Respect for whose autonomy? Communicating with patients regarding trainee involvement

It is common for patients to make requests regarding their perioperative care. These requests may relate to their preferences for communication, preferred time the procedure will take place, or even method of anesthesia. Often, surgeons work to accommodate these requests because it helps them deliver more patient-centered care. However, at times patients make requests that are difficult to accommodate or that challenge the standard of care. One example of such a request is when patients ask that trainees not participate in their care.

Case study

A 59-year-old woman with a newly diagnosed colonic adenocarcinoma presents to a surgical oncology clinic at a large teaching hospital. She is initially seen by a surgical chief resident, who completes a history and physical exam as part of the preoperative workup. Afterward, the resident presents the case to the attending surgeon. After reviewing the patient’s information, the resident and attending decide to recommend a laparoscopic left hemicolectomy with a primary anastomosis. They return to speak with the patient together. The attending broadly discusses the indication for surgery, details of the operation, and the expectations for the patient’s postoperative course and future oncologic care. The attending leaves the room and asks the surgical resident to finish the consent process. The resident discusses the specific risks of the operation but neglects to describe how the medical team is structured or the specific duties of the residents and attending surgeons. While preparing to sign the informed consent form, the patient tells the chief resident, “I don’t want any residents taking care of me.”

The U.S. health care system has become increasingly complex in recent decades. Today, more people are employed in health care than in any other professional sector.¹ The system isn’t just expanding in size; new roles have been developed to match the needs of our growing system and those of the patients we serve. Even seasoned surgeons may find it difficult to identify the roles and responsibilities of the medical scribes, nurse navigators, care coordinators, and clinical documentation specialists whom they work alongside. It should come as no surprise that patients also have difficulty making these distinctions. Studies suggest that patients often are unable to differentiate members of their medical teams and may be unaware of the qualifications of individuals occupying these roles.^2,3 Misinformation is common and may influence how patients make decisions regarding their care.

In academic medical centers, attending surgeons exercise their professional autonomy by allowing trainees to perform certain clinical activities independently.⁴ As in the case described at the beginning of this article, patients who receive care in these settings may request that trainees not participate in their care. These requests are made for numerous reasons, such as a prior negative experience, a desire for more streamlined care, or a fear of being cared for by learners still honing their skills. In these scenarios, respect for patient autonomy and the desire to provide patient-centered care may conflict with the professional autonomy of surgeons.

Patients who request that trainees be excluded from their care may not recognize that the level of independence trainees are given is dependent upon a rigorous system of evaluation. Supervisors continuously observe and critique trainees’ skills, allowing them to practice independently only after they demonstrate competence. This framework of graded responsibility allows surgical trainees to progress toward safe and independent practice, which, in addition to patient care, is central to the mission of teaching hospitals.

Patient requests to exclude trainee participation, effectively undermining the system of graded responsibility, are not without costs. In academic medical centers, where trainee participation is the standard of care, these requests can render care less efficient and timely. The downstream effects may be subtler, though perhaps even more important. Reducing trainees’ learning opportunities threatens the preparation and productivity of the graduating surgical workforce, which may in turn affect the quality of surgical care delivered.

Surgeons who receive patient requests to exclude trainees from their care need to consider the following questions:

• Are patients who make these requests making informed decisions?
• What are the harms, if any, associated with such requests?
• Under what circumstances are these requests appropriate?
• How can health care professionals help patients to better understand the roles of surgical faculty and trainees?

This article examines the limits of patient autonomy and the professional autonomy of surgeons in an effort to explore the associated tensions that arise when the two conflict. In light of this analysis, the authors provide recommendations on how surgeons can best counsel patients on trainee participation in their care.

