American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Featured Commentary

Our online subscription format, SRGS Connect, features 10 commentaries on recently published articles in top medical journals with each new edition. The commentaries are by practicing surgeons and focus on the strengths and weaknesses of the research and its contribution to advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of SRGS Connect, What You Should Know.

McAlister C. Breaking the Silence of the Switch--Increasing Transparency about Trainee Participation in Surgery. N Engl J Med. 2015;372(26):2477-2479. Free full text

Commentary by: Mark A. Malangoni, MD, FACS

One of the more gratifying experiences in more than three decades of educating surgery residents has been teaching them how to operate. What is often initially interpreted as a purely technical exercise becomes transformed into an adventure of coordinating the complexities of care, from the initial encounter with the patient through recovery. The return on investment is the personal satisfaction of knowing you have advanced a trainee along the pathway to proficiency while providing a necessary service to a patient in need.

In this provocative article, McAlister advocates for greater transparency about the participation of trainees in operative care. Using her own experiences in cataract surgery as a paradigm, she explores key issues behind an important component of informed consent—who is actually going to do what in the operating room (OR).

There are three major issues addressed...

First, informed consent: previous publications about the acceptance of surgical resident participation in patient care have shown that patients generally welcome the involvement of residents in their care. This acceptance becomes tempered when the issue of resident participation in the OR arises; most patients retreat from a position of overwhelming acceptance to one of reluctance, which is directly related to the amount of detail provided.

Why does this happen? If a resident can be trusted by a patient to provide care at the bedside, the intensive care unit, or emergency department, why is it different in the OR? The OR is the epitome of faculty supervision, a site where the attending surgeon ultimately determines what aspects of the operation she or he will delegate to the resident in training. Perhaps this is more of an issue in cataract surgery, where the patient is more aware of the situation and it is difficult for multiple operators to work at once. Yet that situation isn't much different than allowing a resident to complete a bowel or blood vessel anastomosis. All are high stakes operations where mistakes can be disastrous.

A publication based on the NSQIP database has identified that resident participation in general and vascular surgery operations results in a slightly higher rate of morbidity but slightly lower rate of mortality per 1,000 patients treated. The most common complication in this study was surgical site infection, which could be greater in the resident participation group due to differences in case mix and patient risk. We also don't know the degree of involvement of residents or faculty in these operations. Either could be doing the majority of the case or just holding retractors. Importantly, both mortality and failure to rescue, an outcome indicator of increasing importance, were lower when residents were involved in the OR.

The second area that McAllister addresses is creating transparency in the relationship between the patient, surgeon, and resident. I agree with her premise that establishing a relationship between the patient and resident who will be helping with the case before the operation is important. All of us are more likely to trust someone we know and have confidence in. My personal practice has been to be honest in emphasizing that I will be present for the entire operation and will be assisted by a resident. Their help is not only appreciated, but often moves the operation along. If there was no resident available, I would be working alone or with an assistant who is often less skilled. Emphasizing the importance of the entire team in the conduct of the operation can help patients understand that my performance isn't the only thing that will affect the outcome.

Finally, there is the question of moral angst among residents who are concerned that patients do not sufficiently understand their role in the OR. Some of the angst will be relieved by addressing the points above. McAlister professes that simulation can improve a resident's ability to perform an operation with greater skill. Her point that properly directed simulation may reduce the incidence of complications is intuitive as part of the simulation exercise involves demonstrating safe technical practices. This should be reassuring to both residents and patients.

Part of teaching residents how to operate is recognizing when they can do an operation well with minimal guidance:this is the closest thing there is to true autonomy in the OR. Creating a situation where residents demonstrate that they can direct an operation isn't easy. Detailed preparation, knowledge of anatomy, simulation, understanding the sequential steps of the procedure, progressive responsibility, and orchestrating the OR team are all essential to achieving the best result. We should commit to educating our patients about the important role residents have in providing care both in and out of the OR. It is with transparency and the establishment of trust that everyone's goals will be achieved.