By Stacey Kusterbeck
As a medical student who routinely performed minor procedures, Nhon Le, MD, often was struck by the ethical complexity of informed consent conversations.
There was a need to be transparent with patients, while at the same time prioritizing education.
“Navigating these complex situations was daunting, especially when small missteps in communication could have long-lasting implications on the patient-doctor relationship,” recalls Le, now an assistant professor in the Division of Ophthalmology at University of Texas (UT) Southwestern Medical Center. The primary ethical concern is that, during informed consent discussions, patients are not always adequately informed that part (or in some cases, all) of the surgery might be done by a surgical resident.
Given conflicting opinions about disclosing trainee participation in surgery, Le and colleagues developed an ethical framework to guide surgeons in disclosing resident involvement during the informed consent process.1 The authors hoped to spark discussion among surgical teams on how to navigate these conversations.
“The reason this discussion is necessary is the tension between the essential need to train future surgeons, who by definition will have less experience, and the appropriate desire of patients to be cared for by someone with experience and expertise,” says Mary Brandt, MD, MDiv, another of the authors and a distinguished emeritus professor of surgery, pediatrics, and medical ethics at Baylor College of Medicine’s Center for Medical Ethics and Health Policy.
Informed consent requires disclosure of all information that a reasonable patient would need to make a well-informed decision about whether to undergo a surgical procedure. “There is little doubt that if a resident takes the lead, which is completely appropriate in many settings, this would be ethically important information,” says Brandt.
On the other end of the spectrum, if an intern is assisting a senior attending only by cutting sutures and holding retractors, that is unlikely to affect the patient’s decision on whether to proceed with the surgery. Thus, disclosure of the resident’s involvement in such a case may not be ethically necessary, says Brandt.
For all cases, though, it is ethically important to convey that there is a surgical team working under the direct supervision of an attending surgeon, according to the authors. Whether there is an ethical obligation for the surgeon to disclose more detail varies, depending on the degree of resident involvement and the complexity of the case.
“It is this continuum that makes the ethical considerations of informed consent in training hospitals so interesting and worth thinking about,” says Brandt.
Educating the patient about how surgeons are trained is an important aspect of informed consent conversations. Surgeons have an ethical obligation to explain the system, giving patients a fuller understanding of the responsibilities and experience of each of the members of the team, assert the authors.
“It’s been our experience that patients understand the benefit of having a team composed of surgeons at varying levels of training, if the training system is explained to them,” reports Brandt.
Another ethical consideration with surgical resident involvement is trust. “Patients who learn after the fact that a resident played a major role in a complex procedure may experience nondisclosure as a betrayal of trust,” notes Mary Majumder, JD, PhD, the Dalton Tomlin professor of medical ethics and health policy at Baylor College of Medicine’s Center for Medical Ethics and Health Policy.
In contrast, informed patients generally are appreciative of the training system and, therefore, more receptive to resident participation.
The authors hope that the ethical framework will assist surgical teams in preserving both the training system and patient trust. “Most patients not only understand but appreciate the presence of residents when it is made clear that the attending surgeon is always present and always responsible. Patients deserve honesty about their procedures and the system that makes their care possible,” underscores Majumder.
- Le NT, Brandt ML, Majumder MA. An ethical framework for disclosing the training status and roles of resident-level surgeons to patients. J Surg Educ 2024;81:1446-1451.
