Another article targeting simultaneous surgery

[DoctwoB]

This time, it's a Urologist at Lenox Hill.

https://www.bostonglobe.com/metro/2...-procedures/YgyMjLLbxHjIZIbWCNtOMO/story.html

I feel the article properly makes the point that since there is no significant data showing simultaneous surgery worsens outcomes, the key issue is patient consent, which he apparently was not obtaining. This guy has already been somewhat of a pariah within Urology for outrageous marketing claims to the point where the AUA stepped in.

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[Psai]

One issue is that people don't seem to understand the surgery involves risks and that no matter who's doing the procedure, there are a lot of things that can go wrong. Just because someone is a famous surgeon doesn't mean that you'll somehow come out of surgery even better than when you went in.

 

[Gastrapathy]

This is the sellout who went on Fox News to speculate about Clinton's health.

 

[Winged Scapula]

Jeebus...I can barely get a second room, let alone get away with this stuff. Its amazing what a "celebrity" surgeon can get away with; as long as it brings Lenox Hill patients, who cares if its bad care?

 

[cpants]

I feel bad for his residents.

 

[Brahnold Bloodaxe]

Keep these articles coming, they are basically helping save surgeons from themselves. Betcha the gas passers wish they had encountered this kind of resistance back in the day when letting CRNA's loose seemed like a grand idea for fun and profit.

 

[vhawk]

This time, it's a Urologist at Lenox Hill.

He’s a celebrated urologist, but authorities are investigating his surgical practice - The Boston Globe

I feel the article properly makes the point that since there is no significant data showing simultaneous surgery worsens outcomes, the key issue is patient consent, which he apparently was not obtaining. This guy has already been somewhat of a pariah within Urology for outrageous marketing claims to the point where the AUA stepped in.

Consent for what? What aspects of the conduct of the operation require specific mention in the consent discussion, in your opinion?

 

[ProfMD]

There are times when surgeries can overlap without compromising patient care, primarily opening and closing. Otherwise, the attending surgeon really ought to be present. Whether this is covered in the consent will be a matter of hospital policy. In today's environment, I would suggest that each hospital have a policy and follow it. My place has such a policy including that patients must be informed about overlapping surgeries and consent to it. Personally, I only run one room. Even on days that I could get a second room, I'm not really comfortable splitting my attention like that.

One thing that the article did not bring up is insurance fraud. If his residents were doing cases without him present and he billed for those cases, that is fraud. I am surprised that the insurance companies have not jumped all over this.

 

[dpmd]

Consent for what? What aspects of the conduct of the operation require specific mention in the consent discussion, in your opinion?

I don't know that consent is really needed, but this guy was advertising that he was doing the surgery personally. Since that was not always the case I think itis reasonable to say that he should have informed those patients that would not be getting him doing the case. Now if no such claims are made I think the context becomes important. Surgery done at a teaching institution-the notation on the consent form that others may be involved is probably sufficient. At a private institution I can see the argument that you should advise the patient if you plan to have a resident or assistant doing parts of the procedure alone (less convincing if you are going to be there participating).

 

[Raryn]

I personally think consent *is* necessary if the overlap is for anything other than induction/closing.

I'm not a surgeon, but if I personally needed any kind of operation, I'd be perfectly fine going to a teaching hospital and letting a supervised resident perform the procedure. I'm convinced of the safety, if there's an experienced set of hands/eyes there watching whats going on and ready to take over if anything goes wrong.

On the other hand, if someone is running 2 rooms concurrently and large portions of the operation are done by the resident without supervision, even if the surgeons deem them "non-critical"? I would not consent to that. Period. And according to the article, neither would 95% of other Americans.

Have two rooms ready so you can open the next patient as soon as the operation on the first is done, but I think more aggressive than that is wrong.

 

[vhawk]

There are times when surgeries can overlap without compromising patient care, primarily opening and closing. Otherwise, the attending surgeon really ought to be present. Whether this is covered in the consent will be a matter of hospital policy. In today's environment, I would suggest that each hospital have a policy and follow it. My place has such a policy including that patients must be informed about overlapping surgeries and consent to it. Personally, I only run one room. Even on days that I could get a second room, I'm not really comfortable splitting my attention like that.

One thing that the article did not bring up is insurance fraud. If his residents were doing cases without him present and he billed for those cases, that is fraud. I am surprised that the insurance companies have not jumped all over this.

There is no risk to patients having residents open and close unsupervised?

 

[vhawk]

Imho if people think there is nothing wrong with this practice, then why is there any resistance to consenting/informing the patient of it?

Exactly. Same with patients recording operations or clinic visits. What do you have to hide?

