Residents revisted
Seems like my posting the other day on the Resident versus the Physician has caused quite a stir, and rightfully so. It is a controversial issue that is rarely discussed and it seems like there are very strong opinions on both sides. I decided to expand on my thoughts on this topic after reading the responses to the prior posting.
Let me first start with what in my opinion is the most important factor here: the patient's right to know. Almost every hospital has a Patient Bill of Rights posted in the hallway. These rights were adopted by the US Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1998. These rights include (and I am quoting here) "Participation in Treatment Decisions: You have the right to know your treatment options and to participate in decisions about your care" and "Choice of Providers and Plans: You have the right to a choice of health care providers that is sufficient to provide you with access to appropriate high-quality health care."
The patient must be told in advance if someone else is going to do the surgery. When I say in advance, I mean when the initial consultation is done, not 30 minutes before the surgery that the patient waited two months for. I also believe it is unethical for doctors to give patients 5-10-page long consent forms before the surgery while hovering over them and then later say "Well, you consented to a resident treating you on the form" if the patient complains. Informed consent forms are useless if the patient does not know what he/she is signing. In my hospital, I have an informed consent form that I go over with every patient to get permission for me to enter their data in a statistical database for research purposes. Even though it eats into my clinical time, I go over the form and the risks and benefits. Bottom line: people need to know what they are signing and getting into. Inconvenience is no excuse.
Several people have written in that "residents won't be able to be trained" if patients have a choice, but it is important to keep in mind that there is no "Resident Bill of Rights." Secondly, I do not even believe the prior statement is true. For example, in my case, my daughter had to get her tonsils out…period. I had a few choices in town. If each person told me he was using a resident for part of the procedure, I would have no choice to consent to this. If the lesser trained doctor told me he was doing the entire procedure, whereas the highly trained doctor said he would do most of the procedure and the resident would only do a small part, I would pick the doctor who uses the resident.
So the issue is not so black and white as is implied by statements such as "if you have a choice, residents won't get trained." I simply cannot envision a scenario in which every surgeon in town would say that only he/she would do the surgery and that there would be no assistance from residents. Residents will always be a part of the medical establishment and patients will consent to their use because there simply are not enough surgeons. When someone needs surgery for a medical problem, they are going to consent to a lesser trained person taking part in the procedure if the alternative is waiting an unreasonable amount of time for another physician who is not using residents.
The next point is that like it or not, the reality of our current medical system is that disadvantaged groups (e.g.,uninsured) are whom many residents train on. For example, in one city I worked in there was a dental clinic in the hospital for people who could not otherwise afford dental care. The patient's knew there was a supervising dentist present but that the people providing the care and doing the bulk of the dental work were dentists in training. These patients understood the situation and consented to having a lesser trained person provide medical care.
One last point. I was talking to a physician today who needed back surgery a year ago. When he went to the hospital, he demanded that no resident take part in the case because in his words "I didn't want to wind up paralyzed." Probably an extreme statement, but you get the point. So for every physician who writes in telling me that we need to keep the system the way it is because residents won't get trained, I would like to know if you would consent to a resident doing most of your cardiac bypass surgery or most of your brain tumor resection? No? Didn't think so.
posted by MedFriendly | 7:06 PM
23 Comments:
I certainly would not choose to have a resident do most of my surgery...but many patients don't even understand the difference between residents and attendings. They understand that a doctor will be cutting into them and not a nurse. I find in my practice that the ones who question me about who will do their surgery are either physicians themselves or have close friends/family who are nurses and/or doctors to advise them on such issues.
While I certainly would not wish to have a resident doing the bulk of my surgery, if given a choice, I realize that if such attitudes were universalized then there would be no resident training except for in cases where immediate surgery is necessary and patients would not have the option of waiting for an experienced surgeon to become available.
