Determining the best way to discuss the role of interns, residents, and fellows and their participation in surgical care is a common challenge that surgeon-educators face. Most patients are unfamiliar with the intricacies of graduated responsibility and workflow in the operating room (OR). For many patients, the only context for understanding surgical training might be the dramatic misrepresentations on TV and social media.1 Thus, surgeons are faced not only with introducing this concept at a stressful time for a patient, but also dispelling any of these fictionalized characterizations. Patients understandably want the focus of their operation to be fixing their problem, and the idea that the operation might also serve to train a junior surgeon can be concerning.
Unquestionably, the attending surgeon’s primary obligation is to the individual patient. However, academic surgeons also have the societal responsibility of ensuring that the next generation of surgeons is adequately trained to provide quality care for future patients. During residency and fellowship, each trainee must be empowered to move beyond the assistant role to primary and, ultimately, independent surgeon.2,3 Yet, most patients have some trepidation at the thought of a less experienced surgeon performing some or all of their operation.
These challenges have existed in the surgical profession for some time now. The disconnect between patient expectations and the realities of surgical training first gained widespread public attention when the issue was covered in 1978 by the television show 60 Minutes,4 one of the most popular television news programs at that time. In the intervening 40-plus years, we have struggled to message the concept of trainee participation, with a recent example of the 2015 Boston Globe exposé on overlapping surgery highlighting that surgeons still have difficulty explaining the logistics of surgical training and team surgery.5 To help practicing surgeons think through this thorny topic, this article looks at strategies to help attendings address the role of surgical training with their patients.
The benefits of trainee involvement
Surgical trainees provide numerous benefits to patient care. In addition to serving as a skilled set of hands in the OR, trainees offer an extra pair of eyes to identify potential complications or provide additional solutions to complex problems. They further provide the capacity to enable academic medical centers to take on the most complex, labor-intensive cases and help more patients benefit from the attendings’ specialized knowledge. Being closer to the training offered in medical school and gaining cross-specialty exposure by rotating on multiple services, trainees might be more informed than their attendings on certain aspects of patient care.
During residency and fellowship, each trainee must be empowered to move beyond the assistant role to primary and, ultimately, independent surgeon. Yet, most patients have some trepidation at the thought of a less experienced surgeon performing some or all of their operation.
Admittedly, trainee involvement has potential downsides, including longer operative times, increased wound infection rates, and other minor clinical complications (the latter of which may be directly due to trainee involvement or secondary to longer operative times).6-8 However, many studies have shown that trainee participation has little to no negative effect,9-11 even when trainees are the primary surgeon,10 and the most recent analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) data demonstrated that trainee involvement was associated with lower mortality rates.12 It is likely that these studies have an unmeasured selection bias because attending surgeons assign less operatively challenging cases to trainees (that is, “complication smoothing”); however, these nuanced management decisions are exactly why surgical education and training can coexist with patient safety. Indeed, revealing to patients how we focus on safety and outcomes, while still affording trainees surgical experience, may be a strategy for alleviating patient anxiety.
The patient perspective
Studies examining general perspectives of trainee involvement in care show patients to be favorable toward trainee participation and the necessity of educating future surgeons.13,14 However, these perspectives may be rooted in faulty assumptions that trainees play a marginalized role in patient care.
For example, in a survey of 200 gastrointestinal surgery patients, only 8 percent of the respondents thought that the trainee was involved in a “significant amount of the operation.”13 Furthermore, when given specific, realistic scenarios involving trainee participation, patients in other studies became increasingly reluctant to consent to trainee involvement in their surgical care.14,15 Faced with this hurdle, surgeons may wonder whether it’s possible to explicitly disclose trainee involvement without provoking undue anxiety or negatively affecting the care of tomorrow’s patients.
Because many patients think that the attending surgeon is the one performing most of their operation unless otherwise informed,13 baseline satisfaction with trainee participation reported in past surveys must be tempered with knowledge of this common misconception. Whereas some patients may prefer not to hear details of trainee involvement and would rather put their trust in the process,10 most patients will want more information once the idea of trainees actively and independently participating in a procedure has been flagged.14,15
Providing these details can relieve the anxiety surrounding trainee participation for some, but not all, patients.16,17 Thus, the pursuit of this “language of transparency”—finding the right words that are both reassuring and truthful—is ongoing and likely will be modified considerably based on a patient’s past experiences,10 demographic characteristics,11 and the nature of the proposed intervention.