 

[vhawk]

I personally think consent *is* necessary if the overlap is for anything other than induction/closing.

I'm not a surgeon, but if I personally needed any kind of operation, I'd be perfectly fine going to a teaching hospital and letting a supervised resident perform the procedure. I'm convinced of the safety, if there's an experienced set of hands/eyes there watching whats going on and ready to take over if anything goes wrong.

What has so convinced you of the safety? Because there is some decent evidence that it is less safe and there is harm done to patients.

On the other hand, if someone is running 2 rooms concurrently and large portions of the operation are done by the resident without supervision, even if the surgeons deem them "non-critical"? I would not consent to that. Period. And according to the article, neither would 95% of other Americans.

But the difference seems to be that YOU think opening and closing are "non critical" since you just suggested that that would be OK. Why is your assessment of the non critical portions, as an admitted non surgeon, your guiding principle here? There are definitely situations where opening is one of the most critical portions of the case.

Have two rooms ready so you can open the next patient as soon as the operation on the first is done, but I think more aggressive than that is wrong.

Do you feel you have justification for drawing this line where you have drawn it? Is it evidenced based?

 

[Raryn]

What has so convinced you of the safety? Because there is some decent evidence that it is less safe and there is harm done to patients.

I'm not aware of any clear evidence that shows outcomes are worse with trainee involvement. I am aware of evidence in many cases that outcomes do correlate with volumes of that procedure done, so I wouldn't be that surprised, but even if the outcomes were slightly worse, I think it would be hypocritical of me to set the line at no trainees. That said, if I needed a procedure done that did have outcomes explicitly correlated with # of procedures done (like a thyroidectomy say), I'd make sure I went to an attending that had those high volumes (and thus would more likely be found in an academic medical center). If trainees are involved as well, so be it.

But the difference seems to be that YOU think opening and closing are "non critical" since you just suggested that that would be OK. Why is your assessment of the non critical portions, as an admitted non surgeon, your guiding principle here? There are definitely situations where opening is one of the most critical portions of the case.

I said induction and closing, someone else above said opening/closing. I think personally opening is fairly risky, but I think that the physical closing less so, but that may be conjecture based on my few months of surgery as a medical student.

Do you feel you have justification for drawing this line where you have drawn it? Is it evidenced based?

My level of comfort primarily. That is, if the attending wants to come in when the patient is already asleep and supervise from the point of opening, that's something I would feel comfortable with. And he if wants to be present for completion of all portions of the procedure outside of suturing fascia/skin and then leave to get ready for the next case, I personally would feel comfortable with that as well.

I would consent to that, but I would not consent to someone who will not be physically in the room for other portions of the procedure. And if the surgeon tells me that is his standard policy (outside of an emergency surgery), I would find a new surgeon.

 

[deleted480308]

Imho if people think there is nothing wrong with this practice, then why is there any resistance to consenting/informing the patient of it?

yep, full disclosure all around is good

 

[ProfMD]

There is no risk to patients having residents open and close unsupervised?

There is risk when I do it myself.

I don't let junior residents open without me, but a senior or chief ought to be able to. Depends entirely on the specific procedure and the resident.

 

[surgonc2017]

A question for those who say the attending should be present for the whole case or for everything but opening/closing. Say the attending isn't running two rooms, but leaves a senior/chief to do a portion of the case autonomously for learning, or for taking a break in a 12 hour case? Is that also wrong?


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[vhawk]

I'm not aware of any clear evidence that shows outcomes are worse with trainee involvement. I am aware of evidence in many cases that outcomes do correlate with volumes of that procedure done, so I wouldn't be that surprised, but even if the outcomes were slightly worse, I think it would be hypocritical of me to set the line at no trainees. That said, if I needed a procedure done that did have outcomes explicitly correlated with # of procedures done (like a thyroidectomy say), I'd make sure I went to an attending that had those high volumes (and thus would more likely be found in an academic medical center). If trainees are involved as well, so be it.

There is somewhat mixed data and good large randomly controlled studies arent really possible, but the prevailing consensus would be that having trainees involved increases things like operative time (which we do know has an impact on outcomes), blood loss, and some other measures like wound infection rates. There is no evidence that it increases major complications....but that fact alone is really just a testament to the solid judgment of attending surgeons.

And yes it would be very hypocritical of you to set the line at no trainees but thats a whole other soapbox for me to get on.

I said induction and closing, someone else above said opening/closing. I think personally opening is fairly risky, but I think that the physical closing less so, but that may be conjecture based on my few months of surgery as a medical student.

