manner in which we obtain surgical consent, which
establishes a covenant of trust between us and our
patients, would evolve accordingly.
Those of us in training today have never really
experienced it, but paternalism was the defining
characteristic of the surgeon-patient relationship in
the first half of the 20th century. At that time, surgeons routinely made decisions on behalf of their
patients without much input from these individuals—
something that is clearly out of step with how we
6, 7 We now practice in the era of patient-centered care in which patients seek to understand
all potential treatment options and demand transparency. It is no longer enough to tell patients that we
will take good care of them; rather, patients want
solid evidence that their providers will deliver positive outcomes.
Patient satisfaction also is now factored into payment and overall quality decisions, further empowering
patients to shape the way that health care is delivered
in the U.S.
8 As a result, surgeons’ relationships with
their patients demand increased transparency.
For example, with the increased attention to physician work hours, many patients now ask their surgeon
how much he or she slept before the start of an elective
operation. The impact of surgeon sleep deprivation
and fatigue on patient care has been at the forefront
of discussions regarding patient safety, disclosure, and
informed consent since the widely publicized death of
Libby Zion in March 1984. Lawyers for the family cited
the residents’ sleep deprivation as a factor in Ms. Zion’s
death, leading the Accreditation Council for Graduate
Medical Education (ACGME) to develop the 80-hour
workweek restrictions that took effect in 2003.9, 10
Sleep deprivation is known to adversely affect
mood and cognition, and its effects are often com-
pared to that of alcohol intoxication with similar
impairment of psychomotor function.
show an increased risk of complications when
sleep-deprived surgeons perform procedures, and
80 percent of patients indicate that they would request
a different surgeon if they knew their surgeon had
been awake for the last 24 hours.
Beyond factors pertaining to the surgeon who is
treating them, patients also want information about
the other health care professionals who will be participating in the operation. Recent press coverage about
concurrent and overlapping surgeries in the Boston
Globe has unleashed a wave of controversy and discussion among physicians and the lay public alike.
3, 4, 14-16
The role of trainee surgeons in the OR, particularly
in concurrent and overlapping operations, is poorly
understood by patients and therefore should be
addressed head-on and discussed openly by surgeons
rather than skimmed over.
17 Disclosing the details of
concurrent procedures can lead to an improved relationship between the surgeon and his or her patient,
and describing the role of the trainee can often be
gratifying to both the trainee and the patient.
Preoperative disclosures and erosion
of the physician-patient relationship
Merriam-Webster defines paternalism as “the attitude
or actions of a person, organization…that protects
people and gives them what they need but does not
give them any responsibility or freedom of choice.”
Surgical training is designed to hone an individual surgeon’s judgment—to know where, when, and how to
wield a scalpel, and how to comprehensively care for a
patient throughout the full course of their illness. Most
patients do not have this specialized knowledge and,
therefore, rely on their surgeon to make decisions for
them. While patient autonomy is imperative for shared
decision making, it is impossible and impractical for
patients to understand the nuances of each decision
made by their surgeon, thereby requiring some level
19 As such, patient-centered care and
paternalism, practiced correctly, are not necessarily
We now practice in the era of patient-centered care in which
patients seek to understand all potential treatment options and
demand transparency. It is no longer enough to tell patients
that we will take good care of them; rather, patients want solid
evidence that their providers will deliver positive outcomes.