P plate surgeons – teaching, learning and ethics

The New England Journal of Medicine has published a fantastic article on trainee participation in surgery. The story is told by an ophthalmology resident (registrar equivalent) with a patient, none the wiser that a training surgeon, fully supervised, has just performed successful cataract surgery. The author talks about striking the right balance between teaching and training and what the patient would wish to have happen.

Hospitals, especially teaching hospitals, are home to doctors of vastly different experiences. There is the professor, with thirty years of experience on one side of the table. On the other side of the table, there may be a doctor with weeks, months or only a few years experience. It is through this vast experience that an exchange of knowledge and learning of skills takes place. And at the centre of this is the patient.

I have always found that patients, by and large, do not have an understanding of the medical hierarchy. Which is understandable. There are so many words, terms, faces. Interns, residents, registrars, fellows, consultants. Age, or rather a perception of the doctor’s age, is one thing I think patients use to try and work out who is in charge or experienced. They may perceive the person they have had the most contact with as the leader or the person who spoke to them for the longest. While I’m sure the patients appreciate that a hierarchy exists, I’m not sure that they always appreciate that there can be a chasm of experience, skill and knowledge between two people.

But whether they appreciate that difference or not, the patient has a most vital and important role in closing that knowledge gap. It is through their illness that junior doctors learn. I actually loathe to use the word practice. To me, that sounds akin to shooting hoops from the free throw line, over and over, hoping you get one in. Refinement. Advancement. Training. That is what it is actually like. A process rather than a crack at the goal. And with an experienced person standing there. I’m not sure during training that we say often enough that we are thankful for the trust our patients place in us. Without them, we simply could not learn.

But we don’t say it. Very often, we don’t specifically inform a patient that a surgeon in training may perform some or all of their surgery. A number of consent forms have a standard provision that reads something along the lines of ‘a doctor other than the admitting doctor may perform the procedure’. As the New England article mentions, the patient may well not consent to a trainee performing their procedure. Which leaves us in somewhat of a pickle. Like so many situations, we have an obligation to more than one person. We have a very important responsibility to protect our patients and their health and well being. And we also have an obligation to train surgeons, for without them future generations would not benefit from medical care.

A number of things are leading to concerns with training young surgeons. Sicker patients requiring true expert intervention, changes to surgical training program execution, excessive working hour restrictions and oversubscription of doctors at certain levels of training. The use of simulation in both high and low fidelity models has been used to teach, develop and refine skills prior to getting to the operating theatre. I had the opportunity to practice on some fantastic models during my training. Paul Ramphal, an American surgeon who works in the Bahamas, has a fantastic simulator that uses a pig heart in a model chest cavity and has engineered in a way that it ‘beats’. I had the opportunity to practice coronary bypass grafting on this model several years ago. And it was great fun. There is nothing quite like the real deal, but I think we will move towards simulation more and more as a way of teaching and training. Aviation and sport have made use of such technology for years and medicine is now catching up.

But what about for the now? Well, for starters, in cardiothoracic surgery, the literature seems to support that a patient’s operation will not be compromised by having it performed by a junior surgeon. For coronary artery bypass grafting and valve surgery, there have been a number of publications that suggest that the outcomes are similar between a training surgeon and an experienced operator. In my field therefore, I can tell a patient that having a trainee operate should not adversely impact on their outcome. Their grafts will still flow and their valves will still open and close.

But we do need to be more open. And we need to do it such a way that the patient is not only reassured but also happy to be part of a very important process. The New England article makes mention of another ophthalmology publication whereby the authors got 95% of patients to consent to trainee participation by honest and open discussion in the informed consent process. And honesty and openness is so important to not only the consent process but the respect for the patient’s autonomy and as a fellow human.

Personally, I think that moving towards transparency is the correct move. I think if I can reassure a patient that their outcome is unlikely to be unchanged, that they will participate in a very important process and of course, that trainee surgeons have appropriate supervision, then that is a process that it is ethically sound. However, I would be lying if I thought that a proportion of patients would decline a trainee surgeon or that all of their anxieties would be put to rest by any open and honest discussion. Going for surgery is scary at the best of times, adding another possibly worry into the mix may not be helpful for some people.

During my training, a small proportion of patients have asked who will actually be doing the surgery. Most of the time, I answered that it will be the consultant they were admitted under. If I knew that I was going to be do that patient’s operation, I told them that too. I am very, very grateful for the patients who taught me. Who taught me simple things like placing an IV cannula. To the ones who showed me where their good veins were for taking blood. I am grateful for donor families who trusted me to use their loved one’s organs for transplant and to the patient on whom I learnt how to perform joins in arteries with a suture the thickness of your hair. I am grateful for the learning because my future patient’s will reap those rewards. But most of all I am grateful that you trusted us, all of us, to look after you when we were still learning the nitty gritty of just how to do that.

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