Guess you've never sewn in a drain or taken care of an enterocutaneous fistula. Yes it is very true that opening and closing are, in general, the safest parts of the case, but there is still risk, and that risk could be mitigated to a small degree by more careful supervision. The point I'm trying to get people to see is that it is all about tradeoffs. People tend to get emotional about this issue and they start to take black/white stances, and I am nearly certain that those stances can't be justified.

My level of comfort primarily. That is, if the attending wants to come in when the patient is already asleep and supervise from the point of opening, that's something I would feel comfortable with. And he if wants to be present for completion of all portions of the procedure outside of suturing fascia/skin and then leave to get ready for the next case, I personally would feel comfortable with that as well.

Ok but thats a pretty nebulous line. What you, personally, are comfortable with?

I would consent to that, but I would not consent to someone who will not be physically in the room for other portions of the procedure. And if the surgeon tells me that is his standard policy (outside of an emergency surgery), I would find a new surgeon.

Right but this is just a restatement of your earlier arbitrary line drawing, not an explanation for WHY you draw the line there.

 

[vhawk]

There is risk when I do it myself.

I don't let junior residents open without me, but a senior or chief ought to be able to. Depends entirely on the specific procedure and the resident.

You are right, I omitted the word "increased" before risk.

 

[vhawk]

A question for those who say the attending should be present for the whole case or for everything but opening/closing. Say the attending isn't running two rooms, but leaves a senior/chief to do a portion of the case autonomously for learning, or for taking a break in a 12 hour case? Is that also wrong?


Sent from my iPhone using SDN mobile

Shhh.....stop focusing on the benefits, we are making black and white moral pronouncements here, we only focus on the costs!

 

[dpmd]

A question for those who say the attending should be present for the whole case or for everything but opening/closing. Say the attending isn't running two rooms, but leaves a senior/chief to do a portion of the case autonomously for learning, or for taking a break in a 12 hour case? Is that also wrong?


Sent from my iPhone using SDN mobile

I think the difference is availability in the event of trouble. Also, to bill without fraud you need to be there fo the critical portion of the case (defined by who?). That is easy to do if you are in the caf having lunch or in your on campus office doing charts, but harder if you are in the middle of a complicated case.

 

[vhawk]

Imho if people think there is nothing wrong with this practice, then why is there any resistance to consenting/informing the patient of it?

Let me give you my serious answer to this question. There are costs associated with everything, and that includes the things you include in the consent discussion. Do you tell patients that you are going to have a medical student close their skin incisions at the end of the case? Many, probably even most, would have no problem with that. But a not-tiny minority would object. So....why dont you include it? Well it would be tedious, but there is a real downside to that. If they object, what are you going to tell them? You are going to explain that they will be supervised, blah blah, ok, that convinces some of that group, but some will still say no. So...what then? The med student doesnt get to close those incisions? She just doesnt get to learn that day? Take that to the next level, and "opening and closing" which seems to be meeting some sort of thread consensus is "ok." Well...do you say that in your consent? Dont say that there is a line on the back that talks about trainees, do you specifically tell patients that you will not be in the room when a trainee takes a large knife and cuts their abdomen open? Why not, what have you got to hide? You know with certainty that some of those patients will say no. This will happen at EVERY level of decision-making through the entire course of the patients care. And education will suffer.

Now is attendings no longer having 2 rooms gonna be some major blow to the education of residents and students? Of course not. What percentage of attendings even are afforded the luxury of this? Its gotta be way less than 10%. But the principle is the same.

And I fully recognize that, taken to the opposite extreme, my argument is a justification for paternalism in medicine. I think the key point I'm trying to make is that everything is about tradeoffs. On this issue, people tend to think its "just wrong" for a surgeon to run two rooms, but they focus solely on the risks and never on the benefits, and dont realize that the right answer to the question is "it depends." Some surgeons (really, nearly ALL surgeons) are capable of doing this in a responsible way, or as someone said upthread, just not doing it because they dont feel comfortable. And a small minority of surgeons would abuse the situation for selfish reasons, use bad judgment, and harm patients. Kind of like....everything else. Some small minority of surgeons are bad.

 

[vhawk]

The real crux of the discussion then, to me, is this:

Do patients have the right to dictate the degree of trainee involvement in their care? Of which a special case would be, do patients have the right to refuse trainee involvement at all?

I think the answer has to be no with maybe some special exceptions. But I recognize that isnt the standard accepted answer.

 

[Gastrapathy]

How can the answer to that question be no. Let's say I'm admitted on a trauma service. I can't choose to leave. I don't have the right to decline the involvement of a trainee in my surgery? If I told you no trainee involvement and you ignored me, that is battery. If I told you no trainee involvement and you refused to care for me, that is abandonment. This is Ethics 101. This is basic autonomy. The fact that training tends to be performed on poorer patients, veterans, etc demonstrates the slippery slope that comes with medical education. If you add a policy that removes autonomy, you are using vulnerable people for the greater good and that should sound scary.