Also, when residents operate, it's not as if they are the ones in charge. The attendings tell them where to cut, how much tissue to resect, how to suture/staple, etc. The executive decisions are made by those with more experience. The working hands are those of residents. And while I would still prefer a more experienced surgeon to do the physical surgery, it comforts me to know that an experienced mind is behind the major decisions, even if inexperienced hands are doing the work.
Since we have a new blog entry... I want to make a point from the previous blog entry comments from MedFriendly wrote...
"We go through all sorts of informed consents for research projects which do not come anywhere close to causing the potential harm that a botched surgey can, yet there is no informed consent that a resident may do the surgery?"
Are you suggesting when research scientist consent patients to double blind controlled studies (with an unknown outcome) do not cause harm? How many people have to have serious complications (i.e. GI bleeds, CVAs, MIs, or even death) before the trial is stopped??
Research requires acceptable risk each individual needs to consider... are we willing to better our medicine practice through the utilization of research projects and physician services?
While I agree patients should know that a resident will be part of the surgical experience... I think most patients know when they entire a "teaching hospital" that they will not only receive cutting edge medical care, but also will experience those being taught. If a patient does not desire to go to a teaching hospital... don't go!
In response to KC, there are of course research studies that can cause harm and even death, but at least the person consented to the study and understood the risks. But in my prior post what I was referring to is that we have to consent patients in any research situation in which no physical or psychological harm can result (e.g., consenting to have test data entered into a statistical databse) but there is NO consent for knowing a resident will do most of your surgery. That my friends, is ridiculous with a capital R.
The other point is that it is not so simple to say "if you don't want a teaching hospital, don't go." This is because there are many counties where there is basically one major hospital that serves as the main place where people go for medical care and the ONLY place where certain surgeries can be performed. In such cases the choice should not be: don't go the teaching hospital (and die as a result since there is no one near by that can perform the life saving surgery you need) or let the resident operate on people without them knowing.
Yes, to say that the patient can just choose a non-teaching facility elides the many ways in which "choice" is constrained by economic, cultural and geographic factors. Financial necessity is a form of coercion -- the only folks at the student dental clinic are those who lack dental insurance or the funds to pay a trained dentist.
I dont understand what the problem is. As long as the consent form specifically states that residents may do part of the surgery and the patient is verbally consented the same way, then its not a problem.
Now, if they were not including this info in either verbal or written consents, then its a problem but I've seen hundreds of surgeries and NEVER seen that happen.
The larger issue over whether residents are as qualified or as good as attendings is irrelevant. Obviously we need a way to train future surgeons and obviously the only way to make that happen is to let them get experience as newbies.
Summary: as long as you do the consents properly, this issue is much ado about nothing.
The problem is that in my experience and in the experience of most people I have spoken to, they were never TOLD that a resident may be working on the case. Sure, it may be written in the consent form somewhere, but like I said, people just don't read long forms, especially when someone is hovering over and says, "Sign this form to allow us to treat you."
And this consent should not be occuring 20 minutes before the surgery, whether it is verbal, written, or both. It should be explained to the patient before they make the decision for surgery.
The last anonymous statement makes it sound that he/she has never seen a surgical patient not properly consented. Well, if your hospital is doing proper consents, I applaud you. But I am telling you that I was NOT consented that a resident would be operated on my duaghter and neither was the person who wrote in who had her child die. You can have the attending physician watch the procedure as much as you want but that is not going to correct the accidental newbie slip of the scalpel that causes serious injury. Eyes cannot stop hands.
Great, a PhD posing as a "Doctor"...
MedFriendly,
While you bring many heart felt opinons to the surface, many will never come to a common solution. Most thoughts from this discussion are formed by experiences. Perhaps medicine should return to the old days when medical/surgical treatment was traded for goods... and third party insurance companies who now dictate care are removed from the process. As the residency programs continue to struggle to fill their positions each year in most specialties, who will care for our families of tomorrow?
