I very much enjoyed this most important and insightful editorial by Dr. Frederick Greene on the perceptions of the American public concerning resident participation in surgical care. The well-described wide spectrum of tolerance of trainee participation by patients in their surgical care is an age-old issue, but deserves fresh discussion, particularly in light of the new paradigms in surgical training.
Academic training programs have the immense responsibility of producing a competent, safe and dedicated workforce needed to meet the varied and complex needs of our surgical patients. Over the past few decades, socioeconomic, regulatory and generational pressures have made this task increasingly difficult, mainly through reductions in resident operative experience and autonomy. Surgery, not unlike many other professions, such as airline piloting, is a physical discipline that requires repetitive practice, graded responsibility and autonomy to reach the desired goal of competency. Although the current sophistication of simulators and like teaching aides are helpful, there is absolutely no substitute for real operative experience to gain the skills and judgment needed to safely practice this most complex and demanding art. Any further limitations or reductions of this most critical part of training will significantly limit overall competency and the safe delivery of surgical care to our patients.
I have had the immense privilege of working in both private and academic practice, and have participated in residency operative training at all levels of surgical sophistication. Assuming adequate supervision and a procedure tailored to the level of the resident’s skill, I have found that resident participation is safe, and in no way reduces the quality of the conduct of the procedure. Quite honestly, residents often enhance the quality of the experience with their elevated academic thoughts, questions and perspectives. Furthermore, I am aware of no serious study that has found an increase in complications or diminutive outcome rate with resident participation in surgery.
Therefore, I firmly believe that resident participation in surgery is safe, that it frequently elevates the quality of care, and that it is an essential societal requirement for the production of competent surgeons and the future quality of surgical care for all our patients. I agree with Dr. Greene that our profession needs to undertake a vigorous campaign to educate the populous as to the importance, safety and benefits of resident surgical participation in academic surgical training.
James K. Elsey, MD, FACS
Professor of Surgery, Medical University of South Carolina, Charleston
This article is from the May 2021 print issue.
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As per bioethics and the Hippocratic Oath, the current generation of physicians are responsible for training the next generation(s).
"To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others."
Ethically, this requirement would apply to ALL disciplines of healthcare. Ethically, and per the Hippocratic Oath, this obligation would continue for the practitioner's lifetime; being their profession provided for (at least some portion of) their retirement.
One can argue that this requires mandatory participation of medical trainees (of all disciplines) in the medical care of other providers.
The easiest way to accomplish this would be through the state licensing systems. Providers that are or were ever required to be licensed to practice any discipline of healthcare would be required to allow student participation in their healthcare. As part of the licensing process, licensed providers agree to allow the participation of students in their healthcare.
The practice would be reciprocal of disciplines: just as a respiratory therapist would have surgical residents involved in their surgical procedures, residents and surgeons would have students participate in their respiratory therapy. Medical training schools would have to develop a method for facilities to notify them of upcoming procedures by providers so to arrange student participation in the encounter.
Logically, current licensed and retired practitioners owe a debt to patients who they trained upon, they will pay that back by allowing students to participate in their healthcare so there is one less patient needed to be found to train a student. The next generation will then be obligated to do the same that a provider did for their learning.
This will also lead by example and show society that all the arguments that the profession of medicine uses to convince non-provider patients to allow students participate in their care, they, themselves, believe them. This is the same argument being made today for providers to be vaccinated. (Ref: https://blog.abim.org/board-certified-doctors-can-lead-by-example-with-the-covid-19-vaccine/ )
Another issue is intimate exams on patients by students WITHOUT consent (or consent buried in multi-page consent forms) still occurs TO THIS DAY. (Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223770/ ) Patients may fear being violated when an intimate exam is not even related to the procedure they are presenting for.
Janine, a nurse in Arizona, checked into the hospital for stomach surgery in 2017. Before the procedure, she told her physician that she did not want medical students to be directly involved. But after the operation, Janine said, as the anesthesia wore off, a resident came by to inform her that she had gotten her period; the resident had noticed while conducting a pelvic exam. (Source: https://www.nytimes.com/2020/02/17/health/pelvic-medical-exam-unconscious.html )
This is a practice that should have been eliminated many years ago. This too influences public perception, especially since the profession has NOT done this, many providers and students support the practice to this day, and the public has had to depend on state legislators to protect them (further eroding public trust in the profession of medicine).
The once common practice of students performing peer physical exams on each other (pre-1990's) should also be reinstated. Again, if the profession believes what they tell patients, practitioners need to lead by example. The fact that students are exempt from procedures considered uncomfortable, but patients are expected to participate only furthers the patients position and reinforces their argument.
Responding to patient concern about exposure with the rebuttal "you don't have anything we haven't seen before" is dismissive of the patient's feelings and says that as the provider, I am not uncomfortable with your exposure. In the same way, when people use terms like "medical rape," practitioners are swift to admonish patients for their feelings:
"...Ubel stated, “We don’t see a pelvic exam as having any sexual content at all, but that’s not how other people perceive it” (Goldstein 2003). “There’s no way a physician would ever equate a pelvic exam with rape—there is no rape content to it. But the fact that someone else perceives it that way makes it important” (Goldstein 2003). An unconsented intimate exam may feel like a sexual violation to patients." (Source: https://link.springer.com/article/10.1007/s10730-020-09399-4 )
After making these changes, public education campaign can show how the profession is "leading by example," further protecting patients' human dignity by substituting providers for non-provider patients in medical education, and making atonements for past wrongs and violation of patients' bodily integrity and right to choose (ref: https://www.wearyourvoicemag.com/racist-roots-gynecology-black-women-birthed/ ).
Between the requirement of students performing peer physical exams on each other, practicing and retired licensed healthcare providers, standardized patients, and non-provider patients willing to allow student participation in their healthcare (including the hesitant that would now allow student participation), there is more than enough opportunity for residents and students of all medical disciplines to adequately learn performing real procedures on real patients.
Additional resources:
https://journals.library.columbia.edu/index.php/bioethics/article/view/5904
https://www.epsteinprogram.com/pelvic-exams
https://blogs.bmj.com/bmj/2020/07/08/how-can-we-encourage-more-female-medical-students-to-participate-in-peer-to-peer-teaching-of-physical-exams/