"Everybody line up to do the pelvic exam now that she's out" -think we really had informed consent for that?

If you refuse to operate without trainees on routine procedures, that is your choice provided you can find me an alternative. It would make me wonder if you are capable (I know a place that had "nonscoping" GI attendings who billed for fellow endoscopy but never took the scope and would call in a senior fellow if the junior needed help).

Look there are certain situations where I would decline trainee involvement. Would you let an IR resident coil something in your brain? How about an Ortho resident operate on your hands? In those cases, I'd pick the person. Taking out my GB, meh, go for it (and we all know that means a R3 might put a clip across my CBD but it's a level of risk I'm willing to accept).

I know surgical journals have written on the subject and said "just convince the patient that we need the team" but it's not my fault that the attending doesn't know where he last placed his stethoscope in 1987. If I demand it (maybe even to my detriment) it's my choice. Most patients won't and the smart ones will certainly want house staff involved pre and postop. The student will survive.

 

[Gastrapathy]

[QUOTE="vhawk, post: 18766639, member: 42384]

Right but this is just a restatement of your earlier arbitrary line drawing, not an explanation for WHY you draw the line there.[/QUOTE]

I would draw the line there because it removes a clear financial incentive for my surgeon to cut corners. We are all human and it doesn't have to be conscious to gradually change behavior about what "really" requires supervision.

It's also more about autonomy than outcomes. I would have wanted a chief resident rather than half the surgical attendings where I trained. Thankfully that's no longer true.

 

[vhawk]

How can the answer to that question be no. Let's say I'm admitted on a trauma service. I can't choose to leave. I don't have the right to decline the involvement of a trainee in my surgery? If I told you no trainee involvement and you ignored me, that is battery. If I told you no trainee involvement and you refused to care for me, that is abandonment. This is Ethics 101. This is basic autonomy. The fact that training tends to be performed on poorer patients, veterans, etc demonstrates the slippery slope that comes with medical education. If you add a policy that removes autonomy, you are using vulnerable people for the greater good and that should sound scary.

"Everybody line up to do the pelvic exam now that she's out" -think we really had informed consent for that?

If you refuse to operate without trainees on routine procedures, that is your choice provided you can find me an alternative. It would make me wonder if you are capable (I know a place that had "nonscoping" GI attendings who billed for fellow endoscopy but never took the scope and would call in a senior fellow if the junior needed help).

Look there are certain situations where I would decline trainee involvement. Would you let an IR resident coil something in your brain? How about an Ortho resident operate on your hands? In those cases, I'd pick the person. Taking out my GB, meh, go for it (and we all know that means a R3 might put a clip across my CBD but it's a level of risk I'm willing to accept).

I know surgical journals have written on the subject and said "just convince the patient that we need the team" but it's not my fault that the attending doesn't know where he last placed his stethoscope in 1987. If I demand it (maybe even to my detriment) it's my choice. Most patients won't and the smart ones will certainly want house staff involved pre and postop. The student will survive.

How can the answer be yes? If everyone refuses to allow trainees the medical education system grinds to a halt and we no longer are able to provide medical care in the future. Your preference to not have trainees involved seems like a right because only a minority of patients exercise it. If it became more common you'd begin to realize how morally dubious it is. And you are drawing the wrong conclusion about the fact that training tends to be performed on poorer and more vulnerable populations. Your insistence on patient autonomy is what exacerbates this problem. The underserved and vulnerable populations are less likely to refuse trainee involvement. Respecting this form of autonomy only puts MORE undue burden on this group. The poor get experimented on by med students while the wealthy reap the benefits of the well trained physician. That's an argument for MY side not yours.

I agree you have that right but only in special circumstances. For example, if the attending that is caring for you did not receive any training at all or at least any training involving human patients, then I think it's acceptable for you to refuse trainee involvement. I'm not sure where you'd find such a person, or how comfortable you'd be receiving care from them, but either way.

Patient autonomy is one of the principles guiding medical ethics. It isn't the only one. We are fortunate that the majority of patients aren't selfish inconsiderate expertise-thiefs so we don't really have to confront the ethical problems associated with this. But they are there under the surface. You don't have a right to benefit from the sacrifice of patients past due to your comfort. Unless we live in anarchocapitalism world. But in any modern liberal society with any social contracts whatsoever, this is a no brainer mandatory one. You steal from past patients and harm future patients with your refusal for trainee involvement. Why does your autonomy trump all that harm?

