Soroush Shabani, Class of 2020
A surgical procedure is a very stressful period in a patient’s life. The potentially life-threatening nature of invasive surgeries drastically shapes the surgeon-patient relationships. The almost complete transfer of autonomy to physicians inherent in surgical procedures emphasizes the moral obligations implied in the surgeon-patient relationship (1). People naturally look to the reputation of the institution and the surgeon, such as education, awards, and years of experience, as a natural way to calm themselves. In return, these patients naturally invest more trust within their doctor. Therefore, it begs to question whether it is ethical to allow residents to perform operations on patients as a form of training.
To fully understand the ethical dilemma of allowing residents to participate in surgeries, it is important to understand their range of roles during an operation. An attending physician first demonstrates how the surgery is done. Once the attending believes the resident is competent in the procedure, the attending will let the resident mimic simple portions of the operation while verbally guiding the resident. In a more complex procedure, the learning is more protracted, and the resident can perform on small parts of the procedure. Eventually, the resident will be allowed to perform the entire procedure while the attending proctors. This strategy of learning is common in virtually all surgical disciplines (4).
Many surgeries at academic hospitals are operated with residents as a form of education and practice. Although patients may meet the residents that perform on them, a study found that residents spend only around 10% their time with patients (3). In a traumatic time, this 10% may not be enough for the patient to develop a sense of trust in the resident. In fact, a study focused on gynecology found that patients do not fully understand the role of residents and are uncomfortable with having them operate with attending supervision (2). The decision to inform patients that a resident will be taking part in the surgery is specific to each hospital as there is no governmental or ethical regulation requiring so (4). However, United States courts have universally recognized that, except for emergency situations, the relationship between a doctor and a patient is contractual in both implied and expressive dialogues (4). Therefore, although attendings are not legally required to disclose the role of residents in a patient’s surgery, the attendings are still held accountable for their actions and any affiliates’ during the operation.
Although it seems that academic institutions are disadvantageous with their use of residents during operations, many independent publications have emphasized a contrasting reality. A study by Dr. David Shahian evaluated the outcome of over 1.5 million Medicare patients, from 2009 to 2010, experiencing three common health issues including heart attacks, heart failure, and pneumonia. The study found that patients treated at academic hospitals with residency programs were at a 10% reduced risk of mortality than at independent organizations (5). Another study by Dr. Stephen Yang compared the outcomes for lung cancer patients at teaching hospitals and nonteaching hospitals using the National Inpatient Sample database. The study found that there was less mortality and complications at academic hospitals. Across different surgical fields, introducing surgical residency programs involved in patient procedures leads to better outcomes than at private institutions (5).
The trends of better patient outcomes at academic institutions follows the inherent benefit at academic institutions: academic hospitals are actively at the forefront of medical research and the centers for rare cases. Although patients must deal with stressful moments and invest a great deal of trust in their doctors, teaching the residents forces the attending surgeons to remain current with recent literature. In a way, this method of teaching residents creates a vibrant intellectual environment that further encourages advancement and progress in medicine. Therefore, although a patient will be frightened to realize that a resident might operate on them, this very practice will result in a better outcome for them and concurrently lead to further medical progress.
References
To fully understand the ethical dilemma of allowing residents to participate in surgeries, it is important to understand their range of roles during an operation. An attending physician first demonstrates how the surgery is done. Once the attending believes the resident is competent in the procedure, the attending will let the resident mimic simple portions of the operation while verbally guiding the resident. In a more complex procedure, the learning is more protracted, and the resident can perform on small parts of the procedure. Eventually, the resident will be allowed to perform the entire procedure while the attending proctors. This strategy of learning is common in virtually all surgical disciplines (4).
Many surgeries at academic hospitals are operated with residents as a form of education and practice. Although patients may meet the residents that perform on them, a study found that residents spend only around 10% their time with patients (3). In a traumatic time, this 10% may not be enough for the patient to develop a sense of trust in the resident. In fact, a study focused on gynecology found that patients do not fully understand the role of residents and are uncomfortable with having them operate with attending supervision (2). The decision to inform patients that a resident will be taking part in the surgery is specific to each hospital as there is no governmental or ethical regulation requiring so (4). However, United States courts have universally recognized that, except for emergency situations, the relationship between a doctor and a patient is contractual in both implied and expressive dialogues (4). Therefore, although attendings are not legally required to disclose the role of residents in a patient’s surgery, the attendings are still held accountable for their actions and any affiliates’ during the operation.
Although it seems that academic institutions are disadvantageous with their use of residents during operations, many independent publications have emphasized a contrasting reality. A study by Dr. David Shahian evaluated the outcome of over 1.5 million Medicare patients, from 2009 to 2010, experiencing three common health issues including heart attacks, heart failure, and pneumonia. The study found that patients treated at academic hospitals with residency programs were at a 10% reduced risk of mortality than at independent organizations (5). Another study by Dr. Stephen Yang compared the outcomes for lung cancer patients at teaching hospitals and nonteaching hospitals using the National Inpatient Sample database. The study found that there was less mortality and complications at academic hospitals. Across different surgical fields, introducing surgical residency programs involved in patient procedures leads to better outcomes than at private institutions (5).
The trends of better patient outcomes at academic institutions follows the inherent benefit at academic institutions: academic hospitals are actively at the forefront of medical research and the centers for rare cases. Although patients must deal with stressful moments and invest a great deal of trust in their doctors, teaching the residents forces the attending surgeons to remain current with recent literature. In a way, this method of teaching residents creates a vibrant intellectual environment that further encourages advancement and progress in medicine. Therefore, although a patient will be frightened to realize that a resident might operate on them, this very practice will result in a better outcome for them and concurrently lead to further medical progress.
References
- Axelrod, David A. “Maintaining Trust in the Surgeon-Patient Relationship.” Archives of Surgery, vol. 135, no. 1, 2000, p. 55., doi:10.1001/archsurg.135.1.55.
- Cantor, Arielle, et al. “Do Patients Understand the Role of Resident Physicians in the Operating Room? A Survey of Gynaecology Patients.” Journal of Obstetrics and Gynaecology Canada, vol. 40, no. 1, Jan. 2018, pp. 24–28., doi:10.1016/j.jogc.2017.05.036.
- Mamykina, Lena, et al. “How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers.” Academic Medicine, vol. 91, no. 6, 1 June 2017, pp. 827–832., doi:10.1097/acm.0000000000001148.
- Miloro, Michael. “Should Patients Be Told of Resident Role in Their Surgery?” Journal of Oral and Maxillofacial Surgery, vol. 58, no. 6, 2000, pp. 652–653., doi:10.1053/joms.2000.6210.
- Webster, Hannah. “Is Surgery Safer at a Teaching Hospital?” U.S. News & World Report, U.S. News & World Report, 27 Oct. 2014, health.usnews.com/health-news/patient-advice/articles/2014/10/27/is-surgery-safer-at-a-teaching-hospital.
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