Respect for patient autonomy

Respect for autonomy is a bedrock principle of clinical medical ethics in the U.S.⁵ For adult patients with decisional capacity, respect for autonomy and self-determination guide care. When a patient’s decisions conflict with what medical teams believe is in the best interests of the patient, respect for autonomy outweighs beneficence. The primacy of patient autonomy has not always been standard. Until the late 1900s, physicians were far more paternalistic and directed medical care based on their perception of their patients’ best interests, rather than respecting their patients’ preferences.⁶ In fact, the rights of patients were not mentioned in the American Medical Association Principles of Medical Ethics until 2001.⁷

Throughout the latter half of the 20th century, medicine increasingly recognized respect for patient autonomy. In their landmark 1979 publication, Principles of Biomedical Ethics, Beauchamp and Childress defined four ethical principles that ought to guide physicians’ practice and decision making, an approach now referred to as principlism.⁸ Beauchamp and Childress included respect for patient autonomy in their principles, challenging paternalism in medical practice. Prominent legislation, such as the Patient Self-Determination Act of 1990 and death with dignity laws enacted today, also reflect this change in perspective. Today, it is accepted that adult patients with decisional capacity can refuse recommended medical care, even in situations where such care is lifesaving.

Patients with decisional capacity may choose whether to receive medical treatment, but can they dictate which members of the medical team provide this care? In some cases, this practice is acceptable. For instance, in cases of sexual assault, victims are allowed to choose the gender of their examiner whenever possible. These requests become harder to accommodate when they burden the system in its capacity for delivering care. In academic medical centers, when patients request to exclude trainees from their care, the resulting interruptions to the trainee-centric workflow may compromise patient care.

Professional autonomy, graded responsibility, and trainee independence

Individual surgeons and the surgical profession as a whole are perceived as autonomous. The notion of professional autonomy is reliant on adherence to core areas of medical ethics, including abiding by patients’ wishes and key elements of professionalism. Professional autonomy allows surgeons to define the nature of surgical practice, criteria for surgical quality, requirements for entry into the workforce, continuing education, methods of regulation, and professional ethics.⁹ Laurence McCullough discusses professional autonomy as it relates to individual surgeons in his book Surgical Ethics, noting that surgeons have professional autonomy to decide what treatments, operations, and procedures, if any, suit the needs of their patients.¹⁰ Surgical trainees cannot exercise the same professional autonomy as those who train them. However, they are allowed to act independently in certain scenarios. The surgical profession at large has judged this practice of graded responsibility to be a viable educational model for training, whereby surgeon educators use their discretion to define the nature and scope of the tasks that a trainee may perform independently.

Graded responsibility, or “performing increasingly complex functions over time and experiencing gradual reductions in supervision,” is a mainstay of surgical education.¹¹ As trainees demonstrate their competency, they are allowed to independently perform diverse tasks, such as procedures and operations, advanced communication, leadership of surgical teams, and teaching. This practice provides trainees with opportunities to further develop their skills in a supervised environment before practicing independently. Graded responsibility also ensures appropriate delegation of tasks such that all members of surgical teams are performing at their greatest professional capacity. This practice maximizes the efficiency of the surgical workforce. Within teaching hospitals, it is a requirement for meeting the demands of patient care.

The theoretical advantages underlying a system of graded responsibility are self-evident, but the practice remains somewhat subjective. Although the general surgery milestones introduced by the Accreditation Council for Graduate Medical Education are a step toward defining competency for trainees, the educational community has yet to agree upon a process for faculty surgeons to interpret the milestones, assess competency, and advance the trainee accordingly.

In the past, William S. Halsted, MD, FACS, provided a concrete, if imperfect, framework of “see one, do one, teach one” for advancing trainees.¹² Today, calls for patient safety and heightened transparency require a more measured approach to training. Trainees should not perform procedures that they aren’t prepared to do. Paradoxically, trainees need opportunities to perform procedures they have never done for the express purpose of achieving the competencies necessary to become a surgeon.¹³

Relying on the system of graded responsibility requires education, engagement, and accountability at every level of the surgical hierarchy. Supervising attendings exercise their professional autonomy, continuously judging whether trainees are capable of performing assigned tasks. Trainees are expected to communicate when they feel unable to accomplish assigned tasks safely or when they require assistance. Despite trainees performing tasks independently, attending surgeons are still responsible for the care that they provide. This process and the level of rigor it demands may not be apparent to patients. This lack of transparency may account for patient requests that residents be excluded from their care. Surgeons often work to honor these requests, respecting their patients’ autonomy, but should they? And if so, are there limits to this practice? Attendings who choose to practice in a teaching environment also shoulder the responsibility of training the next generation of surgeons. How, then, can surgeons balance their duty to patients and their trainees? Achieving this equilibrium requires careful and compassionate communication between surgeons and their patients.