I would refuse to operate on you without trainee involvement but it isn't because I'm incompetent. It's because I have an ethical and moral duty to train the next generation of surgeons (in fact I even swore an oath!) and while I like to try to accommodate patient preferences this isn't Burger King.

This is Ethics 201.

 

[vhawk]

I would draw the line there because it removes a clear financial incentive for my surgeon to cut corners. We are all human and it doesn't have to be conscious to gradually change behavior about what "really" requires supervision.

It's also more about autonomy than outcomes. I would have wanted a chief resident rather than half the surgical attendings where I trained. Thankfully that's no longer true.

So why do you think the attending doesn't want to be there for opening and closing? Or in the middle of the night when you are hypotensive? You don't think that's an incentive for the physician to misbehave? Your concerns are valid it's just your line drawing doesn't resolve them.

 

[deleted480308]

A question for those who say the attending should be present for the whole case or for everything but opening/closing. Say the attending isn't running two rooms, but leaves a senior/chief to do a portion of the case autonomously for learning, or for taking a break in a 12 hour case? Is that also wrong?


Sent from my iPhone using SDN mobile

Senior/chief never has to leave to teach autonomous learning, they just have to shutup

 

[deleted480308]

How can the answer to that question be no. Let's say I'm admitted on a trauma service. I can't choose to leave. I don't have the right to decline the involvement of a trainee in my surgery? If I told you no trainee involvement and you ignored me, that is battery. If I told you no trainee involvement and you refused to care for me, that is abandonment. This is Ethics 101. This is basic autonomy. The fact that training tends to be performed on poorer patients, veterans, etc demonstrates the slippery slope that comes with medical education. If you add a policy that removes autonomy, you are using vulnerable people for the greater good and that should sound scary.

"Everybody line up to do the pelvic exam now that she's out" -think we really had informed consent for that?

If you refuse to operate without trainees on routine procedures, that is your choice provided you can find me an alternative. It would make me wonder if you are capable (I know a place that had "nonscoping" GI attendings who billed for fellow endoscopy but never took the scope and would call in a senior fellow if the junior needed help).

Look there are certain situations where I would decline trainee involvement. Would you let an IR resident coil something in your brain? How about an Ortho resident operate on your hands? In those cases, I'd pick the person. Taking out my GB, meh, go for it (and we all know that means a R3 might put a clip across my CBD but it's a level of risk I'm willing to accept).

I know surgical journals have written on the subject and said "just convince the patient that we need the team" but it's not my fault that the attending doesn't know where he last placed his stethoscope in 1987. If I demand it (maybe even to my detriment) it's my choice. Most patients won't and the smart ones will certainly want house staff involved pre and postop. The student will survive.

I'm with you on this. Patient always has the right to say no to anything or anyone (minus the really weird typhoid mary type situations)

I don't think the hospital should be required to provide options though. Our only consulting pulmonologist always has students and you don't want students? You can consent or we can refer you out or transfer at your expense. You don't want a male obgyn to do your csection? If there's a female one around you can have her but if not we aren't liable for that

(These discussions are another reason folks should pay their own bills and we shouldn't have certificates of need for hospital construction but that's a rabbit trail)

I give a 5-10 sec speech about medical students at a teaching hospital and how I'll be back later with the doctor before I start interviewing/examining any patient. Consent isn't hard to obtain, and reasonable attempts at full disclosure aren't hard to make

 

[vhawk]

I'm with you on this. Patient always has the right to say no to anything or anyone (minus the really weird typhoid mary type situations)

I don't think the hospital should be required to provide options though. Our only consulting pulmonologist always has students and you don't want students? You can consent or we can refer you out or transfer at your expense. You don't want a male obgyn to do your csection? If there's a female one around you can have her but if not we aren't liable for that

(These discussions are another reason folks should pay their own bills and we shouldn't have certificates of need for hospital construction but that's a rabbit trail)

I give a 5-10 sec speech about medical students at a teaching hospital and how I'll be back later with the doctor before I start interviewing/examining any patient. Consent isn't hard to obtain, and reasonable attempts at full disclosure aren't hard to make

I think that's a valid concession to the conflict between patient autonomy and other relevant ethical considerations but what about in Gastrapathys trauma situation when transfer isn't feasible? Does the patient have the right in that situation to dictate the manner in which care is provided to him?

I'm sure your 10 second speech is a good one but have you failed to convince (sorry did I say convince I meant consent, silly me) any of them yet? If you give a worse speech do you just get worse training? What happens if you train in a more affluent and entitled patient population?

