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.4,6 A study examining different techniques of obtaining informed consent for cataract surgery demonstrated that patient consent to resident involvement in their procedure is significantly higher when full disclosure through a personal conversation with the attending surgeon occurs.4 These findings were corroborated in a survey of Massachusetts surgeons, which found that in 84% of the cases in which a patient expressed concerns regarding trainee participation in their operation, they ultimately agreed after further discussion with the attending surgeon.6 These surgeons noted success with one or more arguments, including the benefit of improved quality of care with resident participation, the ethical need to train the next generation of surgeons, and the impracticality of attempting to perform an operation unassisted.6
This conversation should be properly documented in the patient's medical record with a statement regarding the exact role of the resident in the operation and, if known preoperatively, the name of the resident. In doing so, the attending surgeon achieves 3 important goals—demonstrating respect for patient autonomy, initiating a discussion about the appropriate degree of resident autonomy for that case, and strengthening her/his medicolegal position. In fact, the Centers for Medicare and Medicaid Services recently initiated a national project to “increase the attention and effort that hospitals dedicate to supporting high-quality informed consent.”7 The disclosure of trainee involvement should certainly be a quality metric included in their effort.
Next, trainees must participate in all phases of surgical care. It is not difficult to understand why a patient may be surprised, even concerned, when the first person whom they encounter on the morning of surgery is an unfamiliar trainee. Instead, resident physicians should be the first person they meet during their preoperative clinic visit. The traditional Halstedian apprenticeship-model of surgical training, which promoted resident participation in all phases of patient care as they were mentored by a single surgeon, has decreased significantly due to duty-hour restrictions and the increase in surgical sub-specialization. A detailed analysis of surgical resident rotations found that residents actually have many underutilized opportunities to enhance continuity of care.8 In this study, apprenticeship-model rotations increased continuity of care to a level near that of attending surgeons.8 Surgical programs today should make a concerted effort to incorporate apprenticeship-model rotations in which residents train with high-volume surgeons across the continuum of residency training. This would promote progressive operative autonomy while ensuring that a large number of patients encounter a trainee during the preoperative visit.
In the modern day service-model rotations, several logistical changes should be considered to optimize resident-patient continuity of care: (1) the Accreditation Council for Graduate Medical Education (ACGME) outpatient clinic requirement should be fulfilled by utilizing residents in clinics in which they will assist in the operations performed on patients they encounter; (2) resident operating room assignments should be made with consideration of who performed the preoperative history and physical; and (3) electronic medical record software developers should incorporate systems to alert trainees of when their patients are scheduled for follow-up appointments with the attending surgeon.8 Despite our best efforts, there will inevitably be situations in which resident continuity of care is not maintained. However, implementation of the aforementioned strategies will increase the presence of other trainees during the continuum of care, which may still aid in fostering patient understanding and acceptance.
Finally, it is imperative that as surgical training moves toward competency-based education that we develop a standardized system to measure and track resident progression. The General Surgery Milestone Project, which is a joint collaboration between the ACGME and the American Board of Surgery (ABS), began the effort by outlining the milestones that residents should achieve as they progress through training to become proficient in key elements of physician competency. This system provides a global sense of resident progression, but is not useful in conveying an individual resident's skill level to the patient. The next phase, which must be an effort led by national organizations including both the ACGME and the ABS, should organize common general surgery operations into Entrustable Professional Activities (EPAs). EPAs are discrete tasks or responsibilities that supervisors entrust to trainees once they have obtained proficiency and are used to ground competencies in day-to-day practice.9 Successful implementation of such a system will require the standardization of validated objective assessments of both technical and nontechnical skills, as it relates to the specific EPA by supervisors educated in formative assessment techniques.10 This system would provide the attending surgeon with invaluable information regarding an individual resident's proficiency level for a given operation that will allow them to grant the trainee the appropriate amount of autonomy while ensuring the best possible outcome for the patient. This information may also be utilized during the informed consent discussion, as previous studies note that patients are more likely to permit greater resident autonomy in their operation if they can be assured similar outcomes.5
In summary, although surgical trainees are an integral component of the American health care system, resident participation and autonomy are often not directly discussed with patients by attending surgeons. The surgical community must work together with other medical organizations and patient advocacy groups to generate feasible solutions that improve patient understanding and acceptance of resident involvement in their care, in and out of the operating room. We should not consider the disclosure of trainee participation during the informed consent process as the opening of Pandora's Box. Instead, it should be embraced as an opportunity to meet our ethical imperative of respect for patient autonomy and our societal duty of training the next generation of surgeons.
1. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academic Press; 2001.
2. Childers R, Lipsett PA, Pawlik TM. Informed consent and the surgeon. J Am Coll Surg
3. Council on Ethical Judicial Affairs of the American Medical Association. Medical students’ involvement in patient care. J Clin Ethics
4. Sharda RK, Sher JH, Chan BJ, et al. A comparison of techniques: informed consent for resident involvement in cataract surgery. Can J Ophthalmol
5. Kempenich JW, Willis RE, Rakosi R, et al. How do perceptions of autonomy differ in general surgery training between faculty, senior residents, hospital administrators, and the general public? A multi-institutional study. J Surg Educ
6. Counihan TC, Nye D, Wu JJ. Surgeons’ experiences with patients’ concerns regarding trainees. J Surg Educ
8. Turner JP, Rodriguez HE, Daskin MS, et al. Overcoming obstacles to resident-patient continuity of care. Ann Surg
9. Ten Cate O, Chen HC, Hoff RG, et al. Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Med Teach
10. Ghaderi I, Manji F, Park YS, et al. Technical skills assessment toolbox: a review using the unitary framework of validity. Ann Surg