Discussing trainee involvement in patient care

Attending surgeons practicing in teaching hospitals have a dual commitment to trainee education and patient-centered care. Balancing these duties can be difficult. If they are poorly managed, untoward effects on patient outcomes and the readiness of future generations of surgeons for independent practice may result. The teaching paradigm of graded responsibility requires a continuous benefit-burden analysis that factors in patient safety and time management. Although trainees may be keenly aware of this interplay, patients may not. The informed consent process is one arena in which this conflict commonly materializes. It may be the first time that a detailed account of the roles and responsibilities of surgical learners is verbalized to the patient. A surgeon who aims to have this discussion is confronted with a challenging ethical question: Does a lack of transparency regarding trainee participation in patient care limit patient autonomy? Conversely, would more transparency limit the professional autonomy of surgeons?

Informed consent has been an integral part of medicine since the earliest recorded days, but it was not until 1914, with Scholendorff v. The Society of the New York Hospital, that the principles of informed consent were first established in the U.S.¹⁴ Beyond determining decisional capacity, key portions of any procedural consent require clear identification of who will be performing the procedure; the diagnosis; the procedure to be performed; and the risks, benefits, and alternatives to surgical intervention. The American College of Surgeons and the American Medical Association both have set guidelines stating that patients must be informed of trainee involvement in their care.^15,16 Nonetheless, studies suggest that surgeons may be missing the mark when it comes to discussing the role of trainee involvement in patient care.

Knifed and colleagues set out to determine what surgeons disclose to patients regarding intraoperative involvement of surgical trainees when obtaining informed consent. A survey and in-person interviews were conducted to determine when and how surgeons discuss the role of trainees. Of the 138 surgeons who completed the survey, 83 percent did not volunteer this information to patients unless asked, and 75 percent did not insist that their trainees meet patients before the procedure.¹⁷

Of the 39 surgeons interviewed in person, 87 percent allowed trainees to operate while they themselves were not scrubbed, and 77 percent allowed trainees to operate while they themselves were not present in the operating room. The reasons surgeons did not explicitly discuss the role of trainees with their patients included time constraints or a perception that the role of trainees was already implied to the patient. These results suggest that at least some surgeons use their professional autonomy to override the autonomy of their patients, prioritizing trainee independence more highly than patient requests. In this study, the perceived effects of full disclosure were surmised. Other studies have sought to expound on the implications of such disclosures.¹⁷

Porta and colleagues examined the effect of patient willingness to proceed with surgical procedures after full disclosure of intraoperative trainee involvement by distributing 500 patient surveys at a single center.¹⁴ Subjects reported demographic characteristics and were asked to describe their understanding of the concept of a teaching hospital, their planned surgical procedure, and comfort level receiving care at a teaching facility. Definitions of teaching hospital, medical student, intern, resident, and staff surgeon were provided. The last section of the survey described nine scenarios for the respondents’ proposed surgical procedure with increasing levels of trainee participation and decreasing levels of staff surgeon participation. Subjects (n = 316) were asked to report their willingness to participate, response to training scenarios, and willingness to consent to procedures involving trainees. Some of the results were sobering. With respect to willingness to participate, 79 percent of patients knew the study institution was a teaching facility and supported the idea of trainee involvement in their procedure, and 94 percent of patients would consent to the involvement of a surgical trainee.

