Training surgeons and the informed consent discussion in paediatric patients: a qualitative study examining trainee participation disclosure

Physician Disclosure and Patient Awareness of Resident Involvement During Podiatric Surgery: Do Patients Deserve to Know Who is Holding the Scalpel?

An anonymous questionnaire consisting of multiple-choice style questions was created at www.surveymonkey.com to assess physicians' perspectives regarding podiatric resident involvement disclosures in the surgical setting. The survey link was sent to podiatric residency program directors, attendings, residents, and fellows through email, social media outlets, and direct contact. For the purpose of this study, residents and fellows will be grouped together as trainees. A total of 201 participants were surveyed, including 63 program directors, 61 attendings, and 77 trainees. Of the respondents, 89.5% reported that at least 1 resident introduces themselves to the patient as a participant in the case. Additionally, 99% of responses revealed that trainees are performing at least 50% of the case. However, surgeons perceive that only 25% of patients are truly aware of this advanced level of involvement. This study suggests that 89.5% of podiatric physicians do in fact disclose trainee surgical participation. However, it is perceived that patients are still unaware of the extent of trainee involvement. Further studies are warranted which would account for both patient and physician understanding of this controversial topic.

Understanding the effectiveness of consent processes and conversations in pediatric surgery: A systematic-scoping review

BACKGROUND

The consent conversation in pediatric surgery is an essential part of pre-operative care which, when inadequate, can lead to significant adverse consequences for the child, parents, surgeon, other healthcare workers and the healthcare system. We reviewed the published literature on what key stakeholders perceive are the components of effective and ineffective consenting processes in pediatric surgery.

METHODS

A medical librarian searched seven databases to retrieve articles looking at the informed consenting process in surgical care for the pediatric population. Two independent reviewers screened all publications and categorized them by stakeholder perspectives (patient/family, surgical team, other healthcare team, and hospital administration or policy maker). General study characteristics, interventions to improve consent and features of effective and ineffective consent conversations were extracted.

RESULTS

5079 titles and abstracts were screened, resulting in 88 full-text studies and 43 articles included in the final review. Most publications (51%) discussed informed consent only from the patient/family perspective, while 21% added surgeon's perspective. No study approached the consenting process from the perspective of all stakeholder groups. Effective consent components identified included use of multimedia, presence of multiple conversations prior to surgery, and individualized communication catered to unique family knowledge and needs. In contrast, ineffective conversations did not include a clear assessment of parental understanding, delivered too much information, and did not address parental anxiety.

CONCLUSIONS

The literature on the consenting process in pediatric surgery is narrow in stakeholder perspectives. Our findings highlight gaps in the literature and opportunities to improve the informed consent processes prior to pediatric surgery.

Patient Perceptions of Resident Involvement in Surgery: A Qualitative Study Using Surgical Video

OBJECTIVE

To improve patient-centered perioperative informed consent, this study used real surgical footage to identify key topics which might be discussed with patients regarding resident involvement in surgery.

DESIGN

We conducted semi-structured qualitative interviews with 27 participants. The interviews included a video showing an attending and resident performing a procedure together. Questions focused on comfort with resident involvement and preferences regarding preoperative informed consent. Participants also described residents' participation in their own words.

SETTING

Participants were recruited from the infusion room of the allergy clinic and the treatment room of the dialysis clinic at a tertiary care facility in Nashville, TN (Vanderbilt University Medical Center).

PARTICIPANTS

Adult medical patients were recruited via periodic verbal announcements by the interviewer in the waiting rooms. Purposive sampling was used to increase demographic diversity. Participants with training in the clinical health professions (i.e., physicians, nurses, and medical assistants) were excluded.

RESULTS

Before watching the video, roughly half of participants imagined the resident to have a passive, bystander role, while the remaining imagined a more active role. Despite these differences, most participants found the video of attending-resident teamwork to be a reassuring depiction of resident involvement. When asked the best way to describe resident participation depicted in the video to patients, participants emphasized the need to focus on attending supervision, teamwork, reassurance, as well as resident presence, specific activities, and experience.

CONCLUSION

Although patients have varying perceptions regarding the role of trainees in surgery, most participants were comfortable with teamwork between an attending and resident, as depicted in the video. Our participants provided multiple practical ways to transparently articulate resident involvement for testing in future research.

Informed consent: perceptions and practice of orthopaedic trainees

BACKGROUND

The purpose of informed consent is to provide patients with adequate information about a proposed plan or intervention, including the benefits and risks, so that they can make an informed decision about their medical treatment. The literature suggests that trainees are often delegated the task of obtaining consent with inadequate knowledge, skill or experience. The aim of this study is to determine the extent orthopaedic surgical trainees have been exposed to education about the informed consent, their perceived ability to obtain consent effectively and the frequency with which they routinely address elements of the process when consenting patients.

METHODS

An eight-item questionnaire assessing trainees' experience with informed consent was distributed to trainees undertaking Australian orthopaedic surgery training in 2019.

RESULTS

Of the 239 trainees, 102 completed the questionnaire. Although 99% of trainees were confident that they can obtain valid consent from patients, when asked about aspects of the process, many trainees do not address them. Only 29% of trainees always ask patients about goals of care and 21% always advise the patient of who will be performing the procedure. Trainees who indicated that they had received education on informed consent during surgical training are significantly more likely to address key elements.

CONCLUSION

Trainees' perceptions of their knowledge and skill in relation to informed consent does not align with their reported practice. Although the majority of trainees had received some education on informed consent, greater emphasis on explicit teaching and formal assessment should be undertaken during surgical training, prior to trainees completing this activity independently.

Patient Perceptions of Trust in Trainees During Delivery of Surgical Care: A Thematic Analysis

OBJECTIVE

Trust is an essential element of an effective physician-patient relationship. There is limited literature examining trust between trainees and patients in the surgical setting. The goal of this study was to investigate how otolaryngology patients perceive trust in trainees during delivery of surgical care.

DESIGN

We extracted trainee-specific data from a larger, qualitative interview study examining trust in the surgeon-patient relationship. We then used realist thematic analysis to explore preoperative otolaryngology patients' perceptions of trust in trainees during delivery of surgical care.

SETTING

Department of Otolaryngology-Head and Neck Surgery at Michigan Medicine in Ann Arbor, MI, a tertiary academic medical center.

PARTICIPANTS

Using convenience sampling, adults 18 years or older scheduled to undergo elective otolaryngologic surgery between February and June 2019 were invited, and 12 agreed to participate in the study.

RESULTS

All participants (n = 12) self-identified as White/Caucasian with a mean age of 60 years (range, 28-82). Participants were 50% (n = 6) female and 50% (n = 6) male. Thematic analysis of participants' perspectives about trust in trainees during delivery of surgical care revealed 3 themes. Trust in trainees is conditional based on (i) level of trainee involvement; (ii) trust in the attending surgeon; and, (iii) trust in the institution.

CONCLUSION

Trust in trainees during delivery of surgical care is conditional on types of tasks trainees perform, bounded by trust in their attending surgeon, and positively influenced by institutional trust. Trainees and surgical educators must look to innovative methods to engender trust more efficiently in the clinic and immediate pre-operative setting. Such approaches can have a positive impact on patient outcomes, facilitate stronger trainee-attending interpersonal relationships, and empower surgeons to practice the professional values integral to surgical care.