To better understand your position at the University and your thoughts on healthcare... are you a grant funded employee or are you reimbursed by insurance companies for your services?
Have fun in Syracuse... Don't miss your winters at all!
In response to the last post, I am a state employee and paid directly by the state. I am not directly paid by insurance companies but our department does bill the insurance company for my services to make money.
Let me start by saying that I am not a medical professional. I don't have any friends or family who are medical professionals.
My husband and I are on the county MIA program, which greatly limits our choices for medical care. Our county runs a resident program, which is where they get most of the doctors for the MIA program.
It wasn't until we went on MIA that I learned that our most commonly used local hospital is a teaching hospital. Although I had been treated there several times, nobody had ever told me that I was being treated by residents. And I'm one of the rare ones that reads consent forms.
My husband was admitted to the hospital and a doctor was assigned to his case. He saw thw doctor daily and I spoke to him a couple of times. It wasn't until that doctor became our primary care provider a few months later that we learned that he was a resident. I say these things as an example of the fact that proper notification isn't happening.
As for my feelings on this subject, I like having a resident working with my doctor. To me it feels like I'm getting the best of both worlds. I have a doctor that was just trained, which increases the odds that he's been trained in the most up to date breakthroughs. I also have an experienced doctor who's seen this a million times and knows the best way of dealing with it.
I really don't think that informed consent would lead to there being no way to train residents. There have got to be a whole lot more people who don't miind having a resident treat them. I do think that I should have the right to know who's working on me. I want to meet you so that I can judge for myself if I'm comfortable with having you provide my care, even if I am unconscious. In the end, it should be my choice as to whether or not you work on me, right?
I agree with much of what Buckeye surgeon wrote from the previous post and comments. I remember a patient from residency who insisted the attending surgeon come in and place his central line. He ended up with a pneumothorax, because the attending hadn't placed a central line since he was a resident. Yes experience certainly plays a role in outcome, especially with surgery, but you have to get that experience somewhere and what better way than to be supervised by someone with that experience.
PS Jamie, while a medical resident doesn't have the experience, he/she probably has more up to date information and knowledge than the vast majority of physicians out in practice, a very different situation than surgery.
To start, I wanted to say that I have enjoyed reading all of the posts and comments aout this very important issue.
I have had several experiences with doctors, residents, and other medical professionals over the years. My husband and I both suffer from chronic health issues, and my husband is also a cancer survivor - so we have seen a lot of things in the world of medicine from a patients point of view.
We have had both good and bad experiences with residents. On the bad side is a resident who misunderstood vital symptoms and test findings in my husband which lead to the wrong diagnosis. Thankfully, this resident had proper supervision from his attending (who then properly diagnosed my husband with cancer).
Within 48 hours of the diagnosis, my husband had surgery. Again a resident (different resident) made a mistake. Again (thankfully) the supervising attending (same attending) recognized the error before it could harm my husband and the surgery was a success.
Several years later my primary care physician had a medical student working in her office. Before the resident started, my primary care physician asked me if I would be willing to allow the student to participate in my care, and I said yes.
As a bit of breif background - I have had chronic medical issues for years without a firm and concrete diagnosis as to why. I had seen countless specialists, but the best any doctor could offer was treatment of symptoms to make me more comfortable.
The medical student ccame to my primary care physicians office and during my first appointment with this student, he asked me to go over my entire medical history with him. I talked, he looked at my file and asked lots of questions. The whole thing took more than an hour, and while I was chatting with the student my primary care physician saw at least 5 other patients in the room next door.
To make a long story a bit shorter - this medical student was the one and only medical professional who ever took the time and energy to put ALL of the pieces of my medical history together, and it was this student who ended up finding the correct diagnosis for my long history of unexplainable medical symptoms.
Follow-up testing showed that the diagnosis made by the student was 100% correct - a very rare disease called acute intermittent porphyria, and thankfully the proper diagnosis lead to proper treatment, and I am feeling better than I have in years.