The necessity of active trainee involvement in the OR
Attending surgeons must continually balance the dual responsibilities of providing high-quality care to their patients with enabling trainee growth through supervised independence. Many attending-trainee operations are conducted using a team-based approach, but in several key situations, attendings allow trainees to actively perform most of the procedure with direct or indirect supervision.
Attending surgeons must continually balance the dual responsibilities of providing high-quality care to their patients with enabling trainee growth through supervised independence.
For example, trainees are given independence in particular portions of a procedure as part of their progression through the graduated surgical education model. They begin their training by assisting the attending surgeon, and progress to performing the procedure with assistance, and ultimately completing the procedure without the attending’s active assistance.18 Survey data indicate that most attendings allow adequately trained residents opportunities to operate when the staff surgeon was unscrubbed or absent from the OR at some point in their training.19 Another example is procedures that are single-operator only (such as cataract surgery, sinus surgery); at some point, a trainee must move from watching to doing and, thus, active operating is a must.
These opportunities for independence with supervision are necessary during residency training, while an attending who knows their residents’ abilities provides oversight and backup.20 This approach ensures that trainees can gain the particular skill set of exercising clinical judgment and applying surgical techniques independently before graduation. Depriving trainees of meaningful autonomy with experienced oversight does a disservice to the patients they will start treating as soon as they enter practice. Thus, allowing experienced trainees to function as active operators and, eventually, as the lead surgeon, is both a common and necessary occurrence in academic surgical centers, despite adding to the complexity of the preoperative informed consent process. Even when a trainee is an active or lead operator in a case, it is still the attending surgeon who bears the responsibility of obtaining informed consent.
Surgeons’ informed consent strategies
Attending surgeons at academic institutions follow various informed consent strategies regarding trainee involvement in surgery, and, for a substantial portion of surgeons, their primary strategy is avoidance of the topic. In one study, only 17 percent of the surgeons surveyed explicitly disclosed to patients without being prompted that trainees might do a portion of their procedure.19 In both published studies and in unpublished interviews with the authors, surgeons gave the following explanations for why they avoid raising this topic:19,21
- Time constraints limit the ability to explain the trainee role
- Informed consent forms sufficiently explain trainee involvement
- Patients implicitly consent to trainee involvement by seeking care at a teaching hospital
- Discussion of trainee involvement provokes too much anxiety in patients
- Surgeons who discuss trainees may lose business to surgeons who do not
- Trainee participation is viewed as a “difficult topic”—one that complicates an already challenging time for patients and will add stress with no benefit
The veracity of these rationales might be questioned, but we suspect these perceptions are widely held. Unfortunately, the end result is a failure to fulfill the informational needs of patients and a subversion of respect for the patient’s autonomy, which is required for informed consent.
Avoiding this topic also sets a negative example for trainees. Often tasked with obtaining the patient’s signature on the consent form, trainees have the opportunity during that interaction to further explain their role in surgery and form a burgeoning surgeon-patient relationship. However, trainees may feel unwelcome to broach the subject with patients if their attending does not first disclose it. Attending surgeons are the team members ultimately responsible for a patient’s care, and trainees acknowledge that this creates a power dynamic that favors the attending’s ownership over all aspects of care—from informed consent to adverse events.22,23
Based on interviews with trainees rotating at an academic children’s hospital, the primary strategy that trainees used when faced with questions about their involvement was to keep conversations nonspecific.22,23 This approach was partly because of legitimate uncertainty about their exact role in the procedure, but also because of fears that increased disclosure may add to a patient’s anxiety, curtail the resident’s surgical exposure, and hamper training.23 Although trainees avoid misleading patients, they are put in a situation where their discussion of involvement must be framed according to their attending surgeon’s standard, leaving them little freedom to reframe issues with patients. Ultimately, this paradigm can result in a cycle of avoiding the difficult topic and leave trainees without a transparency model to follow, perpetuating this behavior when they enter practice.
In contrast to avoidant or nonspecific approaches to discussing trainee involvement with patients, many surgeons in our unpublished interviews reported being upfront and frank with patients regarding the role of trainees. These surgeons reported discussion strategies such as explaining to the patient the safety of trainee involvement, the potential benefit of trainee participation, and their endorsement of a trainee’s abilities. They also commonly discussed the nature of a surgical “team” and how each team member performs tasks appropriate to level of training. This latter strategy attempts to dispel the idea of a single person as the sole surgical caregiver, as J. H. Foster advocated for in 1981 in the wake of the media attention from the 60 Minutes segment discussed earlier in this article.24 Foster stated the following:
The myth about the omnipotent surgeon must gently be laid aside. Perhaps in times past, the surgeon could direct every detail of the total care of the patient and could do operations safely with relatively unskilled help. If it were ever true, alas, it is no longer so. Today, patient acceptance of shared responsibility with anesthesiologists, nurses, and medical consultants is generally good; however, because we often perpetuate the myth, patients still may expect their surgeon to make every cut and to tie every knot in the operating room. 24
Whatever the strategy employed, we are ethically obligated to ensure patients are informed about trainee involvement; the challenge is doing so in a truthful and reassuring manner.
