Surgical residency: Swap the white coat for a scarlet letter?

September 14, 2015

Urology Times blogger Ashley G. Winter, MD, writes of "a growing and dangerous turn in how the medical community envisions surgical training."

Dr. Winter is chief resident in urology at Weill Cornell Medical College in New York. Follow her on Twitter at @AshleyGWinter.

I am currently a chief resident at a high-profile academic institution in Manhattan. 

Two populations are at odds in that environment. At an “academic institution,” house-staff training is imperative. At a “Manhattan institution,” we garner some high-intensity clientele who envision medicine as one more in the litany of service industries they consume. As a young doctor growing up in a Manhattan teaching hospital, I am not new to the patient who finds my presence undesirable. With no qualm (and in my earshot), these patients tell attendings, “I don’t want any residents to do my surgery.” With patience and honesty, my mentors respond, “I cannot perform surgery without assistance.”

We move forward, the cases get done, and the patients receive (dare I say) excellent care. My sense of propriety, of deserving my education, is unscathed. I know I am supported.

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But there is a growing and dangerous turn in how the medical community envisions surgical training. In what I consider “dogmatic anti-paternalism,” we may be unfurling a slippery slope that undermines the belief that surgical residents deserve their education.

Let me explain. This past June I read a New England Journal of Medicine editorial titled “Breaking the Silence of the Switch-Increasing Transparency about Trainee Participation in Surgery” (2015; 372:2477-9). The article, written by an ophthalmologist (but intended to address all surgical specialties), is a thoughtful treatise that suggests patients should meet the resident involved in their case at the time of consent (generally an outpatient setting). Trainee participation is referred to as “a struggle… with… a fiduciary commitment to patient care,” and proposals are made for “mitigating and identifying outcome deficits” associated with surgical teaching.

Aside from the logistical difficulties inherent in predicting which resident will assist in a case (oftentimes before they are scheduled), the entire article is belied by a fundamentally flawed argument. The author implies that somehow, trainee participation in surgery is deceptive. But this involvement can only be deceptive if surgery can be performed in isolation, if trainee participation is not an organic part of academic center operations.

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Are surgical residents less a cog in the wheel than any other part that makes the engine roar? No medical care stands alone. If you have the junior scrub tech, your surgery takes longer. If the scope lens is broken, your case may proceed with suboptimal visualization. Did you consent the scrub tech? Did the patient meet with the device company that supplies the hospital?

When the nurse calls the overnight intern for an order, the intern does not have to walk to the patient’s bedside and provide a lengthy disclosure of the fact that she, and not the attending, is placing the orders. Yet if sepsis goes improperly managed, or if a post-op ST-elevation myocardial infarction isn’t recognized, patients die. Are we immoral if the attending physician is not the one watching the monitor? No. The imperative is not that the attending live at the patient bedside. The imperative is that the attending teach trainees to make reasonable, evidence-based decisions, and ask for help when needed.

The implication of informed consent is that the attending physician takes ownership for the care, process, and outcome of the patient. Informed consent does not state that the “attending stands alone.” Involvement of trainees should have no fundamental impact on that vision. The error is not that I participate; rather, my obligation is to admit what I can do, know my limitations, and always be safe. The injunction of the attending is to communicate these expectations as well.

We will be real anti-paternalists and patient advocates when we readjust the lexicon of surgical training from “deceptive” and “fiduciary struggle” to “inherent” and “natural.” When we stop putting red tape around the paradigm that has allowed our profession to exist, we can start taking care of patients.

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