Preoperative Disclosure of Surgical Trainee Involvement: Pandora’s Box or an Opportunity for Enlightenment? Brandon M. Wojcik, MD, Roy Phitayakorn, MD, MHPE, Keith D. Lillemoe, MD, David C. Chang, PhD, MPH, MBA, and John T. Mullen, MD I n its landmark 2001 report, Crossing the Quality Chasm, the Institute of Medicine named patient-centered care as 1 of the 6 fundamental aims of the United States health care system. 1 They define patient-centered care as ‘‘health care that establishes a partner- ship among practitioners, patients, and their families (when appro- priate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.’’ In the field of surgery, where the patient is particularly vulnerable as they are often sedated during an operation, nowhere is shared decision- making between patient and surgeon more evident than in the process of informed consent. Informed consent includes 3 elements: (1) disclosure by the surgeon of pertinent information regarding the diagnosis and an explanation of the operation, alternative therapies, and the risks and benefits associated with each; (2) assessing that the patient fully understands the information by providing them the opportunity to ask questions and clarifying misunderstandings; and (3) allowing the patient to synthesize the information they have received from both the surgeon and other sources until they have reached their own decision. 2 However, an often undiscussed—yet ethically imperative—aspect of the informed consent process is the disclosure to the patient of the fact that (and of the extent to which) trainees will participate in their care. 3 Whether the dialogue is initiated by the patient or the surgeon, the issue of trainee involvement is sensitive. Indeed, prior studies have found that surgeons often avoid disclosing the extent of resident support in patient care for a variety of reasons, including the fear of provoking anxiety and of lengthening the informed consent discus- sion. 4 Despite these fears, however, patients are actually more receptive to trainee involvement than attending surgeons perceive. A survey of the general public found that 96% of respondents welcomed resident participation. 5 In this study, the vast majority of residents, faculty, and administrators felt that the inclusion of residents improved the quality of patient care, and only 3% of patients disagreed. These sentiments are likely reflective of patient views of resident assistance in the postoperative phase of care, as they are more likely to express concerns when the topic of trainee participation in an operation is approached. 5,6 This is a challenging time for us all in the field of surgery. We must make good on our promise to deliver high-quality, patient- centered care, in which patient autonomy is not only respected but also encouraged. This requires surgeons to respect a patient’s right to refuse resident involvement in their operation. At the same time, we must also make good on our pledge to society, and to our resident trainees, to deliver high-quality, resident-centered education, in which resident autonomy is respected and encouraged by both patients and faculty. This requires patients to respect a surgeon’s right to refuse to perform their operation without a trainee in elective situations. In an effort to deliver on our obligations to both patients and trainees, surgical departments must fully embrace several implicit responsibilities that will help to ensure that everyone benefits from a highly skilled surgical workforce. First, we must be transparent during every preoperative patient encounter in our disclosure of the resident’s role in the operation and also the postoperative phase of care. This exchange should convey the degree of autonomy that the resident will have during key portions of the operation and how the attending surgeon will super- vise their work. An early and direct conversation with the attending surgeon is the most effective strategy. 4,6 A study examining different techniques of obtaining informed consent for cataract surgery dem- onstrated that patient consent to resident involvement in their pro- cedure is significantly higher when full disclosure through a personal conversation with the attending surgeon occurs. 4 These findings were corroborated in a survey of Massachusetts surgeons, which found that in 84% of the cases in which a patient expressed concerns regarding trainee participation in their operation, they ultimately agreed after further discussion with the attending surgeon. 6 These surgeons noted success with one or more arguments, including the benefit of improved quality of care with resident participation, the ethical need to train the next generation of surgeons, and the impracticality of attempting to perform an operation unassisted. 6 This conversation should be properly documented in the patient’s medical record with a statement regarding the exact role of the resident in the operation and, if known preoperatively, the name of the resident. In doing so, the attending surgeon achieves 3 important goals—demonstrating respect for patient autonomy, ini- tiating a discussion about the appropriate degree of resident auto- nomy for that case, and strengthening her/his medicolegal position. In fact, the Centers for Medicare and Medicaid Services recently initiated a national project to ‘‘increase the attention and effort that hospitals dedicate to supporting high-quality informed consent.’’ 7 The disclosure of trainee involvement should certainly be a quality metric included in their effort. Next, trainees must participate in all phases of surgical care. It is not difficult to understand why a patient may be surprised, even concerned, when the first person whom they encounter on the morning of surgery is an unfamiliar trainee. Instead, resident phys- icians should be the first person they meet during their preoperative clinic visit. The traditional Halstedian apprenticeship-model of surgical training, which promoted resident participation in all phases of patient care as they were mentored by a single surgeon, has decreased significantly due to duty-hour restrictions and the increase in surgical sub-specialization. A detailed analysis of surgical resident rotations found that residents actually have many underutilized opportunities to enhance continuity of care. 8 In this study, From the Department of Surgery, Massachusetts General Hospital, Boston, MA. The authors report no conflicts of interest. Reprints: Brandon M. Wojcik, MD, Massachusetts General Hospital, Boston, MA 02114. E-mail: bwojcik@partners.org. Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/16/XXXX-0001 DOI: 10.1097/SLA.0000000000002136 Annals of Surgery  Volume XX, Number XX, Month 2016 www.annalsofsurgery.com | 1 SURGICAL PERSPECTIVE Copyright © 2017 Wolters Kluwer Health, Inc. 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