I think your male female obgyn analogy is an apt one. For those who feel patient autonomy trumps all and patients have an absolute right to refuse trainee involvement, replace trainee with "black guy" and see how the argument holds up.

 

[vhawk]

Senior/chief never has to leave to teach autonomous learning, they just have to shutup

No offense but are you a med student? This isn't actually true. Doing a case with a junior resident while your attending is there but shutting up is not the same attending doing a case alone.

 

[deleted480308]

I think that's a valid concession to the conflict between patient autonomy and other relevant ethical considerations but what about in Gastrapathys trauma situation when transfer isn't feasible? Does the patient have the right in that situation to dictate the manner in which care is provided to him?

I'm sure your 10 second speech is a good one but have you failed to convince (sorry did I say convince I meant consent, silly me) any of them yet? If you give a worse speech do you just get worse training? What happens if you train in a more affluent and entitled patient population?

I think your male female obgyn analogy is an apt one. For those who feel patient autonomy trumps all and patients have an absolute right to refuse trainee involvement, replace trainee with "black guy" and see how the argument holds up.

Unconscious trauma isn't physically capable of even consenting to the physician, so a trainee being involved isn't different if the trainee is competent to do what they are attempting. Conscious trauma? Yes they always have a right to refuse a trainee.

And yes, Patients have a natural right to refuse black, white, left handed, tall, or ugly providers. I just don't think a hospital is liable to provide alternatives. You hate black people? Well our only general surgeon is black and your appendix just ruptured. You have to decide just HOW racist you are, but it's not our problem

To your other points, I have had patients say they don't want to have to talk to a student so I left them alone. I've had one say they didn't want me there for a procedure so I stepped out. It's not a big deal

 

[deleted480308]

No offense but are you a med student? This isn't actually true. Doing a case with a junior resident while your attending is there but shutting up is not the same attending doing a case alone.

that isn't the point I was making

For the purposes of the junior learning "autonomy ". The attending doesn't have to leave or even scrub out. They just have to shut up and let the junior run the room while they observe as the safety net

 

[vhawk]

Unconscious trauma isn't physically capable of even consenting to the physician, so a trainee being involved isn't different if the trainee is competent to do what they are attempting. Conscious trauma? Yes they always have a right to refuse a trainee.

And yes, Patients have a natural right to refuse black, white, left handed, tall, or ugly providers. I just don't think a hospital is liable to provide alternatives. You hate black people? Well our only general surgeon is black and your appendix just ruptured. You have to decide just HOW racist you are, but it's not our problem

To your other points, I have had patients say they don't want to have to talk to a student so I left them alone. I've had one say they didn't want me there for a procedure so I stepped out. It's not a big deal

OK. Now what if it wasn't a minority of patients. Is it only the first 10 patients who get to exercise this right? That's the point I'm trying to make. It "isn't a big deal" because in most training environment patient populations it's fairly rare. But that's just a fortunate coincidence it isn't some fact of nature. What if that changed?

The racist patient analogy was one I didn't expect you to have much of a problem with. But for the conscious trauma patient, the alternative to a trainee is presumably death, right? Some would feel that that places undue coercion on the decision. How is a conscious trauma patient able to consent to having trainee involvement if the alternative is they bleed to death? If your answer is too bad, then why pretend you care about consent?

 

[vhawk]

that isn't the point I was making

For the purposes of the junior learning "autonomy ". The attending doesn't have to leave or even scrub out. They just have to shut up and let the junior run the room while they observe as the safety net

Juniors aren't the only ones who need to learn autonomy. Senior residents do too. And you seem to be ignoring MY point. You don't recognize the educational value in being the most senior person in the room.

 

[deleted480308]

Juniors aren't the only ones who need to learn autonomy. Senior residents do too. And you seem to be ignoring MY point. You don't recognize the educational value in being the most senior person in the room.

Then replace junior with senior

 

[deleted480308]

OK. Now what if it wasn't a minority of patients. Is it only the first 10 patients who get to exercise this right? That's the point I'm trying to make. It "isn't a big deal" because in most training environment patient populations it's fairly rare. But that's just a fortunate coincidence it isn't some fact of nature. What if that changed?

The racist patient analogy was one I didn't expect you to have much of a problem with. But for the conscious trauma patient, the alternative to a trainee is presumably death, right? Some would feel that that places undue coercion on the decision. How is a conscious trauma patient able to consent to having trainee involvement if the alternative is they bleed to death? If your answer is too bad, then why pretend you care about consent?

If you don't want a resident to touch you and that's all we have then yes, you might be choosing death or trainee. (Which is another argmument for ditching certificate of need and allowing more likelihood for some niche hospitals to open and brag about "no trainees"...conscious trauma can ask to go there if they hate trainees)

But if the question is "can the resident/student help the attending " and you say no, the one in question leaves and the attending does the case.