As for training scenarios, 95 percent of patients would consent to no direct trainee involvement; 83 percent of patients would consent to a senior surgical trainee assisting, 58 percent with a junior surgical trainee, and 55 percent with an intern; and 58 percent would consent to a junior surgical trainee acting as first assistant, 26 percent with the trainee acting as the operating surgeon with direct staff observation, and 18 percent as operating surgeon without direct staff observation.¹⁴

The study suggests that patients want to know more about trainee involvement, but when they are provided with this information, may change the likelihood to consent. The fact of the matter remains, however, that surgeons are obligated to facilitate the surgical education of trainees through graded responsibility in order to produce competent and safe surgeons.

How then, can surgeons fulfill their dual obligations to patient care and trainee education? The authors believe that achieving this balance requires careful communication between attending surgeons and their patients.

Handling requests for limited trainee involvement in care

The case presented at the beginning of this article, although relatively rare in occurrence, is representative of the ethical dilemma that confronts a surgeon when a patient requests to limit trainee involvement. Although it is unclear why the patient in this case made this request, typically such requests arise from a lack of information or misperceptions about the capability of trainees. Effective communication can help clarify these gaps and facilitate trainee involvement. Following are several communication strategies that can be implemented with minimal interference to a standard clinical workflow designed to navigate patient requests to limit trainee involvement in their care:

• Actively involve the attending surgeon in the conversation: While the attending will be faced with a conflict of commitments to the present patient, future patients, and to the surgical trainee, the attending surgeon is well positioned to fully explain the dynamics of the surgical team and the concept of graded responsibility.¹⁸ Ideally, the attending will play a proactive role in explaining how trainees contribute to patient care.
• Take some time to explore the request: Patients have many reasons for making these types of requests, ranging from a misunderstanding of the trainee’s role, to concerns for privacy, to prior negative experiences in a teaching hospital, and beyond. As when taking a history, asking open-ended questions about the request will help prompt the patient to explain the rationale for the decision and help mitigate a sense of confrontation. Knowing why the patient is making the request will dictate what to communicate moving forward.
• Appeal to the mission of the teaching hospital: In many cases, effective communication will elucidate reasons for patient requests that can be easily remedied by providing missing information or clarifying misperceptions. When patients persist in asking to exclude trainees from their care, however, attendings may succeed in explaining that allowing trainees to participate in the provision of care has the additional benefit of helping to train a future generation of surgeons. This mission of teaching hospitals is not always readily apparent to the patient.
• Offer a compromise: For patients who are still unwilling to allow trainee participation, surgeons can seek common ground. In many cases, reassurance that trainees are qualified physicians under the supervision of attendings and operating under an established system of graded responsibility will assuage patient concerns. Surgeons also can appeal to the fact that operations require more than one set of hands, and that having trainees assist may be necessary to the successful completion of the operation.
• Offer to refer the patient to another physician not involved in trainee education: Ultimately, patients have a legal right to refuse care from trainees. By the same token, attending surgeons have an ethical responsibility to their trainees. Rather than abrogate that responsibility, surgeons have the right to refer patients to other physicians who are not involved in surgical education. This process should be done respectfully so as not to leave patients with a sense of abandonment.
• Surgical training requires trainee engagement in all elements of patient care: According to Escobar and McCullough, “it is not the sole responsibility of the surgery faculty to protect the residents. Residents must take responsibility for their own training.”¹⁸ Surgical training encompasses much more than achieving certain technical skills; the preoperative assessment, including the decision to operate, as well as the postoperative management of both routine operations and of complications are just as crucial to master. Whenever possible, trainees must be committed to developing relationships with their patients. Except in emergency scenarios, trainees should not expect patients to allow them to participate in operative elements of their care in the absence of a physician-patient relationship. This position is not new among surgeons. The surgical community confronted similar arrangements nearly 100 years ago, when the practice of “itinerant surgery,” in which surgeons operated on patients in the absence of a physician-patient relationship and delegated nonoperative elements of surgical care to other clinicians, was deemed unethical.²⁰

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