Ethical Challenges in the Operating Room

As surgeons, we must recognize that this responsibility has not been as thoroughly discharged as required, and many patients who are cared for in an academic medical center will not understand fully the levels of educational trainees who participate as part of their clinical and surgical care. This author readily admits to having failed on occasion to fully inform the patient of the roles that the medical students, residents, and fellows might discharge on their behalf and their specific roles in the patient’s surgical procedure(s). However, it is possible, if not likely, that the recent discourse on overlapping and sequenced operations may require that both academic and nonacademic otolaryngologists better inform their patients about surgical assistants (including physician assistants) and the extent to which they will participate in surgical procedure(s).

Many academic medical centers and community practices that utilize physician assistants in surgery are revisiting their procedures for informing patients of the types of providers who will participate in their clinical care in various settings. In non-surgical practices, patients are becoming increasingly aware of the use of midlevel providers (advanced nurse practitioners and physician assistants), as well as medical technicians and medical assistants. The situation is a bit more complicated in a surgical practice, due to the participation of a range of individuals in a patient’s surgical care.

Patients have the ethical right to understand just who is/will be participating in their surgical care and what role each participant will play. The implication is that a patient who presents for care in a teaching hospital is at least “aware” that medical students, nursing students, and physicians-in-training will be involved in their care. What role these trainees may be taking, and their level of experience, may be less clear to the patient. Some training programs are now posting signage that introduces the patient to the concept of trainee participation in their healthcare, and others provide an explanatory document explicitly indicating the types of trainees and a general description of their role in patient care. Disclosure and explanation need to become mandated processes in all educational settings.

Educating the Educators

The ethical implications in the surgical consent process are many. The patient has a fundamental, ethical right to self determination in her/his healthcare decisions. Such autonomy about what happens to a patient’s body requires both disclosure about all important aspects of the surgical procedure(s) and the knowledge of who will be performing any aspect of a procedure. Medicines have been prescribed, blood tests ordered, and non-invasive imaging studies conducted for decades with the “assent” of the patient, rather than an informed consent (with the exception of procedures that were part of a study approved by an internal review board). Surgical procedures, however, due to the nature of their invasiveness, require a high level of explanation, including risks/benefits; alternatives to care, including no surgery; and careful, thorough, and clear answers to the patient’s questions.