The building isn't responsible for providing you the baskin robbins 31 flavors of options. You can pick from the options available or leave.

 

[vhawk]

If you don't want a resident to touch you and that's all we have then yes, you might be choosing death or trainee. (Which is another argmument for ditching certificate of need and allowing more likelihood for some niche hospitals to open and brag about "no trainees"...conscious trauma can ask to go there if they hate trainees)

But if the question is "can the resident/student help the attending " and you say no, the one in question leaves and the attending does the case.

The building isn't responsible for providing you the baskin robbins 31 flavors of options. You can pick from the options available or leave.

The middle paragraph doesn't seem consistent with the outside paragraphs.

 

[vhawk]

Then replace junior with senior

I guess my point is your assertion that all that is needed for autonomy is the attending to sit in the back of the room and be quiet is an assertion that can only be made by someone who's never gotten into bleeding at 2 am by themselves. It simply isn't true. But it's an honest mistake.

 

[deleted480308]

I guess my point is your assertion that all that is needed for autonomy is the attending to sit in the back of the room and be quiet is an assertion that can only be made by someone who's never gotten into bleeding at 2 am by themselves. It simply isn't true. But it's an honest mistake.

If the bleeding is bad enough that you should have called the attending, they needed to be there to help

If you thought the bleeding was bad enough to need help and they thought you were wrong, they can tell you that because they are there and make you work through it

If you don't think it's bad enough to need help and it is, they can help because they are there

If nothing goes wrong, there is no harm to having them more available in the room than down the hall or on another floor in a call room. They don't have to leave for your education. They may leave for budget reasons or sleep or paperwork but it isn't necessary to teach you

 

[deleted480308]

The middle paragraph doesn't seem consistent with the outside paragraphs.

Then there is a communication issue

 

[vhawk]

Then there is a communication issue

Pick residents or die.

If you don't want a med student that's OK the attending has to do it.

This isn't Baskin Robbins.

I guess you can call it a communication issue if you want, but the issue is that the middle paragraph isn't consistent with the other two paragraphs. I'd call it more of a reasoning issue. It isn't like the font was too small.

 

[Gastrapathy]

Die or let the resident learn on my body if I lack the resources to flee. The greater good paid for by the poor. And we wonder why they don't trust us.

 

[dpmd]

If the bleeding is bad enough that you should have called the attending, they needed to be there to help

If you thought the bleeding was bad enough to need help and they thought you were wrong, they can tell you that because they are there and make you work through it

If you don't think it's bad enough to need help and it is, they can help because they are there

If nothing goes wrong, there is no harm to having them more available in the room than down the hall or on another floor in a call room. They don't have to leave for your education. They may leave for budget reasons or sleep or paperwork but it isn't necessary to teach you

I think you are asking too much of attendings. If they are scrubbed it is natural for them to do he damned attending finger thing if the resident is going too slowly or too gingerly. It is hard to stand by and do nothing when you can do something. They are also going to retract in a way that makes the resident's life easier without them knowing it (possibly not until they are out of their own and wondering why the case is so much harder than they are used to). Similar **** will happen when they are unscrubbed in the room. Even if they manage to keep their mouth shut against the helpful tips they might have as they see you doing something the hard way, asking then not to try to guide things when **** goes wrong is pretty difficult. At some point leaving the room is going to force the resident to really be in charge instead of them knowing backup is right there. Is that appropriate the first case you do with that resident? No. Is it appropriate for every case? No. But let's not pretend there isn't some benefit to the resident having to troubleshoot for themselves and determine if help is needed.

 

[VA Hopeful Dr]

Pick residents or die.

If you don't want a med student that's OK the attending has to do it.

This isn't Baskin Robbins.

I guess you can call it a communication issue if you want, but the issue is that the middle paragraph isn't consistent with the other two paragraphs. I'd call it more of a reasoning issue. It isn't like the font was too small.

I mean, that's kinda true. Is there a Level 1 trauma center anywhere that doesn't use general surgery residents at a minimum?

 

[vhawk]

I mean, that's kinda true. Is there a Level 1 trauma center anywhere that doesn't use general surgery residents at a minimum?

It uses them, the question is if they are absolutely essentially necessary. So if I come in as a GSW and I say I dont want trainees, what happens? You can CLAIM that there is no way for you to care for that patient adequately without residents, but it probably isnt true. You could put the chest tube in yourself, you could have the ED attending intubate, and you could do the trauma exlap.

