The answer to "who's doing my surgery"?

[TulipsAndSunscreen]

So something I've been thinking about a lot lately - when patient's ask who is doing their surgery at academic medical centers, the party line is for the resident/fellow to say "I will be assisting Dr. [attending] with the procedure". Now, clearly the attending is in a supervisory role and depending on the surgery may do almost all/most/some of the procedure. But in some cases, especially with simple things or "bread and butter" surgeries, residents are much less supervised or they do the majority of the case. Now in some cases, the residents may be even more familiar with these surgeries since they do them every day but in other cases, it's the first one they've ever done (obviously more closely supervised).

I don't think patients know this. Should they?

Setting aside that of course a doctor has to learn/practice the procedures and activities of a surgeon, is it ethical for patients to be unclear about the extent of participation that a training physician is taking in their care?

[Vanquisher]

It is spelled out in their consent forms that no one reads. The attending is ultimately liable and responsible. I don't know. Tough question.


Heidi

[TulipsAndSunscreen]

It's especially difficult for surgeons where the patient is asleep. If I'm awake, I'm aware visually that a resident is participating in my care and to what extent. But in surgery, that's not the case. I want to be clear, there's nothing wrong with residents learning to do surgery at academic medical centers but I just don't know that patient's always understand that when their community doctor refers them to prestigious Dr. XYZ at the academic center that it's likely residents doing the procedure.

[SoonerTexan]

Legal, yes. Unethical...hard to say but it is sure pretty damn close to the line

[Pollyanna]

Interesting question. Most people have no idea about the specifics of medicine. I have some well educated friends (PhDs in engineering) that were actually shocked that their family practice guy didn't do surgery. They knew there were different specialties but really didn't get the specifics. You know, folks see Grays Anatomy and think that's reality.

Like Heidi said, it's in the consent, no one hides the fact that they are at a training hospital. I'm not sure that physicians have the time to get into the specifics of who is in the OR and who is doing what. It's just too complicated. "Well MrsN, DrS will be closing, he's a second year. We have MsH on the retractor, she's a med student but has great stamina with the retractors, I might let DrS do the incision if he is fully prepared for the surgery..," I'm just not sure how you fully get the patient to grasp the complete picture of what happens in the OR. And then heck, you have anesthesia, they have to come in and explain who their residents are, etc, etc.

Anyway, will love to hear other peoples opinions here. A thought provoking question for sure!!

[WolfpackWife]

I agree, I don't think enough patients understand that either. But I think it goes further - a lot of patients don't understand what they are embarking on when they enter a teaching hospital, or that they are even *in* a teaching hospital/what that actually means. It's par for the course to have multiple levels of docs-in-training (and out of it) have a hand in your care, but I don't think a lot of patients really understand what's going on and that when they are having surgery...well, part of being at a teaching hospital is that the surgeons-in-training have to learn somehow!

Part of that is, I think, ambiguity on the part of the hospital system/team, and part of that is from the lack of motivation on the patient's part to inform themselves of who everyone on their team is/what their role is. Like Heidi said, it's outlined in the forms and if you're not reading those, well, that's sort of on you. I don't know if it should be explicity outlined and discussed elsewhere.

Like LSW said, for more informed patients who know what's what...I think it's perfectly reasonable to say "I don't want to be part of fresh-out-of-intern-year Dr. Babyface to operate on my back. Get someone dumber." One of the women I work with is married to a Uro resident here and when she went into labor, her husband was EXPLICIT that an attending administer her epidural. He was like "sorry, I know y'all need to learn, but it's not going to be on my wife". I don't know if that would become a slippery slope but...like someone said, it's a tough question.

[Pollyanna]

I will say that around here every member of the team comes into your room and introduces themselves, gives their title, asks you your name and birthday, talks about what they will be doing, and asks if you have any questions for them. It's almost too much but it is probably great from a risk management and quality assurance stand point. So truly, if I had any concerns going into my kidney surgery last year I had many people to ask questions of. I wasn't and didn't. I trusted my surgeon and anesthesia team so I was good to go.

[TulipsAndSunscreen]

And to further complicate the issue - there are times when you'd WANT the resident to be the one operating. I know of a case where a (VIP) patient INSISTED the chair of the department do his surgery (not at DH's institution, where DH was a med student) and while the patient was under, the chair was like, this is so silly, I haven't done this type of case in 10 years because it's not the kind of case I specialize in. He tried to explain that to the patient (who had a great outcome btw) but the patient wanted "the best" and "the most senior surgeon" doing his surgery.

[Vanquisher]

Oh exactly!!! It's funny, when DH was an intern they'd have patients insist on plastic surgery instead of the more senior resident or the ED doc to stitch their laceration, and they'd get DH cause he was on his plastics rotation. Anyway, yes, I'd absolutely want the person who had the best outcomes doing my procedure. I don't always agree that that's doing the most of them though. Ahem, I know some real hacks.


Heidi

[scrub-jay]

A slight tangent, but many patients have no idea that their "anesthetist" for surgery is a nurse, not an anesthesiologist. This is especially important where CRNAs (Certified Registered Nurse Anesthetists) can practice independently without any anesthesiologist oversight. They are billed for "anesthesia services" just the same. You'd have to just know that an anesthetist is not a physician.

[SoonerTexan]

^^that exact thing happened to my MIl. She was a radiation oncology resident on her surgical intern year and it was the first day of her plastic surgery rotation. Parents wanted the plastic surgery resident to do it. The chief resident had wayyy more experience, but they were adamant, so the chief walked her through it.

So if I ever need stitches on my face I'm asking for whoever has the most experience!

[DrBandMe]

I'm still unsure what I want when it will come to my pain meds in labor OR my central line. Part of me wants to show faith in our friends and the training my husband is getting but, at the same time, I know how much he doesn't know so I can't stomach the thought of a PGY-2 on his first OB rotation doing anything to me. Maybe a PGY-4...maybe.

[OrionGrad]

I will say that around here every member of the team comes into your room and introduces themselves, gives their title, asks you your name and birthday, talks about what they will be doing, and asks if you have any questions for them. It's almost too much but it is probably great from a risk management and quality assurance stand point.

That's how it is here, too. There's plenty of time for patients to ask specifics about what each person is doing. Of course, I doubt most people actually ask. I've also always been given the option of having a resident or not, although that might be because my husband is also a resident at the sand institution??

I've seen A LOT of residents over the course of 2 pregnancies, multiple biopsies, and 1 surgery at an academic hospital in the last 4 years. The only iffy experience I've had was at the very tail end of my labor. A junior resident was taking a long time figuring out how dilated I was, and I just remember the nurse YELLING at her to hurry up because I didn't have an epidural and I was ready to push. I really appreciated the nurse, but I remember feeling bad for the resident, too.

Anyway, all that to say I'm sure it varies from institution to institution, but they do a pretty good job here of making people aware of how involved residents will or won't be in their care.

[DrBandMe]

Why do you need a central line?

I'm an impossible stick and people finally believe me after my ER trip and a bunch of terrifying details I won't go into again. So we had an anesthesia consult and they feel that's the best course of treatment for me while in labor.

Fun, right?

[DrBandMe]

I'm pretty sure they decided on an IJ. They discussed the PICC and even like a shorter PICC (they called it something but I don't remember now what) and decided to go with an IJ. I think. I was sorta in a daze thinking about what exactly they were gonna do to me and how terrifying it all sounds so hubby did most of the talking. Now I feel like I should ask my OB again to be sure.