Another article I wanted to share with our readers because we are on the other side of the “blood brain barrier” from these surgeons.
Every operation has risks. How does that change – or not – when surgical residents are involved?
Like anything, it takes time and practice to become a qualified surgeon. But what is the appropriate balance of allowing residents to gain experience and giving patients the best care possible? U.S. News explored the risks and benefits to surgery at teaching hospitals: Do the benefits of surgery at a major academic institution outweigh the costs of patients being used as a teaching tool? Is care from a surgical resident of lesser quality than care from an attending surgeon? While opinions vary among patients and medical professionals, the majority agree patients should be well-informed before making any major health care decisions.
Who Is Really Doing My Surgery at a Teaching Hospital?
When you undergo surgery at a hospital with a residency program, you should know residents are going to be involved with your operation and postoperative care. While attending surgeons are required to supervise, and inexperienced residents should not be performing complex procedures, a teaching hospital means new doctors are learning how to perform surgery – that’s how the system works.
David Shahian, a professor of surgery at Harvard Medical School and vice president of the Massachusetts General Hospital Center for Quality and Safety, says patients have the right to know about resident involvement, but he says they should not be concerned as institutions take the necessary precautions to keep patients safe.
“In our health care system, our first responsibility is to provide the best possible care to our patients. But unless we plan for the health care system to stop after this generation of physicians, we have to constantly be training the next generation,” he says.
Sid Schwab, a retired general surgeon from the Everett Clinic in Washington, who assists in the operating room and serves as a mentor for young surgeons, says doctor-patient communication is an important aspect of a successful surgical experience. “Patients ought to be aware that if they’re at a university hospital, there are going to be doctors in training involved in their care,” he says. “It’s up to the people involved in it to make sure the patient knows.”
What Are the Benefits of Surgery at a Teaching Hospital?
While some consider resident involvement a risk to surgery at a teaching hospital, many medical professionals consider residents to be extremely beneficial. Either way, their presence affects what teaching institutions can offer patients.
Shahian points out that teaching hospitals are at the forefront of medical research and are often referral centers for rare and extreme medical cases. They also encourage surgical attendings to be up to date on medical discoveries. “It forces [attending surgeons] to keep up with all the current literature because they are constantly getting questions from the residents,” he says. “The residents bring a vibrant intellectual atmosphere to the institution.”
Jon Schellack, a vascular surgeon in Baton Rouge, Louisiana, and clinical professor of surgery at Louisiana State University Health Sciences Center-New Orleans, has been working with surgical residents for 25 years. He says the residency program creates a better environment for patients and doctors.
“The medical students and the residents are very inquisitive, and they are also always looking up the patient’s problem and diagnosis and researching it and challenging me and asking me questions,” he says.
Shahian adds that people tend to forget residents are qualified medical doctors, and at a teaching institution, certified doctors are constantly available. “I don’t think people realize that after medical school, the period of residency for a surgeon can be anywhere from five to 10 years,” he says.
Shahian conducted a study that evaluated the outcomes of over 1.5 million Medicare patientsexperiencing three commonly treated health problems: heart attacks, heart failure and pneumonia. Using data from 2009 to 2010, the study found that there was a 10 percent reduced risk of mortality by being treated in a teaching hospital.
Stephen Yang, a professor of surgery and oncology at the Johns Hopkins University School of Medicine and chief of thoracic surgery at Johns Hopkins Medicine, wrote a 2008 paper that compared the outcomes for lung cancer patients at teaching hospitals versus nonteaching hospitals using the National Inpatient Sample database. “The mortality was better [and] the complications were less at teaching hospitals,” Yang says, “so overall I think the general outcomes were better.”
David Farley, a professor of surgery at the Mayo Medical School and former program director of the General Surgery Training Program, has also focused on the subject in his research and has seen a difference in procedure lengths. “When you let surgical residents participate in an operation with a staff person close by mentoring, proctoring, helping, the operative times tend to be a little bit longer,” Farley says. However, he adds that the outcomes of teaching versus nonteaching hospitals “are virtually the same and, if anything, maybe slightly improved.”
Can I Refuse Resident Care?
Jarret Brashear, a third-year general surgery resident currently serving as a resident at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana, says he’s never had a patient reject his care because he was a resident. He adds that residents are always supervised when performing procedures, and patient safety is the first priority. “[The anesthesiologist] won’t put the patient to sleep or anything like that without the attending being around,” Brashear says.
However, Erin Moaratty, a spokeswoman for the Patient Advocate Foundation, says patients should ask questions and find a doctor they are comfortable with. She also recommends researching the physician’s education and medical experience. “If at any point the patient is uncomfortable, they can halt the treatment schedule and seek alternate options,” she adds. “Each training facility has a formalized process where the resident is supervised daily by an experienced team of doctors who are fully aware of your medical situation. Asking to speak directly to that team is within your rights as a patient.”
Philip Young, a gynecologic surgeon and clinical professor of reproductive medicine at the University of California-San Diego School of Medicine, says patients shouldn’t avoid a hospital simply because it has a teaching program.
“Having been in both situations in my life, I don’t think it makes a bit of difference as far as the care is concerned,” he says. “A good private hospital will provide you the same care as a good teaching hospital, except a teaching hospital has more resources and is better at taking care of oddball things.”
According to U.S. News Best Hospitals 2014-2015, the top five hospitals in the U.S. have surgical residency programs: Mayo Clinic, Massachusetts General Hospital, Johns Hopkins, Cleveland Clinicand UCLA Medical Center.
If you’re at a reputable hospital, Young says you should feel confident the doctors will provide the best care possible. He does not believe doctors need to conduct a “mini-course in medicine” as part of informed consent. He also says patients should know about the overall outcomes of the procedure, but it’s not necessary for them to be informed of every detail.
Shahian says he believes that at a reputable institution, resident involvement almost always adds to the quality of care. “Sometimes people say they don’t want any residents involved in their care. I think that’s a mistake for a patient because in fact having residents involved in your care is generally to your advantage,” he says.
How Can I Ensure I’m Receiving the Best Care Possible?
Patients can protect themselves by being informed and having a candid, preoperative conversationwith the attending surgeon. Ask questions such as: Who will be performing my surgery? How long should the procedure take? What should I feel like when I wake up? Which parts of the surgery will a resident be allowed to perform?
Surgeons say improvement in supervision and quality of resident care has and continues to take place. “I would say, based on my many years in surgery, that the training of residents is much more closely supervised than it was decades ago,” Shahian says.