Tonsillectomy tales, part 2: The Resident vs the Attending
Today I am going to reveal an inside scoop about hospitals that many in the public have no idea about. Specially, you may think you are getting operated on by a specialist with extensive experience when someone else actually does the surgery. Most hospitals have different levels of physicians who care for patients. At the top of the tier is a doctor known as the "attending physician." At the bottom of the tier is the "resident physician" or "fellow." The residents and fellows are there to learn from the attending physician. They all have medical degrees but the attending physician has far more experience. When you consult with a doctor who will be doing surgery on you or a loved one, you need to ask whether the attending physician will do the surgery or whether the resident will do the surgery. And trust me, there is a difference because the experienced surgeon should definitely be able to do a better job (e.g., less complications, quicker surgery time).
My feeling is that you should have a say on who operates on you or a loved one and should not be allowed to go into a surgical procedure thinking the specialist with 30 years experience will be doing it when it will actually be a resident with one year of experience. Knowing full well that this happens in hospitals, I asked the attending physician who was supposed to be operating on my daughter if he does the surgeries himself or if he is just there to supervise a resident. He paused and said, "Well, that depends." He did not say what it depends on but stated that sometimes the residents do all of the surgery, sometimes they do some, and sometimes they watch him do it. He knew I worked in a hospital and that my wife was a nurse, so when we asked if he could do the entire surgery he said he would. He added that there tends to be less bleeding when he does the surgeries and less pain for the child. So, ummm, yeah, can you do the surgery please?
Turns out, the surgery was a smashing success and my daughter has not been in any pain whatsoever. I cannot stop thinking about how different it would have been if I did not request that he do the surgery and a resident operated on my daughter instead -- because that is what was going to happen. So take this knowledge, pass it on, and make an informed decision the next time you go for a surgical procedure.
posted by MedFriendly | 6:22 PM
21 Comments:
While you comments are correct, how do you propose training new physicians and surgeons? Which patients should only have attendings perform the service? Should it be based on service payment, race, level of patient education, status in the community, etc?
The solution is that patients need to know and consent to a resident/fellow performing part or all of the surgery. 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? That really does not make sense.
It think that you present a very valid point, few people know that the perks of a Teaching Hospital, more research/newer tech, are sometimes diminished by the fact that residents are preforming more procedures. Not just in the OR either, many times pts don't know which is the doc in charge...I've been working on my unit for 4 months and I'm just getting a handle on the order of things...
P.S, I just read your history, I'm glad to see that there are more neuro people out there, I was beginning to feel alone in the blogging world
Under your 'system' (presumably with fully informed consent for every patient), who would ever choose to have their surgery performed by a resident? No-one in their right minds. So, should surgeons in training only ever operate on people out of their right minds? Or is there another group of similarly disadvantaged patients that you propose making available to the surgeon desirous of learning? No-one should get to choose, period.
Well, I disagree that no one would not choose the resident, depending on how the information was presented. For example, if the patient was told up front (before the surgery was scheduled) by the attending physician that he/she will do most of the surgery and that the resident will do some of it, I think many patients would agree if the other choice was to see a less experienced surgeon who did not use residents. Second, if I trusted the physician and he said to me that his resident (Dr. Smith) has done these surgeries many times with no problems and will be there to supervise the entire process, I also think some patients would agree to this. It is simply wrong to essentially trick patients into believing that there surgery will be performed by someone with extensive experience and then have it done by someone with far less experience. In the business world, this is called baiting and switching and is illegal.
Dr. Atul Gawande in his book "Complications", written while he was a resident at Johns Hopkins, describes in the first chapter how his learning was "stolen from the patient, their bodies taken as eminent domain, hidden behind drapes and anesthesia" He then referred to a physician who was a mentor to many doctors in training, and was very generous in allowing hands-on participation in the operating room, even to medical students. This physician's wife was in the hospital and had just delivered. Gawande asks:
"So did you let the resident deliver?" Silent pause. No, admitted the physician. "We didn't even allow residents in the room." I, myself, refused to let a fellow treat my son who had a severe cardiac defect, opting for the very experienced pediatric cardiologist-in-chief at my hospital. I wasn't even torn by this decision, after all, this was my child." Gawande goes on to say:
"Given a choice, people wriggle out (of care by doctors in training), and those choices are not offered equally. They belong to the connected and the knowledgable, to insiders over outsiders, to the doctor's child but not the truck driver's."
