Friday, April 20, 2012

Who is Performing Your Surgery?

This is a legitimate question. Is it an expert attending physician who has performed over a thousand cases? Or is it a resident physician who has performed five? If you could choose, who would you rather have? Should you have a choice? Do certain people deserve to have a choice while others don’t?

Here is the problem: surgeons must be trained, but training them is risky. Who should bear that risk? Who should be a resident’s first case? Should it be a volunteer? Or should it be an unwitting patient who has no idea they are about to be a young surgeon’s first case? When you sign permission for your surgery, do you deserve full disclosure about whether or not a trainee will be operating on you? Do you deserve the right to opt out of having a trainee operate on you?
Well, let me tell you how things really are.
Every expert surgeon began with their first case. Every expert surgeon had more complications when they were beginners, and then they got better over time. We call this the learning curve. Patients who find themselves at the beginning of a surgeon’s learning curve are at a greater risk of having a poor outcome or complication. That’s just how it is. There are ways to reduce this risk, but the risk will always be there. Take any teaching hospital and see if you can find their morbidity and mortality statistics. I’ll bet you anything the worst months are July and August. Why? Because that’s when the new first-year residents start taking care of patients.
So how risky is it to be at the beginning of a surgeon’s learning curve? The risk of the learning curve is the pink elephant in the room. Institutions that train residents are often reluctant to study it or measure it because if word gets out that the risk is large, they will lose customers. And they don’t like to explicitly inform their patients about the degree of resident involvement because most patients in their right mind would want to opt out of a trainee performing procedures on them. But if patients all refuse to allow trainees to be involved in their care, how can we possibly train our young surgeons?
So how does our current system handle this problem? Here are the strategies currently employed:
1)      Be as vague as possible about the level of resident involvement in surgeries so as not to scare away patients. Some attending surgeons don’t mention it at all. Others bury the facts in the fine print of the consent forms. Very few take the time to explicitly explain the degree of trainee involvement and whether or not this imposes any increased risk.
2)      Try to shift most of resident training over to county hospitals or similar types of systems where the patients don’t really have much of a choice about their care. These captive patients are less likely to ask tough questions about who their surgeon is because they are just happy someone is doing their surgery. And they can’t go elsewhere to get their care even if they want to.
3)      If someone tries to buck the system by saying the above strategies are unethical and a form of social injustice, ignore them, or minimize their concerns by justifying the means with the obvious need to train our surgeons.
Tell me, do you think it is ethical to force the uninsured, under-insured, or underprivileged patient populations to bear the brunt of the risk of the surgical learning curve? Or should this risk be spread evenly across the population?
Do you think every patient deserves to be explicitly told whether or not a trainee is operating on them? Or is it okay to hide this fact from patients?
Society has a dilemma here, and in my humble opinion, we aren’t handling it fairly.

1 comment:

D Smith said...

Excellent article! I for one never gave it a second thought if a trainee was performing my surgery... and I have had many of them. In reading your article, it gave me pause to think about this question. I think that surgeons should disclose that a trainee will be in attendance and even assisting, but it should also fall upon the surgeon to assure the patient that he will be the primary surgeon and that the trainee will be assisting. After all, as you pointed out, they have to start somewhere. Thanks for this insightful article!