Keywords
resident surgery - ophthalmic surgery - disclosure of resident involvement
In ophthalmology, as in other surgical specialties, there is a need to train surgeons
comprehensively before entering practice. This presents a potential dilemma between
providing optimal care for patients and providing training sufficient to prepare residents
for comprehensive care. There is a frequently expressed concern among ophthalmologists
and other surgeons that full disclosure of resident involvement in surgery may reduce
patient consent for trainee participation in surgery and decrease surgical training
opportunities for residents.[1]
[2]
[3] Chen et al,[4] in a recent survey of ophthalmology residency program directors (PDs) in the United
States, underscored the paucity of data on current practices and policies regarding
disclosure of resident involvement in ophthalmic surgery. The aim of the current study
is to investigate ophthalmology residents' perspectives regarding disclosure of resident
involvement in ophthalmic surgery.
Methods
Upon obtaining a study exemption from the Penn State College of Medicine Institutional
Review Board, the FREIDA online database (http://www.ama-assn.org/go/frieda) was used to identify all ophthalmology residency programs accredited by the Accreditation
Council for Graduate Medical Education (ACGME). Each program listing was reviewed
to determine the number of residents at each program and to identify each program
coordinator's contact information.
We developed an anonymous survey in multiple-choice and Likert-style format on the
Web site http://www.surveymonkey.com (survey questions and statements, as well as response options, are displayed in [Tables 1] and [2]). An email containing an explanation of the study, an invitation to residents to
participate in the survey, and the link to the survey was sent to each program coordinator.
The program coordinators were asked in the email, and in a subsequent phone call to
each coordinator, to please forward the email to all of the ophthalmology residents
in their program. We considered emailing PDs; however, after speaking with the ophthalmology
residency PDs at several institutions, the consensus was that the most reliable and
efficient way to have our survey reach the residents was through the program coordinators.
Weekly reminders were sent to the program coordinators for the subsequent 3 weeks.
Table 1
Residents' perspectives of responsibility regarding disclosure of resident involvement
in ophthalmic surgery
|
Question number
|
Question
|
Respondents, no. (%)
|
Response count
|
|
1
|
What is your current level of training?
|
|
262
|
|
PGY2
|
98 (37.4)
|
|
|
PGY3
|
79 (30.2)
|
|
|
PGY4
|
85 (32.4)
|
|
|
2
|
Does your program have an established policy on disclosing the level of resident involvement
to patients undergoing ophthalmic surgery?
|
|
254
|
|
Yes
|
66 (25.9)
|
|
|
No
|
188 (74.0)
|
|
|
2a
|
If yes, who has the primary responsibility for informing the patient about the level
of resident involvement in ophthalmic surgery?
|
|
66
|
|
Attending physician
|
31 (46.9)
|
|
|
Resident physician
|
35 (53.0)
|
|
|
Nurse
|
0
|
|
|
Other
|
0
|
|
|
2b
|
If no, who should have the primary responsibility for informing the patient about
the level of resident involvement in ophthalmic surgery?
|
|
189
|
|
Attending physician
|
117 (61.9)
|
|
|
Resident physician
|
70 (37.0)
|
|
|
Nurse
|
0
|
|
|
Other
|
2 (1.1)
|
|
|
3
|
Does your program have a resident-run clinic (VA or hospital)?
|
|
254
|
|
Yes
|
229 (90.2)
|
|
|
No
|
25 (9.8)
|
|
|
3a
|
If yes, does your resident-run clinic (VA or hospital) have an established policy
on disclosing the level of resident involvement to patients undergoing ophthalmic
surgery?
|
|
223
|
|
Yes
|
82 (36.8)
|
|
|
No
|
141 (63.2)
|
|
|
3b
|
If yes, who has the primary responsibility for informing the patient about the level
of resident involvement in ophthalmic surgery at the resident-run clinic?
|
|
82
|
|
Attending physician
|
10 (12.2)
|
|
|
Resident physician
|
72 (87.8)
|
|
|
Nurse
|
0
|
|
|
Other
|
0
|
|
|
3c
|
If no, who should have the primary responsibility for informing the patient about
the level of resident involvement in ophthalmic surgery?
|
|
142
|
|
Attending physician
|
54 (38.0)
|
|
|
Resident physician
|
88 (62.0)
|
|
|
Nurse
|
0
|
|
|
Other
|
0
|
|
Table 2
Residents' perspectives regarding disclosure policies
|
Survey statement
|
Strongly agree or agree (%)
|
Neither agree nor disagree
|
Disagree or strongly disagree
|
Response count
|
|
Patients prefer to be asked permission in advance for a resident to participate in
their ophthalmic surgery
|
168 (69.4)
|
51
|
23
|
242
|
|
Patients prefer complete disclosure regarding the level of resident involvement in
their ophthalmic surgery
|
167 (69.2)
|
50
|
24
|
241
|
|
Disclosure of the level of resident involvement in their ophthalmic surgery increases
a patient's anxiety level
|
145 (59.9)
|
55
|
42
|
242
|
|
Disclosure of the level of resident involvement in ophthalmic surgery reduces consent
for resident participation and decreases opportunities for resident surgical training
|
127 (52.4)
|
55
|
60
|
242
|
|
Disclosure of the level of resident involvement in ophthalmic surgery increases the
attending surgeon's medicolegal risk
|
60 (24.8)
|
65
|
116
|
241
|
|
Official guidelines from a professional organization (e.g., American Academy of Ophthalmology
or ACGME) would assist in disclosing the level of resident involvement in ophthalmic
surgery
|
124 (51.2)
|
65
|
53
|
242
|
|
There is often insufficient time to talk to patients about the level of resident involvement
in their ophthalmic surgery
|
75 (31.1)
|
56
|
110
|
241
|
Results
Survey results are displayed in [Tables 1] and [2]. Responses were received from 19.1% (262/1,374) of ophthalmology residents training
at 117 ACGME-accredited ophthalmology programs in the United States. Sixty-six (25.9%)
of the respondents reported that their programs did have an established policy regarding
disclosure of resident involvement in ophthalmic surgery. Of these 66 residents in
programs with established policies, 35 (53.0%) responded that the resident had the
primary responsibility for informing patients about the level of resident involvement
in surgery. Among the 189 residents at programs without an established policy, 117
(61.9%) indicated that the attending physician should have the primary responsibility
to inform patients about the level of resident involvement in surgery.