But that wasnt really the point of the trauma example, it was more that a timely transfer isnt feasible, so how do we resolve the issue? For my whipple, its easy for me to take a firm stand. I absolutely will not operate on you if you are not willing to allow residents to take part in the case. You can find another surgeon. But in the trauma situation where there is time pressure and a patient cant just leave or be transferred, what do you do? In practice what you do is pretend that you cant provide trauma care without residents even for that single patient and basically just lie.

I mean I can just say I cant close skin without med students or I cant put in postop orders to the EMR without a resident being with me (this one may be true!)

 

[vhawk]

I think you are asking too much of attendings. If they are scrubbed it is natural for them to do he damned attending finger thing if the resident is going too slowly or too gingerly. It is hard to stand by and do nothing when you can do something. They are also going to retract in a way that makes the resident's life easier without them knowing it (possibly not until they are out of their own and wondering why the case is so much harder than they are used to). Similar **** will happen when they are unscrubbed in the room. Even if they manage to keep their mouth shut against the helpful tips they might have as they see you doing something the hard way, asking then not to try to guide things when **** goes wrong is pretty difficult. At some point leaving the room is going to force the resident to really be in charge instead of them knowing backup is right there. Is that appropriate the first case you do with that resident? No. Is it appropriate for every case? No. But let's not pretend there isn't some benefit to the resident having to troubleshoot for themselves and determine if help is needed.

Right and even if they are entirely silent, just the knowledge that they are right there makes it a very different experience for the trainee, as obviously you know well.

 

[vhawk]

Die or let the resident learn on my body if I lack the resources to flee. The greater good paid for by the poor. And we wonder why they don't trust us.

Right....but this is the position you are supporting. Supporting the patients right to choose whether they want trainees involved is, de facto, putting the burden of medical training and learning onto the poor and vulnerable and underserved. Eliminating that right would ALLEVIATE the burden on the poor by spreading it out more uniformly.

I'm not suggesting this as a good reason that patients dont have the right to refuse trainees (because I've got lots of other good reasons, as stated) but by your own reasoning it should be a good reason for YOU to oppose patients rights to refuse trainees. The right to refuse trainees is a practice that, in reality if not in theory, harms the poor.

 

[ProfMD]

This whole discussion of whether patients have the right to refuse care by residents is interesting. Fortunately, in my experience at least, it is rare. I have certainly had patients ask if I would be the one to do the surgery. In these cases I reassure them that I will be there for the critical portion (honestly determined based on the case). In most (if not all) of the situations where this has come up, the case was sufficiently complex where I was going to do it anyway. If I promise a patient that I will do the critical portion myself, I stick to that promise, of course. I do explain to the patient that most of what I do is made much easier with 2 people and the resident will be assisting me.

Regarding whether an attending needs to leave in order to maximize resident learning, I have mixed feelings. I can understand the arguments others have made, but this was not my experience as a resident. I did have some attendings who were very hands off and would come in late in the case. However, I had others who were truly excellent at just standing there and assisting, saying nothing, there to either answer questions, bail me out of small trouble, and keep me out of big trouble. The latter was a good balance of resident education and patient safety.

The reality is, however, that no experience as a trainee truly prepares you for being an attending. Even if the attending is not in the room, knowing he or she is out there, somewhere, gives you a degree of confidence as a resident that you do not have in your first year or so in practice.

 

[VA Hopeful Dr]

It uses them, the question is if they are absolutely essentially necessary. So if I come in as a GSW and I say I dont want trainees, what happens? You can CLAIM that there is no way for you to care for that patient adequately without residents, but it probably isnt true. You could put the chest tube in yourself, you could have the ED attending intubate, and you could do the trauma exlap.

But that wasnt really the point of the trauma example, it was more that a timely transfer isnt feasible, so how do we resolve the issue? For my whipple, its easy for me to take a firm stand. I absolutely will not operate on you if you are not willing to allow residents to take part in the case. You can find another surgeon. But in the trauma situation where there is time pressure and a patient cant just leave or be transferred, what do you do? In practice what you do is pretend that you cant provide trauma care without residents even for that single patient and basically just lie.

I mean I can just say I cant close skin without med students or I cant put in postop orders to the EMR without a resident being with me (this one may be true!)

Heh, if my 66 year-old father-in-law can learn Epic so can you.

I get what you're saying, and there is certainly truth to it. But, I view it kinda like the call schedule. If I come in at 2am with a compound fracture, its either the on-call ortho or no one. The resident trauma service is similar. If you need trauma services, the trauma team cares for you Full stop.

In your example, what if the ED attending is doing a code in another room? What if its a multi-trauma scenario and literally the only person left who can do what needs doing is the resident?