October 17, 2011

Not On My Body! The Dirty Secret of Surgical Training

It's the resident's responsibility the morning of surgery to check on the patient in the pre-operative area, make sure there's a current history & physical, make sure surgical consent has been signed, ensure the surgical site is marked, etc. It's often one of my favorite parts of the day. It puts a face to the person in front of you in the OR, humanizes them after the yellow iodine has been slapped on and the surgical drapes have been placed. Most of the time, it's the first time I'm meeting the patient and it reminds me of how important it is to be meticulous and thoughtful in the operating room. There's often some good-natured banter to soften the patient's nerves. I have a fairly consistent spiel I give when I first walk up.

"Good morning, I'm Dr. MedZag, one of the surgery residents. I'll be helping out with your surgery today."

Some small talk typically follows. I may explain to them what's going to happen during their surgery, or what to expect following it, or let the family know how long the operation is going to last. Many patients are curious about residency and what that actually means I am. I explain that it means I have completed medical school but this is part of my post-graduate training. A mentorship or discipleship, of sorts. I have a medical license but am not board certified. Many people ask how long it lasts. I explain that for the surgical fields, it's between 5 and 7 years, and many of us go on to do fellowships afterwards. "Oh wow, that's a long time!" is the common response. "Well, they don't let us go out and start operating on people without earning it first!" is my usual one liner. But occasionally, I get a bit of a skeptical eye from the patient, and I know what is coming next:

"But Dr. Very-Important-Attending is doing my surgery right?"

I still don't have a good way of answering this question. But I have a few canned responses I cycle through:
1. "Don't worry, Dr. Very-Important-Attending is the boss in the operating room."
2. "I will be assisting Dr. Very-Important-Attending in any way he/she feels necessary."
3. "My role is to help Dr. Very-Important-Attending as appropriate."
4. "Dr. Very-Important-Attending runs the show, simple as that."
5. "Yes, Dr. Very-Important-Attending will be calling all the shots."
6. Variations of above.

I admit that some of my responses are farther from the truth than others and I also acknowledge that I'm always intentionally vague. The fact is that as an intern, yes, for many operations I'm simply there to "assist where appropriate." But for some operations, I'm performing parts if not all of the surgery. This is how we move from "intern" to "junior resident" to "senior resident". You can't become skilled at operating without, well, operating.

But I often wondered what the patient would think if we were brutally honest and told them who would exactly being doing what in the operating room. And the general surgery department at Madigan Medical Center in Washington looked at just that:

It's a very though-provoking study, but there are a few particularly salient and dramatic points they found, with the last two being most interesting:
1. 91% of patients believed their care would be equivalent or better at a teaching institution.
2. 68% of patients perceived a personal benefit from participating in resident training, and 87% believed that their participation would benefit other patients.
3. Patients "overwhelmingly" preferred to be informed if a resident would be performing parts of their operation.
4. 94% of patients stated that they would consent to the involvement of a resident in their operation.
5. However, after being given specifics of the role of resident involvement, patient consent dropped to 32% if the resident was performing the operation with the attending assisting, and 20% if the resident was performing the operation with the attending observing.

The overall message: Patients recognize the importance of training the next generation of surgeons. They just don't want to be the ones being learned on.

There was a great study published in the Journal of the American College of Surgeons earlier this year:

They looked at over 600,000 surgeries at private and training hospitals, and what they found was both expected and surprising. There was a slightly higher rate of complications, but a slightly lower rate of death, when residents were involved in an operation. I find that a very interesting and telling statement. It acknowledges that yes, we are learning, and as such, we make more mistakes. But it also acknowledges that we care about our patients and their care, and I think the mortality benefit reflects the reality that at a teaching institution there are more doctors who care about you keeping their eye on you.

I struggle with this underbelly of my training. The reality is I am learning. But at some point in technical fields such as surgery, you must learn by doing. Even in my short time in residency, I have had complications as a result of things I have done in the operating room. Nothing life-threatening or dangerous, but complications nonetheless. Mistakes that a more experienced surgeon likely would not have made. The reality is that these mistakes follow me. I think about them daily. And I regret that a patient has suffered harm, however great or little, as a result of my actions. But I also recognize that they have imparted to me great lessons, and have made me a better surgeon as a result.

Like I said, I find answering the "but Dr. So-and-So will be doing my surgery, right?" question difficult. Do we accept the half truths that permeate such a conversation as a necessary evil for the greater good so that myself and other surgical trainees will be ready to serve society for the next 30-40 years? Or do we instead veer towards blunt honesty, acknowledging that at an 80% consent attrition rate it would take me 20 years instead of 5 to gain that necessary operations and experience to be a competent surgeon? Do we be completely honest with patients but focus on educating them on what "resident participation" means from a value standpoint? That seems to be the ideal scenario, but my inner pessimist tells me that no amount of patient education would make most people willing to be learned on.

These issues are important ones to think about, but ones I can't afford to think about too much right now. Because I'm an intern, and I have too much to learn and too much to practice. So tomorrow, I will be in the operating room. I'll cut skin with the knife, buzz blood vessels with the cautery, tie sutures. And I'll keep learning.


Anonymous said...

I think that as long as you are honest with your patients in describing your stage of practicing medicine (resident vs. attending), you give them the opportunity to ask further questions, and answer their questions honestly, you've discharged your ethical responsibility to them.

If patients have more specific questions, you should answer them clearly, directly and honestly, as it seems that you do. If someone at a teaching hospital really would refuse surgery performed by a resident with an attending observing/supervising then they should not be at that institution.

Having spent much of the last two months in the OR, I would say that on average, at my institution, attendings spent >75% of the time in the OR in the lead surgeon role. Exceptions were made for clearly simple cases and clearly experienced (>R3) residents. Even when residents were given the lead, they were almost always on a very short leash. Perhaps University Hospital is more conservative in this regard, or the services I was on are more conservative - I was in fact surprised at how little operating the residents did, even in the OR.


MedZag said...

A bit more conservative than where I'm training but within the ballpark. The R1s-R3s don't do much completely solos... but we DO do things solo. There's really three aspects to learning how to "perform surgery":
1. The technical aspect. Dissecting tissue planes, throwing and tying suture, etc.
2. The operative plan. Knowing what you want to accomplish in an operation, beginning to think of the next step of an operation while performing the prior step.
3. Intraoperative decision making. Identifying potential pitfalls and areas you can get hung up on, identifying needlessly dangerous situations, etc.

Generally your junior years are spent working on #1, you work on #2 as you progress towards you chief year, then begin to dabble in #3 as a chief, but really spend an entire career refining that aspect. When an attending is overseeing a case, they can direct up to all or as little as none of these aspects. In the simple stuff, even as an intern, I've been told by an attending "well, get to work" without further direction. Of course they are watching (most) of my moves, and it's a test of sorts. Now if an attending is assisting a junior resident on a more complicated case, they may be directing #s 2 and 3, telling the resident where to cut, saying "no, not there" if they are about to do something dangerous, etc. But generally, most chiefs are all least performing #s 1 and 2 on the complicated cases, and all 3 aspects when they are taking a junior resident through a case.

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