Informed consent is, at its core, based on patient
autonomy and empowerment of patients to make
voluntary and educated health care decisions.
Resident involvement in operations
Another major point of contention is disclosure of the trainee’s
role in invasive procedures. One study of 30 surgeons at an
academic center determined that 83 percent did not discuss
the role of residents during the informed consent process.
However, it’s notable that these surgeons still espoused an educational propensity, with 77 percent permitting independent
operating prior to their presence within the operating room. 16
This practice is in conflict with a recent study of patients surveyed at a large military teaching hospital where only 18. 2
percent agreed that they would consent to such an unsupervised scenario. In fact, in their survey, a realistic description of
trainee involvement reduced patient assent to greater than 50
percent in most cases. 17 These concerns are not well founded,
though. Myriad investigations of outcomes in the American
College of Surgeons National Surgical Quality Improvement
Program suggest that resident involvement is safe and results
in similar morbidity. 18-20
Informed consent is, at its core, based on patient autonomy and empowerment of patients to make voluntary and
educated health care decisions. Legally, we are compelled
to disclose those factors that would pose material risk to the
patient although, at present, no consistent evidence exists
that obligatory disclosure of trainee responsibilities or previous call will result in improved outcomes or that avoidance
of these factors mitigates risk. Ethically, it remains our duty
as physicians to act professionally and provide quality care,
which may require postponing an operation if we are unfit
to provide appropriate supervision to surgical trainees. The
responsibility to make an informed decision together with
the patient cannot be aided or supplanted by mandates from
governing bodies. Instead, the burden should remain on the
physician to ensure excellent care with recognition of the
finite nature of resources and the need for optimal education of trainees. However, surgeons should be supported in
this process by health care systems, specifically by the development of policies that strive to reduce surgeon fatigue and
provide a safe working environment. ♦
11. Chu MW, Stitt LW, Fox SA, et al. Prospective
evaluation of consultant surgeon sleep deprivation
and outcomes in more than 4,000 consecutive
cardiac surgical procedures. Arch Surg. 2011;
12. Ellman PI, Law MG, Tache-Leon C, et al. Sleep
deprivation does not affect operative results in
cardiac surgery. Ann Thorac Surg. 2004; 78( 30):906-911.
13. Asfour L, Asfour V, McCormack D, Attia R. In
surgeons performing cardiothoracic surgery, is sleep
deprivation significant in its impact on morbidity
or mortality? Interact Cardiovasc Thorac Surg.
2014; 19( 3):479-487.
14. Czeisler CA, Pellegrini CA, Sade RA. Should
sleep-deprived surgeons be prohibited from
operating without patients’ consent? Ann Thor Surg.
15. Berg DB, Engel AM, Saba A, Hatton EK. Differences
in public belief and reality in the care of operative
patients in a teaching hospital. J Surg Educ.
2011; 68( 1): 10-17.
16. Knifed E, Taylor B, Bernstein M. What surgeons
tell their patients about the intraoperative role
of residents: A qualitative study. Am J Surg.
17. Porta CR, Sebesta JA, Brown TA, Steele SR, Martin
MJ. Training surgeons and informed consent
process: Routine disclosure of trainee participation
and its effect on patient willingness and consent
rates. Arch Surg. 2012;147( 1): 57-62.
18. Jordan SW, Mioton LM, Smetona J, et al. Resident
involvement and plastic surgery outcomes: An
analysis of 10,356 patients from the ACS National
Surgical Quality Improvement Program database.
Plast Reconstr Surg. 2013;131( 4):763-773.
19. Edelstein AI, Lovecchio FC, Saha S, Hsu WK,
Kim J Y. Impact of resident involvement on
orthopaedic surgery outcomes: An analysis of 30,628
patients from the ACS National Surgical Quality
Improvement Program Database. J Bone Joint Surg
Am. 2014;96( 15):e131.
20. Saliba AN, Taher AT, Tamim H, et al. Impact of
resident involvement in surgery (IRIS-NSQIP):
Looking at the bigger picture based on the
American College of Surgeons NSQIP Database. J
Am Coll Surg. 2016;222( 1): 30-40.