Informed consent and surgeons in training: do patients consent to allow surgical trainees to operate on them?

Is there a standardised consent process within the surgical specialties?

INTRODUCTION

The consent process is central to surgical practice. Subsequent to landmark cases such as Montgomery and Thefaut there is increasing consensus that consent should be a staged process. The aim of our survey was to identify if there was any homogeneity in the practice of surgeons with regards to the consent process in comparison to national guidelines.

METHODS

Our survey was distributed to a broad range of surgical specialties via an anonymous Google Forms questionnaire available online. Consultant Surgeons and Specialist registrars across the United Kingdom were then contacted via their relevant surgical societies and professional. Data collection was based on the Montgomery principles: consent location; face to face meetings; information leaflets (including their source); distribution of copies of letters and consent forms; use of percentage risks; use of pre-printed consent forms.

RESULTS

The total number of replies was 325. The majority of consent was taken on the day of surgery (166/319; 50.8%). Scheduled meeting for the consent process occurred routinely in only 87 cases (87/319; 27.3%). 103 (103/319; 32.9%) responders indicated the use of pre-printed consent forms. Of which 93 (93/103; 90.3%) were produced locally. Risk percentages were routinely used by 103 responders (103/319; 32.9%) Nearly two-thirds never write specific risk percentages routinely (205/319; 64.3%). Copies of consent forms were routinely given out by 210 responders (210/319; 65.8%). Supporting information was routinely given to patients in 248 cases (248/319; 77.7%).

CONCLUSION

Our survey documents significant variation in the practice of consent despite clear guidance on best practice. We believe that most surgeons welcome a more thorough and robust consent process, but hey need the time and infrastructure to be able to do it Introduction.

Does content of informed consent forms make surgeons vulnerable to lawsuits?

BACKGROUND

Written informed consent forms (ICFs) are important for ensuring that physicians disclose core information to patients to help them autonomously decide about treatment and for providing substantial evidence for the surgeon in case of a legal dispute. This paper aims to assess the legal and ethical appropriateness and sufficiency of the contents of ICFs designed for several elective surgical procedures currently in use in Turkish hospitals.

METHODS

One hundred and twenty-six forms were randomly selected and were analyzed for 22 criteria. The results were compared using the Fisher' exact test, and 95% confidence intervals were calculated.

RESULTS

More than 80% of ICFs contained information about the risks of the proposed treatment, the diagnosis of the patient, and the patient's voluntariness/willingness, as well as a designated space for the signatures of the patient and the physician and a description of the proposed treatment. Some ICFs were designed for obtaining blanket consent for using patients' specimens.

CONCLUSIONS

The ICFs for general elective surgery contain many deficiencies regarding disclosure of information, and there is significant variation among primary healthcare providers. Unrealistic expectations regarding the surgery or the post-operative recovery period due to insufficient information disclosure may lead patients, who experience post-surgical inconveniences, to file lawsuits against their surgeons. Although all ICFs, regardless of their institution, are generally insufficient for defending hospital administrations or surgeons during a lawsuit, ICFs of private hospitals might be considered better equipped for the situation than those of state or university hospitals. However, further research is needed to show if private hospitals have lower lawsuit rates or better lawsuit outcomes than state or university hospitals in Turkey.

The trainer, the trainee and the surgeons' assistant: clinical outcomes following total hip replacement

Balancing service provision and surgical training is a challenging issue that affects all healthcare systems. A multicentre prospective study of 1501 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and the grade of the operating surgeon, and whether there is any difference in outcome if surgeons' assistants assist with the operation, rather than orthopaedic trainees. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of revision and dislocation, operating time, and length of hospital stay. There was no significant difference in DeltaOHS or complication rates between operations undertaken by trainers and trainees, or those at which surgeons' assistants and trainees were the assistant. However, there was a significant difference in the duration of surgery, with a mean reduction of 28 minutes in those in which a surgeons' assistant was the assistant. This study provides evidence that total hip replacements can be performed safely and effectively by appropriately trained surgeons in training, and that there are potential benefits of using surgeons' assistants in orthopaedic surgery.

Surgical Training in Singapore: Will Patients Consent to Trainee Surgeons Performing Their Operations?

Introduction: Little is known about the attitudes of Singaporean patients towards the intraoperative involvement of trainee surgeons. We aimed to discover if patients would consent to having a trainee surgeon perform their surgery under the supervision of a consultant and if patients would agree to having their photographs or X-rays used for education or research. We sought to discover if patients’ decisions were related to demographic factors such as ethnicity, gender, age, socioeconomic status and previous hospitalisation. Materials and Methods: A questionnaire was administered to 104 patients immediately after their consent was obtained at the Orthopaedic Surgery Clinic and Hand and Reconstructive Microsurgery Clinic at the National University Hospital, Singapore or after admission at the Day Surgery Centre. Only patients undergoing elective orthopaedic or hand surgery were recruited. Results: Sixty-eight per cent of the patients refused to have a trainee surgeon perform their surgery. However, 96% of the patients consented to the use of their photographs or X-rays for teaching. Demographic factors found to be statistically significant were education level and age of the patients. Patients with higher educational levels were more likely to refuse trainee surgeons compared to the group with little or no education [odds ratio (OR), 4.57] but they were more likely to consent to the use of their photographs or X-rays (OR, 0.13). Conclusions: Most patients are reluctant to have a trainee surgeon operate on them. This was strongly related to the level of education attained by the patient and the age of the patient. Key words: Attitudes, Informed consent, Patients, Surgery, Trainees