September 9, 2009
75% Would Consider Letting Unsupervised Trainee Perform Surgery
Three-quarters of surgical patients would consider allowing a competent unsupervised trainee junior doctor perform their entire operation if it meant they could have it done more quickly, according to a survey published in the September issue of BJUI.
The responses were high regardless of how complex the surgery was, with 80 per cent of those facing minor surgery and 68 per cent of those facing major surgery saying they would consider the suggestion.Eighty patients took part in the survey at the John Radcliffe Hospital in Oxford, UK, after a hundred questionnaires were distributed to patients who had just undergone urological surgery. Just under two-thirds (65 per cent) were men, their average age was 69 and 42.5 per cent were in for major surgery.
"We were surprised by the results, as only 50 per cent of patients felt it was appropriate in general for trainees - even those just about to take up a consultant post - to operate unsupervised and this figure went down to 10 per cent when it came to their own operation" says specialist trainee Mr Robert Ritchie.
"But when waiting times were factored into the equation, it became very clear that patients were prepared to rethink their views if it meant having their operation more quickly."
Most of the respondents (90 per cent) felt that trainees needed to operate under supervision to improve their skills and 77 per cent were happy for a supervised trainee to do their operation. The majority (96 per cent) felt they should be told if a trainee was involved in their procedure.
"The opportunity to learn, repeat and perfect surgical skills is an essential component of any surgical training program and allowing trainee surgeons to operate on patients is important" says Mr Ritchie.
"However, surgical training often fails to take into account individual patients and their right to know who is doing their operation. National Health Service consent forms currently state that the hospital cannot say who will be performing the operation, only that the surgeon will be competent to perform the procedure.
"This can be at odds with informed consent, which under common law requires that patients should be provided with clear and accurate information about the risks of any proposed investigation or treatment.
"It also appears to be at odds with General Medical Council (GMC) Guidelines. These say that surgeons must tell patients who will be mainly responsible for their care and what their roles are. They also state that the surgeon must make sure that the patient agrees to the participation of other professionals in their operation."
Mr Ritchie and his co-author, consultant urologist Mr John Reynard, are calling for a fundamental change in the level of information provided to patients about the identity of the surgeon carrying out their operation, to bring practice in line with this GMC guidance.
"Whether informing patients that trainees will be involved in their operation will lead to a reduction in training opportunities is unclear" says Mr Reynard.
"A study of orthopedic patients published in 2004 showed that 74 per cent were happy for a trainee to perform all or part of their procedure, but a 2005 study of cataract patients showed that only 16 per cent agreed to go ahead if a supervised trainee was directly involved."
The authors say that it is reassuring that patients understand the need for junior doctors to perform procedures as part of their training. But they also feel that it is important to try and address the issues around consent, without this resulting in a loss of training opportunities.
"The results of our study create a challenge for the consultant who has to balance his or her role as a trainer with the responsibility for overall care of the patient" adds Mr Reynard.
"We recommend that both the trainer and trainee see patients before surgery and take the opportunity to explain their respective roles in the operating theatre. It is a good time to stress how important training is in ensuring that high standards of surgical care and operative skills are maintained for present and future generations.
"It is also clearly time for consultant surgeons who allow unsupervised trainees to operate to reappraise this practice."
* Consent for surgery: will you be doing my operation, doctor? Ritchie R W and Reynard J. BJUI. 104, 766-768. (September 2009).
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