Talking with patients about trainees
In pursuit of language that would be both truthful and reassuring, we conducted a study of patient perceptions regarding trainee involvement that we presented at the ACS Clinical Congress 2020.25 We interviewed 27 nonsurgical patients, asking them what they knew and wanted to know about trainee involvement in surgery. The study included participants watching a short video clip of a surgical procedure, which depicted two unidentified sets of hands operating. Ultimately, it was revealed that the pair of hands using the knife and scissors was a resident, and the hands doing the retraction and cauterization were those of an attending. Before watching the video, about half of the participants thought a trainee’s role was only to “assist or watch.” Accordingly, many participants assumed that the pair of hands doing the cutting was the attending. After revealing the two surgeons’ actual roles (trainee and attending), we asked patients how they would explain this scenario of trainees operating to another patient in a truthful and reassuring manner. Six common themes emerged. They are as follows:
- An affirmative statement indicating resident presence
- Confirmation that the resident would be operating
- An explanation of the resident’s prior experience
- A description of attending oversight
- An expression of teamwork
- Reassurance that the resident’s role would not negatively affect care
Patients also indicated that the discussion should occur in a non-coercive environment before the day of surgery and expressed a desire to meet the resident who would be operating on them if possible. These results from a small qualitative study now must be tested on larger samples; however, this framework, at face value, is a reasonable starting point when considering how to talk with patients about trainee supervision.
In our own experience, we have found it helpful to explain to patients the many, varied tasks of an operation when discussing the role of trainees.
Our study did not investigate other instances of trainee independence, such as when an attending might scrub out or even leave the room altogether. In our own experience, we have found it helpful to explain to patients the many, varied tasks of an operation when discussing the role of trainees. As an example, the attending might explain, “An operation has many parts: some are routine that I know my resident can accomplish safely without me; others are so unique or complex that only my hands should be doing them; most are in between, and we do them together.” This type of explanation sets a framework for patients to understand that a team will be performing their procedure, with each member doing what is appropriate.
Our study did not investigate pediatric, emergency, cosmetic, or awake surgery—any of which may modify perceptions or necessitate additional or alternative explanations. Much further research regarding the impact of language and content on patient perceptions and willingness to consent to trainee involvement is warranted.
The path forward for the difficult topic of discussing trainee involvement with patients is to demonstrate our commitment to the care of our patient, while being truthful and reassuring.
Recommendations for discussing trainees with patients
Based on our experience, advice published by others, and the best available evidence so far, we can make some preliminary recommendations for discussing trainee involvement with patients. As Foster stated in Archives of Surgery, “If we can reassure our patients that we have not abandoned personal responsibility for their care, most if not all will accept whatever we decide about the delegation of the details of that care.”24 If this comment is valid, then the path forward for the difficult topic of discussing trainee involvement with patients is to demonstrate our commitment to the care of our patient, while being truthful and reassuring. We consider the following to be “best practices” toward this goal:
- Trainee involvement should be discussed in a noncoercive environment before the day of surgery.
- The surgeon should gauge how much patients want to know about the surgical environment and trainee involvement. Some patients want many details, others none at all.
- The attending surgeon (rather than the trainee) should be the one to introduce this topic to patients, modeling truthfulness and empowering the trainee to discuss this role further if the patient desires.
- The attending should remind patients of trainee involvement on the day of the operation.
- If possible, the attending should introduce the trainee who will participate in the patient’s surgical care, which will bolster the trainee’s important role and highlight the value of patients’ involvement in educating future surgeons.
Additional strategies, such as explaining the necessary role of trainees in care, the potential benefits to the patient, the safety of trainee involvement, the importance of trainees to future patients, the attending’s own personal experience with the trainee, and their deliberate care and oversight regarding safety, all also might be considered. The impact and the optimal wording of these strategies are still under investigation, as are the effects of demographic and procedural factors on the success of these discussions.
The disclosure of trainee involvement in surgery can be a difficult task, which academic surgeons have been wrestling with for decades. Although there are some intuitive and evidence-based best practices, we must continue to seek the best path forward with our patients as a profession. We believe that it is possible and morally imperative to discuss trainee involvement with today’s patients without sacrificing the educational opportunities necessary to care for the patients of tomorrow.
