Teamwork leads to trainee consent

A GROWING trend towards surgical training in private hospitals emphasises the need to educate patients about the importance and safety of surgical teamwork, Australian surgeons say.

They say patient education is the key to ensuring private patients will agree to trainee participation in their surgical procedures.

Professor Michael Morgan, vice president of health and medical development at Macquarie University, Sydney, and a neurosurgeon at Macquarie University Hospital, said with the trend towards training in private hospitals, the need for a team rather than a solo consultant as “ace pilot” should be discussed with patients during the informed consent process.

“Surgeons do not practise in isolation, they need to work in a team and the trainee has a legitimate role in that team”, he said. “[Teamwork] proves to be safest for everyone.”

Professor Morgan was commenting on a study in the Archives of Surgery that found that the more detailed the information given to patients about trainee participation, the less likely they were to consent. (1)

Answering an anonymous study questionnaire, 316 elective surgery patients at a tertiary-level army hospital in Washington, US, were mostly supportive of resident training and most consented to having an intern (85%) or resident (94%) participate in their surgical procedure. But when the patients were given specific scenarios involving trainee involvement, consent rates dropped, sinking from 94% to as low as 18% as the level of resident participation increased.

The authors warned that providing detailed informed consent was preferred by patients but “an unintended consequence of such policies may be harm to surgical education and diminishment of the expertise of graduating surgical trainees”.

“… we believe that broad calls for routine mandated disclosure should be carefully planned and analyzed prior to implementation to avoid any adverse effects on surgical training”, they wrote.

Professor Jeff Hamdorf, head of surgery and director of the Clinical Training and Evaluation Centre at the University of WA, said he explained to public patients that operations were conducted by a team with members performing different tasks according to their seniority and competencies but that the consultant surgeon was ultimately in charge.

He said private patients had the right to be treated by a consultant only and to decline to be treated by a trainee but that rarely happened. Trainees were generally well received by patients.

“I’ve been taking medical students into the private sector since 1997 or so and the students are more welcomed in the private sector than they often are in the public sector”, Professor Hamdorf said. “Private patients are very willing and really keen to help, generally.”

Dr Rob Mitchell, deputy chair of the AMA’s Council of Doctors in Training, said it was incumbent on the doctor performing the procedure to ensure appropriate informed consent was obtained.

“But the work that has been done in Australia indicates that patients are by and large happy to have trainee involvement in their care in private settings”, he said.

A spokesman for the Royal Australasian College of Surgeons said patients treated in public teaching hospitals had no say over whether their procedures were performed by an experienced surgeon or a trainee under supervision. The policy on informing patients was the responsibility of the individual public hospital and varied between hospitals.

“Where [private hospital] training is being funded under a federal government program, it is a requirement of the contract between the college and the private hospital that patients be informed of any involvement of a trainee in the procedure”, the spokesman said.

Carol Bennett, chief executive officer of the Consumers Health Forum, said all health consumers must be given all available information to allow them to provide informed medical as well as financial consent.

“In our view, this information must include the extent of involvement of trainees in any procedure”, she said.

- Cathy Saunders

1. Arch Surg 2011; 19 September

Posted 26 September 2011

[poll id="123"]