Resident Readiness General Surgery (68 page)

1.
How should you manage your lack of comfort with this procedure?

2.
Who would be the appropriate person to speak to in order to ensure that patient safety is maintained while you gain the experience that is required to proceed?

3.
Should you tell the patient of your lack of experience?

4.
How should you answer if the patient asks you, “How many times have you done this before?”

5.
When describing the procedure to your patient, is your level of experience important for the patient’s informed consent?

OVER YOUR HEAD

Answers

1.
When answering this question, it is critical to distinguish between
feelings
of inadequacy and the actual lack of training or experience with a procedure. It is not uncommon for surgical residents to have some concern about doing procedures with which they have little experience. Unfortunately, early in the first year of residency, many procedures fall into the category of “things I have little experience with.” Being self-critical is important for the resident to determine if he or she has been adequately trained in all of the steps of the procedure and has seen it done by others. Lack of such minimal training in a procedure is a clear reason to ask for help from a senior resident or an attending.

2.
Although there is a tendency for surgical residents to sometimes be hesitant to ask for help, doing so should never be seen as a “sign of weakness.” As a physician, a surgical resident has a responsibility to do everything possible to
ensure the safety of the patient. If the resident has not been fully trained in a procedure, to proceed to do it on a patient without adequate training and/or supervision should be viewed as unethical. In some cases, surgical skills are formally taught and competency is assessed formally. However, in many cases, the individual resident is the only one who can assess whether he or she has the training needed to carry out the procedure. A more senior surgical resident or fellow or a faculty member should be asked for help in learning how to do a procedure before it is done on a patient. Depending on the skill in question, you can also ask for help from experienced nurses, physician assistants, or other health providers who are usually happy to teach, assist, or guide you.

3.
It is often challenging for surgical trainees to determine whether conveying information to a patient is helpful to the patient or rather a source of additional concern. If a resident is expressing uncertainty to a patient but is not prepared to get help if the patient requests it, then the uncertainty only causes doubt in the patient. There is no single answer to whether every patient needs to know the first time you do everything. Depending on the procedure and the risks as well as the alternatives available to the patient, the surgical resident should determine whether informed consent for the procedure should require disclosure of the level of experience.

4.
In contrast to question #3 above, patients should be given truthful answers to direct questions. In an effort to alleviate patient concerns, however, the resident should be prepared to follow up the answer with the explanation of what preparation and training has occurred prior to the resident actually doing the procedure.

5.
Similar to the answer to question #3 above, the answer is dependent on the nature of the procedure, the level of risk to the patient, and the alternatives available to the patient. A rule of thumb to use is for the resident to honestly answer the following question, “If I were the patient, would I want to know this information?” If the answer is “Yes,” it becomes difficult to explain why a resident would not offer that information to his or her patient.

TIPS TO REMEMBER

If you feel your lack of experience or knowledge might jeopardize the patient, it is your moral responsibility to ask for help rather than attempting the skill alone.

It is not a sign of weakness to ask for help, but rather a sign of responsible self-awareness and placement of a priority on patient safety.

Be honest with a patient when he or she directly asks about your experience with performing the skill.

There is no one correct answer in determining whether a resident should disclose “this is my first time doing this procedure” to the patient. The decision to disclose this information should take into account the procedure and the risks as well as the alternatives available to the patient.

COMPREHENSION QUESTION

1.
Which of the following statements are false? (Choose all that apply.)

A. Senior residents do not require supervision when performing bedside procedures.

B. The appropriate degree of delegation is important to patient safety.

C. The attending surgeon is ultimately responsible for the patient’s safety.

D. It is at times uncomfortable to ask for help or oversight when performing a skill for the first time on an actual patient.

E. A resident who demonstrates proficiency of a skill in the simulation laboratory is capable of performing that skill on an actual patient.

Answer

1.
A and E
. While senior residents require less direction than junior residents, they must also be supervised—especially for procedures with which they are unfamiliar. Accurately performing a skill in the simulation laboratory may demonstrate proficiency in a controlled environment, but performing the skill on an actual patient requires supervision to ensure positive learning transfer. Some skills may require multiple direct observation type supervision because of the skill’s complexity or difficulty due to patient anatomy or circumstances.

A Surgical Intern in a Moral Dilemma

Peter Angelos, MD, PhD, FACS and Debra A. DaRosa, PhD

You have been on the surgical oncology service for the past 2 weeks. During that time, you have been involved in the care of a 45-year-old gentleman who has had a pancreaticoduodenectomy performed for pancreatic carcinoma. The patient has had a number of complications associated with leaks from his operation and has required percutaneous drainage. His pathology report has come back that shows positive nodes as well as a positive margin. Based on this information, you know that his overall prognosis is poor. The patient has confided in you his desire not to have his life artificially prolonged unnecessarily. Nevertheless, as he has deteriorated and required intubation and pressors for his sepsis, his family has proceeded with a very aggressive course of treatment in accordance with the recommendations of the surgical attending. You believe that perhaps the patient’s wishes have been discounted by the family and the attending surgeon.

1.
How should you approach this issue?

2.
Who would be the appropriate person with whom to raise your concerns?

3.
Do you believe your primary allegiance is to the service or to the patient for whom you have participated in care?

4.
If you believe that the care being rendered is contrary to the patient’s wishes, when is it appropriate to withdraw from this patient’s case?

MORALITY IN THE SURGICAL INTERN

Answers

1.
As a junior member of the surgical team caring for the patient, it can be easy to lose track of the fact that the resident actually has a relationship with the patient and, as a result, responsibilities to the patient. The complicating factor, however, is that your relationship with your patient is not in isolation, but rather is present because of the relationship that the patient has with the attending surgeon. In an elective situation such as this, the patient has made the choice to have the attending surgeon operate on him. The relationship between the attending surgeon and the patient certainly arose prior to the relationship between the resident and the patient. As a result, the issues that are concerning you may have already been addressed preoperatively with the patient or postoperatively with the patient’s family.

2.
For the reasons noted above relating to the relationship between the attending surgeon and the patient, as a resident, you should communicate your concerns to the attending surgeon. This is best done as a private discussion between you
and the attending surgeon and not in the presence of the other members of the team or in front of the family. Although frank discussions and a vigorous debate of alternative approaches to a complex patient’s care should occur in any teaching environment, ethical issues may be particularly emotionally charged for all involved and are best done privately. In such a context, the resident’s concerns can clearly be expressed as being focused on the patient’s interests and not misinterpreted as being a challenge to the attending surgeon’s ethics or judgment.