DC Medical Malpractice & Patient Safety Blog

In theory, people support the presence of trainees for medical procedures. But when it comes to personal practice … not so much.

So says a study in the Archives of Surgery, which examined patient perceptions and willingness to participate in resident education. More than 8 in 10 patients consented to having an intern participate in their surgical procedure, and more than 9 in 10 consented to the presence of a resident. But when presented with a real situation of trainee participation, not even 1 in 5 said OK.

More than half of the survey respondents said that knowing that their operation was a trainee’s first would affect their consent negatively.

As explained on MedPage Today, in the 1980s surgeons thwarted proposed legislation to mandate “informed consent” when trainees were involved in a patient’s procedure. The docs had argued that such patient consent referred only to the “responsible” surgeon who provides supervision and oversight. Today, the study’s researchers noted, it’s still common practice not to inform patients of trainee participation.

In an accompanying commentary to the study, Ali Salim, M.D., wrote “"As part of [the informed consent] discussion, it seems obvious that patients would want the extent of involvement of surgical trainees during a surgical procedure to be disclosed, but current ethical and legal requirements for informed consent for care by trainees have not been well elucidated."

"To my knowledge,” Salim wrote, “no specific requirement or guidance exists regarding disclosure of the extent of participation of surgical trainees."

If that just seems wrong, the writers concur that full disclosure of trainee participation would affect their education negatively, because patients might refuse permission for them to participate in their care. More than 8 in 10 survey respondents indicated they wanted to be informed about trainee participation.

So here’s the quandary: Medical students can’t learn how to be good doctors without hands-on training, and although patients understand that, they don’t want to be the individual guinea pigs. The authors suggested that patients should be better educated about the nature of a teaching hospital and the benefits for patients to have trainees participating in procedures. But they remain wary about full, mandatory informed consent.

"We believe that broad calls for routine mandated disclosure should be carefully planned and analyzed prior to implementation to avoid any adverse effects on surgical training," they concluded.

The Occupational Safety and Health Administration (OSHA), the main federal agency charged with the enforcement of workplace safety and health, is looking at limiting the number of hours medical residents can work to 80 hours a week.

The decision to consider such limits came after OSHA received a petition filed by Public Citizen; the Committee of Interns and Residents/SEIU Healthcare; the American Medical Student Association; Dr. Charles Czeisler, Baldino professor of sleep medicine and director of the division of sleep medicine at Harvard Medical School; Dr. Christopher Landrigan, assistant professor of pediatrics and medicine at Harvard Medical School; and Dr. Bertrand Bell, professor of medicine at Albert Einstein College of Medicine.

Petition signatories noted their concerns about medical residents working extremely long hours,” anc cited evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors, and motor vehicle accidents.

In agreeing to consider the petition, assistant secretary of Labor for Occupational Safety and Health David Michaels, who heads OSHA, noted that “the relationship of long hours, worker fatigue and safety is a concern beyond medical residents, since there is extensive evidence linking fatigue with operator error. In its investigation of the root causes of the BP Texas City oil refinery explosion in 2005, in which 15 workers were killed and approximately 170 injured, the U.S. Chemical Safety Board identified worker fatigue and long work hours as a likely contributing factor to the explosion."

In addition to seeking a limit of 80 hours of work in each and every week for hospital residents, the petition also seeks:

A limit of 16 consecutive hours worked in one shift for all resident physicians and subspecialty resident physicians;
At least one 24-hour period of time off work per week and one 48-hour period of time off work per month, for a total of five days off work per month, without averaging;
In-hospital on-call frequency no more than once every three nights, no averaging;
A minimum of at least 10 hours off work after a day shift, and a minimum of 12 hours off after a night shift;
A maximum of four consecutive night shifts with a minimum of 48 hours off after a sequence of three or four night shifts.

Source: Occupational Health and Safety Magazine

You can view Dr. Michaels' full response to the petition here.

Also, here's one surgeon's entertaining take on the issue, in the Psychology Today blog. You can guess his point of view by his title: "Training surgeons not sissies."

Nurse anesthetists have been proven to deliver about as safe and high quality care as physician anesthesiologists, but there's still a key question every patient should ask before being put to sleep by a nurse anesthetist.

"Is there a doctor anesthesiologist nearby in case there's an emergency during my surgery?"

That's the question you need to get answered. In most hospitals and many free-standing surgery centers, the answer will be, "Of course, we wouldn't dream of putting patients to sleep without an anesthesiologist supervising the anesthetists." But in other facilities, particularly same-day surgery centers, the answer will be, "No, we don't think it's necessary."

And that "no" should give you pause.

Anesthesiologists have MD degrees and broad training in medicine. They also spend a lot more years learning anesthesia than nurses who come up through a "CRNA" program (Certified Registered Nurse Anesthetist). It costs about six times as much to train an anesthesiologist as an anesthetist, and the anesthesiologists are paid about double what nurse anesthetists get paid.

If something goes terribly wrong during surgery -- and luckily that's a rare event nowadays, thanks to improvements in anesthesia technology over the last thirty years -- I know who I want nearby. That's an anesthesiologist.

You can read more about this in a series of letters to the editor in the New York Times debating the merits of state governments passing laws that opt their state out of the Medicare requirement that surgery centers have an anesthesiologist supervisor.

I discuss anesthesia and other issues about safe surgery in my book, "The Life You Save."

A newly minted M.D. doctor wandering the halls of a hospital, working long hours with little sleep as he or she begins years of residency training, can be a potential disaster waiting to happen. That's the source of the old bromide about July being the most dangerous month to get sick, since that's when residency programs start their new year.

In theory, all junior doctors receive careful supervision from senior doctors in training and from full-fledged "attending" physicians. But in practice, in busy institutions junior doctors can work long hours with little supervision, and mistakes that cause injuries to patients can result.

In 2003, residency programs accredited by the official supervisory body, the ACGME, were required to cut resident work weeks from 120 to 80 hours. But in December 2008, the Institute of Medicine, part of the National Academies of Sciences, recommended more changes to improve patient safety in residency programs.

One of them was to end the practice of 24-hour shifts.

The ACGME is now following that advice, but only in part. As of July 2011, first-year residents will be limited to 16-hour shifts, but after the first year, residents will still be able to work a 24-hour shift. Many experts believe the longer shifts are dangerous for patient safety because of sleep deprivation.

The 16-hour limit for first-years is part of a series of recommendations being submitted to the ACGME board for final approval in a few months.

Sidney Wolfe, MD., head of Public Citizen Health Research Group, is critical of the failure of the ACGME to propose a 16-hour limit across the board. He says: "The improvements in the new ACGME guidelines are largely swamped by the failure to cover the majority of medical residents with the protection of not having to work more than 16 hours continuously."

In the new proposal, first-year residents would also be barred from moonlighting at other jobs and from being "on call" in hospitals.

See the article in American Medical News for more details.