- Witzel K, Koch HJ, Kaminski C. Impact of medical TV shows on preprocedural fear of surgical in-house patients. Eur Surg Res. 2017;58(3-4):121-127.
- Drolet BC, Brower JP, Miller BM. Trainee involvement in patient care: A necessity and reality in teaching hospitals. J Grad Med Educ. 2017;9(2):159-161.
- Siegel JH. Surgical training, quality surgical care, and informed consent. Bull NY Acad Med. 1980;56(5):433-452.
- “60 Minutes” Ghost Surgery/Disco/A Man Called L’Amour (TV Episode 1978). IMDB. Available at: www.imdb.com/title/tt10958012/. Accessed February 24, 2021.
- Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care—a Boston Globe spotlight team report. Boston Globe. October 25, 2015. Available at: https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/. Accessed February 24, 2021.
- Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program. Ann Surg. 2012;256(3):469-475.
- Advani V, Ahad S, Gonczy C, Markwell S, Hassan I. Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP. Am J Surg. 2012;203(3):347-352.
- Krell RW, Birkmeyer NJ, Reames BN, Carlin AM, Birkmeyer JD, Finks JF. Effects of resident involvement on complication rates after laparoscopic gastric bypass. J Am Coll Surg. 2014;218(2):253-260.
- Offner PJ, Hawkes A, Madayag R, Seale F, Maines C. General surgery residents improve efficiency but not outcome of trauma care. J Trauma. 2003;55(1):14-19.
- Goodwin AT, Birdi I, Ramesh TPJ, et al. Effect of surgical training on outcome and hospital costs in coronary surgery. Heart. 2001;85(4):454-457.
- van der Leeuw RM, Lombarts KM, Arah OA, Heineman MJ. A systematic review of the effects of residency training on patient outcomes. BMC Med. 2012;10(1):65.
- Saliba AN, Taher AT, Tamim H, et al. Impact of resident involvement in surgery (IRIS-NSQIP): Looking at the bigger picture based on the American College of Surgeons-NSQIP database. J Am Coll Surg. 2016;222(1):30-40.
- Cowles RA, Moyer CA, Sonnad SS, et al. Doctor-patient communication in surgery: Attitudes and expectations of general surgery patients about the involvement and education of surgical residents. J Am Coll Surg. 2001;193(1):73-80.
- Porta CR. Training surgeons and the informed consent process: Routine disclosure of trainee participation and its effect on patient willingness and consent rates. Arch Surg. 2012;147(1):57.
- Arambula A, Bonnet K, Schlundt DG, Langerman A. Patient opinions regarding surgeon presence, trainee participation, and overlapping surgery. Laryngoscope. 2019;129(6):1337-1346.
- Kempenich JW, Willis RE, Blue RJ, et al. The effect of patient education on the perceptions of resident participation in surgical care. J Surg Educ. 2016;73(6):e111-e117.
- Kempenich JW, Willis RE, Fayyadh MA, et al. Video-based patient education improves patient attitudes toward resident participation in outpatient surgical care. J Surg Educ. 2018;75(6):e61-e67.
- George BC. The language of progressive autonomy: Using the Zwisch scale for more than just assessment. Available at: www.facs.org/Education/Division-of-Education/Publications/RISE/articles/zwisch. Accessed February 11, 2021.
- Knifed E, Taylor B, Bernstein M. What surgeons tell their patients about the intraoperative role of residents: A qualitative study. Am J Surg. 2008;196(5):788-794.
- Klingensmith ME, Lewis FR. General surgery residency training issues. Adv Surg. 2013;47(1):251-270.
- Nguyen T-N, Silver D, Arthurs B. Consent to cataract surgery performed by residents. Can J Ophthalmol. 2005;40(1):34-37.
- Sur MD, Schindler N, Singh P, Angelos P, Langerman A. Young surgeons on speaking up: When and how surgical trainees voice concerns about supervisors’ clinical decisions. Am J Surg. 2016;211(2):437-444.
- Bhanot K, Chang J, Grant S, Fecteau A, Camp M. Training surgeons and the informed consent discussion in paediatric patients: A qualitative study examining trainee participation disclosure. BMJ Open Qual. 2019;8(3):e000559.
- Foster JH. Who does an operation? Arch Surg. 1981;116(6):743.
- Naguib M. What patients want to know about resident involvement in their surgery (oral presentation): American College of Surgeons Clinical Congress Scientific Forum. October 3, 2020. Available at: https://cattendee.abstractsonline.com/meeting/9182/Presentation/2668. [Member login required]. Accessed February 11, 2021.