After my husbands experiences, I was quite fearful of medical students/residents. One could have killed him by failing to diagnose cancer, another could have seriously harmed him during surgery. I am thankful that I did not let that fear win when I consented to allowing my primary care doctor to involve a medical student in my own medical care.
My point is this -- as with anything on Earth (especially in medicine) there are risks and benefits to allowing a resident to be involved in your medical care.
In the case of my husband, the risks far outweighed the benefits, but thankfully my husband did not suffer any negative consequences. In my case, the benefits far outweighed the risks and my life is completely different in a good way because of a medical student.
As a private patient, I had 2 open abdominal operations at Cedars Sinai Medical Center in Los Angeles. Nobody went over the consent form with me before either of the operations. It was included with a stack of papers to sign in the admissions office 1 hour before my operation check-in. The clerk only opened the pages where I was to sign. There were patients waiting behind me for their turn.
The paragraph on "teaching hospital" stated:
"Patient acknowledges that Hospital is a teaching hospital and as such the training of physicians and surgeons, nurses and other health care personnel in training takes place at the Hospital. These people in training may participate in the operation."
After one of my operations I had an incident where 3 of the skin staples came out a few hours after I was transferred to my hospital room. A resident followed by several medical students came to check up on the problem. Listening to the discussion, it was revealed that the students did the suturing, whereby the staple gun was passed around the operating room allowing all of them to practice on me. Some weeks later I got a copy of the official operating report. There was no mention of the students doing the suturing. In fact, there was no mention of them even being in the operating room.
Posting anecdotes isn't how to win an argument. In response to yours I could post mine about residents, by virtue of being present in the hospital when no attendings were, being in the right place to have saved lives in emergencies or anecdotes about attendings willingly being operated on by their junior partner and a surgery intern. But that won't prove anything or change minds. You and your lay peanut gallery should take your ignorance, outrage, and sense of entitlement straight to private community hospitals and avoid the whole thing altogether.
By the way, Dominic Carone, PhD, speaking of misleading the health care consumer, perhaps it would be best to stop referring to yourself as "doctor," seeing as you lack an actual professional medical degree. Perhaps you could add it to your consent that you are only a PhD and not a fully trained MD physician?
You should also consider revising your medical information site. I for one don't find a medical information site with myspace.com links credible.
As all can see, "Anonymous" continues his petty obsession with me, continues to distort the argument, and has such an inferiority complex that he just cannot stand that he cannot monopoliz the term "doctor." For more on this, please read here which will fully explain to someone with your limited knowledge base why patients do not need to be consented about the use of that term. See folks, in his mind, he is a "doctor God" and all else are "lay people." Classic.
As evidence of continued disortion, he keeps trying to change what the argument about, which was NEVER about whether residents were good or have saved lives, but it about patients having a right to know they will be involved with their case when they think otherwise. And yes, that does come from a sense of entitlement because we are entitled to know that under the bill of rights.
As for myspace, it is a way to reach out to the younger generation and get them involved and interested in medicine. But I suppose those people are just "lay people" to you. Don't you have a surgery to do rather than continuing to come to this "non-doctor" blog. Oh, I forgot, you don't actually do the surgeries...your resident does them. Thank you for contnuing to send in posts that make you look all the more ridicuous each time. I wish you could really see how elitist you come across.
I am faced with a surgery which will be very complicated because it is a redo of a previous surgery.
Also this surgery quite different because of the way they are doing it, for what they are doing it for and few hospitals do it. I have to fly out of state to get the surgery. A few millermeters off and I could have major problems.
I asked two surgeons at teaching centers if they would do the surgery with n residents or fellows doing all or part of the surgery...they both responded "I do all my own surgeries...but I know at this one hospital that the resident an fellows do the surgery.
So I smiled (and the room was full of people) and then the surgeon responded, "well the students have to learn". Then i asked the other surgeon the same quesion and got the same exact answer "I do all my own surgeries" then I said 3 times will you be the one doing all surgery on me...he never answered.
