A Medical Student and YOU: Like to Know Who is Closing the Incision?
I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania. Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Principle of Patient Autonomy.
A STARTING COMMENT FROM ME:
In the case of surgery, informed consent for a procedure means that the patient understands the need for the surgery, the risks and in general how and specifically who is performing the surgery. By becoming informed and then agreeing, the patient's autonomy is maintained. To intentionally fail to inform the patient beforehand as to who is part of the surgical team, except in the case of an emergent switch of surgeons, defeats the validity of informed consent. Patients expect the best of surgical skills and to have a novice involved without informing the patient and receiving patient consent for that novice is unethical and fails professional standards regardless of the necessity for novice (student) education. ..Maurice.
posted by Maurice Bernstein, M.D. @ 3:29:00 PM
13 comments
13 Comments:
In the case of surgery, informed consent for a procedure means that the patient understands the need for the surgery, the risks and in general how and specifically who is performing the surgery. By becoming informed and then agreeing, the patient's autonomy is maintained. To intentionally fail to inform the patient beforehand as to who is part of the surgical team, except in the case of an emergent switch of surgeons, defeats the validity of informed consent. Patients expect the best of surgical skills and to have a novice involved without informing the patient and receiving patient consent for that novice is unethical and fails professional standards regardless of the necessity for novice (student) education. ..Maurice.
The patient agreed with student assistance. Surgeon can't complete the surgery solo so he asked one of the students to "help" with closing. I don't see the problem with this.
Ed
Ed, thanks for responding but review the vignette again. According to the text "The resident explains that Dr. White will be doing the entire procedure and he will be assisting and the student will be watching." I found that narrative of the dramatic video was consistent with the text. Therefore, the student doing more than just watching would be in violation of the patient's permission based on the information provided by the resident. Battery,defined as "an intentional unpermitted act causing harmful or offensive contact with the 'person' of another" should never be excused on the basis as a requirement for medical education. ..Maurice.
Should a patient recognize the distinction between a student, resident, and intern? The vast majority of patients do not IMO. They are synonymous with a student in training, i.e. not fully qualified to practice medicine without supervision.
Ed
In the United States, no medical student can legally diagnose and treat patients without supervision and the responsibility of a licensed physician. Receiving the doctor of medicine degree at the end of the medical school training still does not allow independent practice of medicine.
However,following completion as a "student" of a medical school doctorate of medicine degree, completion of an "internship" which is considered as the first year of a "residency" program and with the satisfactory completion of a "National Board" examination, the individual can practice medicine, unsupervised, in the state for which the individual is licensed.
"Residents", licensed physicians furthering their knowledge and skills in particular specialties are thus legally able to "moonlight" (but discouraged) and practice medicine outside of their teaching hospital but nevertheless, within the teaching program, their work is under supervision by superiors.
Unfortunately, these distinctions between levels of medical education, experience and responsibilities may not be known or understood by patients and their families but clearly should be part of any informed consent being requested from a patient.
It is essential for the patient to know who and with what skills and responsibilities are the ones for making or closing the incision or all the acts in between. ..Maurice.
Thanks, I'm much more informed about the distinction in this and many other areas thanks to your blog. In the scenario provided, the patient was clear. Once under, there's no guarantee that our stated requests will be honored. Is there any sort of log or record kept during surgery that details who did what during the procedure?
Ed
Ed, as I recall, the operative reports, I have seen, usually discloses the names of the surgeons participating but it isn't like the credit streamers displayed for motion pictures where everyone with any participation (such as the nursing staff or techs) are listed and I also don't recall about visitors. I have not been a general visitor to operating rooms in the past, so I don't know if nursing staff writes and preserves a separate list but if they do I haven't seen anything like that in the patient's chart. ..Maurice.
My point was would the operative report show that the "student" closed the incision. If so, the patient has a legitimate complaint.
Ed
Good point but a student would never be identified as performing a surgical procedure on a patient in a operative report. The legal responsibility for such an act must fall toward the attending surgeon or resident physician since they are the only ones licensed for that responsibility. And it is that very dichotomy in practice of what is legal and what should be part of informed consent which makes this action by the student unethical despite any value for teaching. ..Maurice.
Not to belabor the point but would the operative report clearly show whether the resident closed vice the surgeon?
"I hope that Dr. White is doing the entire operation. I know you are both here to learn, but I came to this hospital because Dr. White is the best and I only want him to operate on me."
The patient clearly expects his surgeon to operate from start to finish. Most patients wouldn't care if a resident closed (IMO) but this patient stated otherwise.
If operative reports do not highlight such details, all patient requests are nothing more than wishful thinking. If that's the case, what's the point in requesting things like no pictures, videos, observers, non-consensual exams, etc.
Ed
Ed, the responsibility for all phases of the operation (including the anestheia by the anesthesiologist) is carried by the primary surgeon (such as Dr. White). So, who does what is immaterial from the chart's point of view because of that established responsibility. Nevertheless, regardless of responsibility for the activity, it would still be unethical and contrary to the informed consent received for the patient's request to be ignored except in a situation of an life and death emergency. For example, it might be necessary for the primary surgeon to leave the room to help another surgeon facing a critical situation in another room. The primary surgeon could leave with knowledge that his or her associate surgeon (even a senior resident) had the skill to continue the surgery until the primary surgeon returns.
These details, I should say, are based on my occasional experience with the operating rooms as an internist and it would be valuable for a surgeon to join this conversation regarding verifying my observations. ..Maurice.
I find it very troubling that the autonomy of the patient is still routinely disregarded.
My wife requested certain things during her surgery. Everything she had requested was agreed to by the surgeon, OR head nurse and hospital administration. As an additional measure, she wrote all those agreements on her consent form.
There is no evidence that any of those things were honored. Before the versed took effect, she saw several people in the OR whose names did not appear anywhere in her records. Further, the anesthesia report clearly showed more than one person’s handwriting.
This was an elective surgery. There were no sentinel events, according to the surgeon and the record. What protection did she really have from ghost surgery, observers and nonconsensual exams? What was the point of going through all that trouble if they were not truly going to honor her requests?
I find it very hard to trust in an institution where, it appears, that once the patient goes into the OR and is drugged, then intubated, has little or no protection from the things she does not want to happen to her.
What is more troubling is that this and other blogs, seem to dismiss the concern the Ed has in regard to patient autonomy by saying that it is the surgeon's responsibility. If the patient consents for Dr White only, how can one justify Dr Jones and Resident Wilson performing part or all of the surgery? Am I missing something?
Or, are you saying that this type of behavior is unethical and contrary to her informed consent?
We need surgeons or OR nurses to write here their explanations. ..Maurice.
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