I’ve been thinking for a few days, ever since this excellent edition of SurgExperiences came out, about these posts by a neuropsychologist (whatever on earth that is – I can’t decide whether it’s more or less scientific than a psychiatrist or a psychologist) about informed consent for resident involvement in surgery (and follow-up). He tells the story of arranging a tonsillectomy for his young daughter, and how, after finding the most experienced and best-recommended surgeon available, he specifically questioned that surgeon about the possible involvement of residents, and then insisted that the attending be the one to do the whole surgery on his daughter. He advocates all patients being equally inquisitive into exactly who will perform their surgery, and clearly feels that patients are getting sub-optimal care if part or most of their surgery is performed by residents.
My first response was anger, probably triggered by guilt. I used to think about this issue – is it fair for me to practice on my patients? How up-front do I need to be about the fact that this is only the first or second time I’ve done X procedure – central line, arterial line, lipoma excision, cholecystectomy, etc (as we proceed towards more complex and riskier matters). As a student, and for the first month of internship, I felt very guilty about practicing on somebody who was expecting to be helped, and who might in fact be in more danger than necessary as a result of my inexperience. It got to be too much for me. I decided, quite successfully, to ignore the whole issue. However feckless I might be right now (or a month ago, as I can feel my technical ability growing every day), in less than a year, I will be a junior resident, responsible to supervise interns and students. I will be alone in the ICU, and I will have to be able to do all kinds of things. People’s lives will depend on it. And right now, I’m more scared of my attendings’ and chiefs’ wrath than of consequences to the patient. It’s a motivator, and quite effective. Usually it makes me more thorough and efficient; sometimes it makes me callous or cavalier. At any rate, I can’t afford to ponder the ethical implications of learning by doing on a patient who hasn’t exactly consented to be my first effort.
Thus, when Dr. Carone urged patients to protect themselves from residents like me, I felt rather angry. Who is he, a non-physician, someone who clearly has little to no experience with the sharp end of anything, to denounce residents who are desperately trying to learn necessary skills? If everyone actually took his advice, I would be out of a job – and in ten or twenty years, we would all be out of surgeons (and interventional radiologists and cardiologists, and ob/gyns, and urologists, etc).
Second thoughts suggested that perhaps I’m over-rating the number of people who would respond as he did. I think a fair number of my patients have recognized, to some extent, that I am still in training, that I am relatively new at a lot of things, or at least that I’m of lower status than the attending. After all, I do introduce myself carefully as “Dr. Alice, a resident working with Dr. Attending.” All of us are careful in our explanations to defer to the attending, making it clear that he has more experience than us, and that he will have the final say in all matters. Even if the exact hierarchy isn’t clear, the fact that we’re lower in rank is clear, as well as the fact that we’re much younger than the attending. Relatively few of my patients have asked more specific questions like, exactly how many times have you done this, exactly how much of the surgery will you do (or in July, when did you graduate from medical school)? (And in my case, since I look like a college student, even in scrubs and a white coat, I’m sure my lack of experience is written on my face.)
But again, I think Dr. Carone underestimates residents, as well. We are doctors, after all. For what it’s worth, we do have the diploma, and an unbelievable number of tests of all sorts that we’ve already passed. We are under continuous, fairly close, supervision, especially in the OR. On the floors, on the other hand, we are the workhorses. We see patients in the middle of the night in the ER, admit them to the hospital, start the series of tests, give the attending his first sight of the situation by phone, and take care of all the emergencies in the hospital. When a surgery patient starts bleeding out, who do you think shows up first, the resident or the attending? The intern, actually. When someone’s blood pressure drops, who has to take care of it? When someone develops chest pain or tachycardia, who’s on the spot to evaluate them and order urgent medications and tests? Or when your pain is out of control in the middle of the night, who gets woken up to do something about it? Otherwise, we’ll deal with it, and let them know later that we have things under control. If Dr. Carone’s daughter developed bleeding after surgery, and had to be brought back to the ER, I’ll bet anything that since the surgeon used residents, his daughter would have been seen and probably treated in the ER by residents. Only if her bleeding was so severe that it required immediate re-operation would the attending have been called in. Since he has no surgical experience, he may not understand this: dealing with the complications of a surgery requires some pretty intimate understanding of the procedure itself. If he excludes residents from the original surgery, he’s just hurting his daughter if, God forbid, she has a complication.
To conclude: I resent Dr. Carone’s attempts to deprive me of the chance to learn my trade. On the other hand, I’m challenged by his insistence on truly informed consent. I’m thinking about experimenting with my current census: telling them point-blank that we are all interns and have only been out of medical school for six months, and see whether they object to us participating in their surgeries. I know at least a few will, because just a week ago there was such an episode. On the other hand, I think we’ve built a good enough rapport with most of the patients that they’d be willing to keep working with us.
And after all, practically, what does Dr. Carone really want? Where does he think the surgeon who operated on his daughter got his experience, except by operating on other people’s children? Why should he expect to reap the benefit of the chances those other children took, and never be involved in the process himself? Is he really prepared to decimate the supply of future surgeons, simply so that current patients can feel more secure? If my experiment turns out badly, I will still feel such an overwhelming obligation to my future patients that I will continue to take advantage of current opportunities, without looking the gift horse too closely in the mouth.
(All this without mentioning that most of us are complete hypocrites on this subject, and would be very reluctant to have surgery by our fellow residents, have our babies delivered by OB residents, or our children seen by pediatrics residents. I think if it came down to it, I might, just because I would feel so guilty if I didn’t. I’m not sure how much of my theoretical reluctance is due to doubts about residents, and how much is due to pure determination never to be a patient myself. At least I’ve put myself down for organ donation on my driver’s license. To refuse that would be just too much hypocrisy for my conscience to handle.)