Dr. Carone, it's a glaring double standard that the bodies of VIPs. medical staff or their families are easily exempt from the noble cause of training future doctors. But the "unconnected" patient is seen as selfish, unreasonable, and perhaps even denied care, if challenging the practice. I am also curious if the surgeon who allows a resident to perform the operation (without explicit informed consent) is required to enter that fact in the patient's medical records.
Thank you
The answer to this problem is simple and only seems shrouded in ethical concerns because doctors prevent medicine from working like a proper market.
If you want the real doctor, you pay for it. If you'll settle for the student, you'll pay less.
Only when price becomes to function to ration medicine will we get any sanity!
While I agree with your position, my question remains... How does the junior resident obtain the necessary hands on skills to become a respected surgeon when most reasonable people would object to junior residents with limited skills (due to their limited exposure) doing the surgery? Would you allow your child to be "worked on" by a resident (Dr. Smith) who has "not done this procedure many times", but needs to learn before graduating and becoming a fully credentialed surgeon?
Perhaps you would support junior residents go abroad to a 3rd world country to "practice" before working in the States... however, their mentor may not be a good/qualified as here.
Residents/Fellows do appear on the Operative Record.
Great discussion! Thanks for responding.
~kc
The question of "who does the surgery" is a little misleading. The attending is always in the room. The days of residents doing colectomies unsupervised are over. The attending is in the room watching and directing. A resident's perception of who does the operation is much different than that of the attending. A resident may very well place all the sutures for a hernia repair and feel he/she actually "did" the case, but it was the Attending decided where the sutures went, decided if they were placed well. It's a little naive to think that, as a patient in the United States, you are going to receive substandard care just because a resident/fellow has performed a substantial portion of your operation.
Buckeye Surgeon,
You may not receive substandard care, but you're certainly not going to receive the quality of care that you contracted and paid for. Or are you saying that the experience a seasoned surgeon has racked up counts for nothing.
Also, it's not very reassuring when doctors or their families are patients, they would choose (and are allowed) to opt out as participants in surgical training. To me, as an "unconnected" patient, that speaks volumes about the quality of care. It also speaks volumes about the doctor's concern (read lack of) in supporting the training of new doctors.
I dont know what this thread is about. EVERY SURGICAL CONSENT FORM specifically states taht residents may be involved in part of the surgery. The attending is always there, and surgeries are NEVER done solo by residents.
Every verbal consenting is also supposed to include that caveat as well, and the hundreds of surgery residents I've worked with do a very good job of talking about it.
As long as the patient is verbally consented and gets written consent form indicating that residents will do part of the surgery, then its not an issue.
But that's just not what happens in practical reality. Click here to read more: Residents revisted.
Anon 8:52:
"Doctor" Carone is just spewing garbage from his mouth. Every consent I have ever used (and discussed with patients) at teaching institutions specifically discusses residents...period. I've been a doc since "Doctor" Carone's mom was wiping his butt. I shouldn't be surprised about such hysteria given that it's from a twit at a third rate institution. Why don't you talk about a real issue next time dom.
Someone once told me that when you are aguing with a fool, to just let them keep speaking because their own words demonstrate their ignorance better than any retort from the other side. That is why I chose to publish the last comment. Anyone who reads them will be able to tell that (along with the MD God complex).
Emily-
"Contracted and paid for"? Wow. It's sad to see that the doctor/patient relationship has deteriorated to such bottom-line, financial terms. Are you just as vigilant when you take your car into the shop; make sure it's the "senior mechanic" who performs all the necessary maneuvers on your transmission?
And there's no misrepresentation going on. Every consent form suggests the possibility of residents and/or fellows doing a substantial portion of the case, under Attending supervision. This is a non-issue. You want to be shocked and appalled by something in the medical world, go rant about access to health care or big pharm.
