At least once a week, when I get to the part in my informed consent discussion where I tell a person that they are at a teaching institution, someone gets a very concerned look in their eye and says something like, “But you’re the one holding the knife and actually doing my surgery? I don’t want to be a guinea pig while someone learns how.”
There are different responses to this concern, some surgeons may minimize resident involvement or reassure a person that they are ultimately responsible. I have found a direct approach that reflects my beliefs of teaching as a necessary and critical part of what I do, and it has worked well for me.
For every patient, even those who have not expressed apprehension, I am very clear before we sign the consent form about what will occur in the operating room. It goes something like this: “Surgery is always a two-person activity. If you have your surgery at the private hospital down the road, the surgical assistant is a person who has done 2-6 years of training to be a surgical assistant. Their job is to work with the surgeon and be the second pair of hands to hold tissue, blot away blood, and shine lights so that the surgeon can work. My assistant is a surgical resident, someone who has done at least 8 years of schooling, has an M.D., and is somewhere along an additional 5 year path of becoming a fully licensed surgeon themselves. If I am working with someone at the beginning of that training, I am performing most of the important steps and the resident is assisting me. If I am working with a chief resident or someone about to graduate, they are performing most of the important moves while I guide them. Either way, my job is to watch them like a hawk to be sure they are doing each move perfectly. I never know exactly who will be assisting me on the day of your surgery, but either way, I am there in the operating room with you the entire time.”
“OK, doc, but you’re the one holding the knife, right?”
I tell them that holding the knife is actually the thing that requires the least amount of skill, so when I am working with an intern, they often are holding the knife (or cautery) and doing the cutting, but if I am working with a more experienced resident, I am holding the knife. The analogy I give here is that of a carpenter. One of steps in building a beautiful wood craft is cutting the wood, but a skilled crafter must plan the design carefully, select the materials, measure each piece (twice), and finally make each carefully planned cut. A skilled surgeon must plan the incisions, find the tissue planes, know where the vital structures are and how to carefully preserve them, and none of that involves cutting.
“I see what you mean, doc, but I mean you’re not letting someone just practice on me, right?”
I remind them that all physicians are “practicing” medicine, every day even the most experienced doctor learns something new. Then I tell them what I read in Malcolm Gladwell’s Outliers: that more plane crashes happen when the more experienced pilot is flying than when the less experienced co-pilot is flying. Now, several experts have subsequently criticized parts of Gladwell’s theory, but one possible reason he offers rings true for many surgeons. Cockpits and operating rooms are by necessity very hierarchical. It is critical that one person is the leader, the decision-maker, the one ultimately responsible. That person is me, and while I work hard to build a culture of teamwork and open communication in my operating room, many residents are used to a “yes, ma’am” way of interacting. If they are operating close to your nerve, I am right there watching so carefully that they do everything perfectly. If they get too close to a structure I want them to stay away from, I stop them immediately and we reassess. If I am operating close to your nerve, though, and for whatever reason I don’t see a small branch or a small blood vessel, even if I’ve created a culture where I expect them to stop me, I think that many residents may not do so. To paraphrase Donald Rumsfeld, they may not know what they don’t know, and questioning authority is not something easily done.
“I came to see you because you have such a great reputation, I want YOU to do my surgery.”
If patients continue to push back on resident involvement, I finally tell patients that it is BECAUSE of my residents that I have such a good reputation as a skilled and knowledgeable surgeon, not in spite of them. Residents ask tough and insightful questions, and I am constantly gathering the latest data about my field to answer those questions, and that translates to patients getting the most up-to-date care. If I were operating with the same surgical technician every day for years and got so good that we were like a well-oiled machine, it would be very comfortable, but I would also be tempted to get very complacent and just keep doing my operations the same way all the time. Residents in the operating room are a vital part of the care I provide and the surgeon that I am, and I cannot do surgery without them. At this point, if a patient still insists on no resident involvement, I would thank them for their time and let them know I cannot be their surgeon. It would be equivalent to them asking the younger of two pilots on their next flight to stay on the ground, and for me, that is not an option.