t want any residents involved!”

The patient sets down the pen and eyes me carefully. These can be uncomfortable conversations. I think back on the times my own family members have needed surgery. We all want “the best” for our loved ones.

I begin. “The operation requires two people to perform. I am right there for every part of the surgery. The resident does nothing without my direct involvement.” These statements are true, but she is not satisfied.

“Not good enough. How will I know for certain? I insist that there be no students or residents scrubbed in at all.” At this point, I need to decide if the proposed operation is one I can do by myself. If so, I might still proceed. The patient has put me in a box but she has the perfect right to make such a demand.

I start again. “I can’t know for certain,” I say, “but changing my usual routine for a complex procedure like yours might place you at some unnecessary risk.” She looks at me skeptically. “In any case,” I add, “I am certain that having a resident involved in your surgery is safe.” Despite having made this claim many times over the years, I have never really known if it is true.

Fortunately, a new research paper confirms that having residents participate in surgery is, indeed, safe.

A study of over 60,000 major operations (40,474 with residents and 20,237 without residents) performed between 2005 and 2007 did find that the resident cases took slightly longer (122 v. 97 minutes) and did show a slightly higher rate of “mild” complications such as superficial wound infections (3% v. 2.2%). Happily, there were no differences in postoperative deaths or major complications such as bleeding, re-operation, heart attack, blood clots, or postoperative length of stay. The resident group had slightly FEWER postoperative strokes. The authors conclude that “resident involvement in surgical procedures is safe.”

One of the things I love most about my career is that I have the opportunity to teach head and neck surgery to the next generation of young physicians. I love seeing the spark of recognition when a young physician finds and hones skills that she or he never knew they possessed. I enjoy watching them find real-world ways to connect theory to technique. I am humbled that there are people all around the country whose lives have been touched by one of the 80 ENT physicians who I have helped train over the past 25 years. I am very proud of our graduates.

My patient thinks for a moment then signs the surgical consent. “Just keep an eye on them.”

“Absolutely,” I assure her. Had she persisted with her objection, I would have had to decide whether to proceed. Over the years, there have been a few situations where I have refused to perform an operation. That has not happened often.

Knowing that our system safely trains young surgeons is comforting. Someday in the not too distant future, the odds are that I will probably need surgery myself. It is great to know that the students and residents training today will be ready to safely help me when that day arrives.

Bruce Campbell is an otolaryngologist who blogs at Reflections in a Head Mirror.

Image credit: Shutterstock.com

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  • Dr. Vibash Wijeratne

    My heartiest congratulations to the writer,

    Great Attitude! Great Teacher!

    Students need to evolve through the mill to be teachers one fine day.

    It says there are no bad students, there are only bad teachers!

    Good luck!

  • http://www.facebook.com/shirie.leng Shirie Leng

    Patients coming to academic medical centers are expecting cutting-edge care but they have to understand that it’s a teaching institution. Patients who demand attending-only service should go to a private hospital. I

  • PatientA

    As a patient, I would be worried if my attending physician had never performed an operation as a resident!

  • Doug Capra

    “We are in the last steps of getting surgery arranged; the counseling is complete and the consent is on the clipboard. Just as the patient is putting pen to paper, she asks, “When I’m asleep, you’re not going to let some trainee practice on me, are you? I mean, I wouldn’t let the brand new stylist cut my hair, right? I don’t want any residents involved!””

    This introduction implies that the patient hasn’t even met the resident. I think this is a key to communication, getting true informed consent, and helping the patient feel more comfortable. I assume this is done in many if not most cases, but perhaps not. The surgeon should find the time to introduce the resident to the patient. This process should not wait until “the last steps of getting surgery” are happening. For the patient, “counseling” may not be complete until an introduction has happened. Some patients need this personal touch more than others. Before the surgery begins, is the patient introduced to the team at some point — everyone who will be in the OR and working on him/her? Medical professionals may do this kind of work every day, but many if not most patients don’t experience this every day and may need a sense of who the people are who will be working with them.

    One person responds: “Patients coming to academic medical centers are expecting cutting-edge care but they have to understand that it’s a teaching institution. Patients who demand attending-only service should go to a private hospital. ”

    Regardless of whether the institution is a teaching hospital or not — patients are not objects whose main purpose is to train medical students. Most patients understand doctors need to be trained by doing, especially surgeons. Most reasonable people will allow this training to happen. It’s how the system goes about letting it happen that matters. Respect and Dignity have meaning, and perhaps they mean that patients are human beings who deserve to be treated as such. High tech and cutting edge will never replace good, empathetic communication.

  • Peggy Zuckerman

    “Slightly longer” operations with residents, with stats going from 97 minutes to 122 minutes? That is a 25% longer time for surgery, with all the resultant risks, etc. That may be safe in most cases,but it is not inconsequential.

  • ninguem

    When I was in academics, the policy backed up by the department chairman, was that such requests “no trainee involvement”, were flatly denied. Not even an attempt to accommodate. There’s a certain quality the person wants, to go to an academic center in the first place. It has that quality BECAUSE of the trainees.

    Suddenly asking the system to change routine to satisfy such whims, is like asking the surgeon to operate with the opposite non-dominant hand.

  • Suzi Q 38

    I remember asking a doctor if he was a student.
    He told me he was the anesthesiologist (I was having a LP).
    I told him that I just did not want a student poking in my back.
    He explained that with the students, the doctors are more careful than usual.
    i will admit that this changed my thoughts on this subject.

  • http://twitter.com/drstephenweber Dr. Stephen Weber

    Thank you for the post. This was a common concern, when I worked at an academic medical center. One of my partners explained this very well to his patients. He stated that residents were involved to an appropriate degree with all of his cases. His outcomes were very, very good. He would then state that the worst thing a patient could do would be to demand that he do something different than what had been working so well and had been providing patients with great oncologic outcomes. Most patients saw the logic in this. Patients are afraid and a lack of information, or misinformation, can cause unnecessary suffering. Knowing that trainees will be supervised and only allowed to participate to a degree justified by their level of training/ skill is usually highly reassuring.

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