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.

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