I talked to a doctor friend and he said "well the surgeons when they said that they are not lying...the are saying they do there own surgery..but not necessary the on you...and obviously he does not do the simple ones..but i said well isn't that deception through sematics, he said well yes it is. But yours is more complicated so he might do you...he said to ask him in person at the pre-op
But i do not know if i can believe him because he said something else that strongly goes against what he wrote or assistated in writing in a medical article.
He told me not to email him any more.
However, this out of network surgeon, who would cost me a major part of my money...I am retired...and does this surgery a lot email me some time ago that he does the surgery 100 percent with no residents or fellows...but that was some time ago...he too is at a teaching hospital...how do i know if i can true him.
I have been told my a nurse who use too be a nurse in surgery at a childrens hospital that they made her swear not to tell the parents that the students (residents and fellows) were doing the surgery.
This is really a shame. My advice would be to contact the hospital's medical staffing office to see if you can get any clarification on this. In this surgeon's prior surgeries, the medical records will list if he residents did the surgery and if he was just present to supervise it. So the hospital should have some inkling. I think you need to point blank tell him that you do NOT want residents operating on you and that if he does not do the entre surgery that you will not consent to it. And make sure you read through the consent thoroughly and do not let them rush you. Some people are ok with residents operating on them. Some are not. It should be your choice though and you have a right to know in advance who is cutting into your body. For Pete's sake, the elitism in medicine can just be so frustrating sometimes despite all the good that physicians do.
Thank you so much for your reply.
I certainly would not mind residents doing part or all of most surgeries on me.
Also i think the problem is not necessary doctors but rather our medical system, and how doctors are paid. I do not think they get paid much unless the turn over a lot of patients. And I think if you complex problem they do not want you, because you would take too much time.
But this surgery is very complex in so many ways. And rarely done even if it was not a redo surgery like mine. I know one medical provider whos wife is a doctor. He traveled about 1500 miles to this one surgeon in private practic surgeon do this complex with out residents and fellows. (and he was not a redo which makes it more complex) This surgeon does this surgery a lot at a teaching hospital. he said he could of have it done in his home town with a top hopital (in the top 15) but he did not want residents and fellow doing him.
However this surgeon would cost me about $50,000 more because he is not in my insurace network..Insurance has really cut back on paying surgeons for this surgery. That is why I think surgeons that are paid by the hospital do it. or they are out of net work.
that is the problem i have limited choices.
and if i call the hospital I think base on the surgeon past action he would cancel me if he got wind of it. He canceled me one before.
Also how do i know i could trust a verbal statement from him. Doctors what there patient to sign lots of thing but i they will put little in writting.
This doctor told me not to email him. he wrote he was advised not to email.
Are you worried the doctor won't do ANY of the surgery on you? If the surgery is as complex as you say, I cannot imagine he would not be involved. And if you don not mind the residents being involved in that case, it seems like the problem is solved.
Thanks again, for your reply.
I think I will eat the $50,000 because this is a very complex surgery.
Even one very experienced surgeon who does not use students would not do me because he never did a redo before.
I think i will go with the expensive surgeon because he does so many of these.
So what if i go broke.
At least I will not be sick any more.
I guess you got pay a lot (and maybe go broke) to get good health care some times.
Geez. That is alot of money, but I hope you feel better when all is said and done.
Yes $50,000 is a lot but it could be $160,000 with hosptal if insurance does not cover it I Know of some one who insurance did not cover it after the said it would for this surgery.
But i have not life now...so might as well go broke and have a life i hope.
I was willing to have two residents team up for GYN surgery, now realize there must have been three and was never introduced to the third. Would have been nice.
However, I did not want a resident doing my cancer surgery, and requested the attending to that. Once sedated they pulled a ghost.
Patients have not rights once they are sedated.
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