Have you even bothered to look at the consents?
From reading your statements methinks you suffer from a PhD know-it-all complex. Try looking at the consent next time. I have always stated that residents are involved in the procedure. In case you haven't noticed (which I find hard to believe), that is one of the purposes of a teaching institution. If there are issues (and it is not an emergency) I also state that is the way I work and if they have an issue with it I recommend a community hospital. Have you ever worked in community hospital? From the sounds of it I highly doubt it. Be honest now. Because at 03:00 there are no doctor's there except the ER doc and emergencies. One of the (many) advantages of a teaching institution is the availability of inhouse coverage 24-7. Next time don't act like a VIP (you are way to full of yourself). Do us all a favor and go to a community hospital. You don't live in the sticks. There are plenty of good community hospitals in syracuse.
I did not read the entire consent form but that is part of my point. These consent forms are often presented to patients a few minutes before the surgery is done, with the doctor standing over them, saying to sign this form so we can treat you. If you don't believe me that patients are not receiving verbal explanations of what is in the consent that is of importance (which is what should happen), just look at the many other comments made in reply to this posting. Going into the procedure, I knew all about the risks and benefits of the tonsillectomy. I also knew I was going to the most recommended surgeon. I also knew I wanted him to do the surgery and regardless of what the consent says, I knew enough to ask him before the surgery if he was going to do the operation or if the resident ways. By his own admission, when he does the surgeries the children are in much less plain and bleed alot less. So, who would you choose for your child? The choice is obvious. Again, whether it is in the written consent does not matter if the patient is pressured to sign the form quickly and does not know what they are signing. A high percentage of patients are porrly educated and cannot even understand the written consent. Someone needs to sit down and explain it.
Funny, I never heard of the PhD know it all complex before. Also funny that personal insults get hurled at me from a physician who feels threatned by what I am saying. For such a non-issue, this person (who does not even have the courage to identify him/herself) seems to spend alot of time writing about it. Why? Because I hit on a valid point.
Again, if any physician tells people ahead of time that the resident will be participating in the procedure, I have no problem, as long as they are told this before they choose to have the surgery with you, not 20-minutes before they are wheeling you in to the OR.
I understand full well the purposes of a teaching hospital and the advantages of it. But guess what? Most patients I have spoken to have no idea that the hospital they are going to is a "teaching hospital" or what that even means. And they have no idea about the difference between a teaching hospital and a community hospital. They see a hospital as a hospital...period. I have no opposition to physicians being trained there, but the key issue is that the patients need to understand what is happening beforehand.
I have mostly worked in academic medical centers but did work in a County Medical Center for a few years. And guess what? They have residents there. Oh, and there is one Community Hospital in Syracuse, not "plenty."
buckeye, since you've criticized me for wanting to get what I paid for from a hospital or surgeon, let me make an analogy to something that might be easier for you to relate to.
Would you complain if you paid for ringside seats at a sporting event only to be given seats in the nosebleed section?
Of course...when the attending does the surgery usually the kids bleed less, because he has caused countless kids to bleed more while he learned how to do the surgery better and better.
I won't deny that more problems can arise when an attending isn't completely doing the case, but when you go to a teaching hospital I believe what you are paying for is redundancy. You have medical students and interns who are up at the crack of dawn (more so the interns) who are making sure that your daughter doesn't die while the attending is at home. You have clinical pharmacists "in training" who are analyzing your daughter's meds, you have nurses in training doing whatever their training entails. But redundancy and oversight keep the ship sailing.
I'm not an attending, nor a resident, but I'm sure that an attending isn't going to let a resident make a mistake that could kill your daughter. Oversight and redundancy, oversight and redundancy.
I have never come to know a group crooks and liars like physicians, and surgeons are the worst. Often there are not clear indications that trainees will be involved. I understand that people need to learn, but then trainees should bother to get to know patients and request consent. I would give consent for some things, not others. I would have gender requirements in some cases. It is our right. No one has the right to be educated by using violence, medical battery and worse. Research has show patients to be very generous, and medical staff cruel and greedy.
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