Two hundred twenty-nine respondents (90.2%) reported that they attend a residency
program that has a resident-run clinic (e.g., at a Veterans Administration [VA] Medical
Center or a hospital). Among the respondents with a resident-run clinic, 141 (63.2%)
reported that their programs do not have an established policy regarding resident
involvement in ophthalmic surgery. Of these 141 residents, 88 (62.0%) reported that
the resident should be responsible for the disclosure of resident involvement in surgery.
Of the 82 residents from programs with resident-run clinics and established policies
regarding resident involvement in ophthalmic surgery, 72 (87.8%) responded that the
resident has the primary responsibility of disclosure.
The majority of respondents (69.4%; 168/242) believed that patients prefer to be asked
permission in advance for a resident to participate in their ophthalmic care, and
69.3% (167/241) believe that patients prefer complete disclosure regarding the level
of resident involvement. About half (52.5%; 127/242) of residents felt that disclosure
of resident involvement reduces consent for resident involvement in surgery and decreases
opportunities for resident surgical training. The majority (59.9%; 145/242) of residents
felt that disclosure of resident involvement increased patient anxiety levels. Approximately
half (51.2%; 124/242) of the residents felt that official guidelines from a professional
organization (e.g., American Academy of Ophthalmology or ACGME) would assist in disclosing
the level of resident involvement in ophthalmic surgery. The minority of respondents
(24.8 and 31.1%, respectively) considered medicolegal risk and insufficient time to
be obstacles to disclosure.
Discussion
The results of this study suggest that only a few ophthalmology GME programs have
established policies for the disclosure of resident involvement in surgery. To our
knowledge, and based on a review of the Medline literature database, this is the first
study that has sought to identify policies regarding primary responsibility for disclosure
of resident involvement in surgical procedures.
In ophthalmology residency programs with established policies, slightly more than
half of the responding residents indicated that residents have the primary responsibility
of informing patients about the level of resident involvement in surgery. The majority
of those without an established policy felt that the responsibility of disclosure
belonged to the attending physician. The results of this study among ophthalmology
residents, when compared with the results from the study among ophthalmology residency
PDs,[4] indicate the similarities between resident and PD responses in programs with established
disclosure policies (53% of residents and 54% of PDs believe that the primary responsibility
of disclosure of resident participation in surgery lies with residents). When comparing
the results of respondents at programs without an established policy, the majority
of residents (61.9%) and PDs (80%) believe that the attending physician should have
the primary responsibility to inform patients about resident involvement. These results
suggest that there is a general lack of consistency between respondents at programs
with versus without an established disclosure policy regarding perceived responsibility
for disclosure of resident participation in ophthalmic surgery and underscore the
need for further research regarding the potential utility of a unified disclosure
policy.
Among resident respondents at programs with resident-run clinics (VA or hospital),
most felt that the resident had the responsibility of disclosing to patients the level
of resident involvement in surgery. Perhaps in resident-run clinics, as opposed to
faculty practices, the resident is perceived to function as the “attending” and, therefore,
to have the primary responsibility of disclosure.
Perceived barriers to disclosure include patient anxiety and potential loss of resident
surgical cases. A minority of respondents considered medicolegal and insufficient
time for disclosure obstacles to disclosure. In a study by Nguyen and colleagues,[5] 20 ophthalmologists were asked if they would use a standardized form that disclosed
resident involvement in cataract surgery. The acceptance rate was poor, with only
five agreeing to such a form. The 15 who did not agree cited perceived barriers to
disclosure similar to those identified in the current study, such as patient anxiety,
potential loss of surgical cases and length of time needed to discuss the resident
involvement.
The current study is limited by the survey response rate of 19%, which may limit the
generalizability of the results. However, this rate is comparable to the response
rate of 23% in a recent survey of U.S. ophthalmology residents.[6] In addition, the multiple-choice format of the survey may have caused bias and prevented
us from uncovering other potential barriers to disclosure.
To our knowledge, there is no publically available primer for steps in disclosing
resident involvement in ophthalmic surgery. The “Informed Consent” section of the
Code of Ethics of the American Academy of Ophthalmology (AAO) states only that “the
performance of medical or surgical procedures shall be preceded by appropriate informed
consent.”[7] In the “Communication with the Patient” section of the AAO's Code of Ethics, it
states that “open communication with the patient is essential.”[7]
The current study suggests a lack of a general policy regarding disclosure of resident
involvement in ophthalmic surgery and a lack of consistency between respondents at
programs with versus without an established disclosure policy regarding perceived
responsibility for such disclosure. This study also suggests that such a policy might
be welcome among ophthalmology residents. Further research is warranted to determine
how different disclosure policies may affect patient consent for resident participation
and resident surgical training opportunities.
