Peter Angelos, MD, PhD, FACS and Debra A. DaRosa, PhD
It is early July. As the first-year surgical resident on the thoracic surgery service, you are asked by the senior resident to remove the chest tube on a patient who recently had a pulmonary resection. You have been on the service for a few days and you have seen the problems that can occur if a chest tube is pulled without appropriate management—namely, the patient may have an air leak into the pleural space requiring replacement of another chest tube. Although you have seen one chest tube removed, you are uncertain of the appropriate steps to take to ensure that the patient does not have a pneumothorax as a result of the chest tube removal.
1. How should you manage your lack of comfort with this procedure?
2. Who would be the appropriate person to speak to in order to ensure that patient safety is maintained while you gain the experience that is required to proceed?
3. Should you tell the patient of your lack of experience?
4. How should you answer if the patient asks you, “How many times have you done this before?”
5. When describing the procedure to your patient, is your level of experience important for the patient’s informed consent?
OVER YOUR HEAD
1. When answering this question, it is critical to distinguish between feelings of inadequacy and the actual lack of training or experience with a procedure. It is not uncommon for surgical residents to have some concern about doing procedures with which they have little experience. Unfortunately, early in the first year of residency, many procedures fall into the category of “things I have little experience with.” Being self-critical is important for the resident to determine if he or she has been adequately trained in all of the steps of the procedure and has seen it done by others. Lack of such minimal training in a procedure is a clear reason to ask for help from a senior resident or an attending.
2. Although there is a tendency for surgical residents to sometimes be hesitant to ask for help, doing so should never be seen as a “sign of weakness.” As a physician, a surgical resident has a responsibility to do everything possible to ensure the safety of the patient. If the resident has not been fully trained in a procedure, to proceed to do it on a patient without adequate training and/or supervision should be viewed as unethical. In some cases, surgical skills are formally taught and competency is assessed formally. However, in many cases, the individual resident is the only one who can assess whether he or she has the training needed to carry out the procedure. A more senior surgical resident or fellow or a faculty member should be asked for help in learning how to do a procedure before it is done on a patient. Depending on the skill in question, you can also ask for help from experienced nurses, physician assistants, or other health providers who are usually happy to teach, assist, or guide you.
3. It is often challenging for surgical trainees to determine whether conveying information to a patient is helpful to the patient or rather a source of additional concern. If a resident is expressing uncertainty to a patient but is not prepared to get help if the patient requests it, then the uncertainty only causes doubt in the patient. There is no single answer to whether every patient needs to know the first time you do everything. Depending on the procedure and the risks as well as the alternatives available to the patient, the surgical resident should determine whether informed consent for the procedure should require disclosure of the level of experience.
4. In contrast to question #3 above, patients should be given truthful answers to direct questions. In an effort to alleviate patient concerns, however, the resident should be prepared to follow up the answer with the explanation of what preparation and training has occurred prior to the resident actually doing the procedure.
5. Similar to the answer to question #3 above, the answer is dependent on the nature of the procedure, the level of risk to the patient, and the alternatives available to the patient. A rule of thumb to use is for the resident to honestly answer the following question, “If I were the patient, would I want to know this information?” If the answer is “Yes,” it becomes difficult to explain why a resident would not offer that information to his or her patient.
TIPS TO REMEMBER
If you feel your lack of experience or knowledge might jeopardize the patient, it is your moral responsibility to ask for help rather than attempting the skill alone.
It is not a sign of weakness to ask for help, but rather a sign of responsible self-awareness and placement of a priority on patient safety.
Be honest with a patient when he or she directly asks about your experience with performing the skill.
There is no one correct answer in determining whether a resident should disclose “this is my first time doing this procedure” to the patient. The decision to disclose this information should take into account the procedure and the risks as well as the alternatives available to the patient.
1. Which of the following statements are false? (Choose all that apply.)
A. Senior residents do not require supervision when performing bedside procedures.
B. The appropriate degree of delegation is important to patient safety.
C. The attending surgeon is ultimately responsible for the patient’s safety.
D. It is at times uncomfortable to ask for help or oversight when performing a skill for the first time on an actual patient.
E. A resident who demonstrates proficiency of a skill in the simulation laboratory is capable of performing that skill on an actual patient.
1. A and E. While senior residents require less direction than junior residents, they must also be supervised—especially for procedures with which they are unfamiliar. Accurately performing a skill in the simulation laboratory may demonstrate proficiency in a controlled environment, but performing the skill on an actual patient requires supervision to ensure positive learning transfer. Some skills may require multiple direct observation type supervision because of the skill’s complexity or difficulty due to patient anatomy or circumstances.