by Maurice Bernstein MD

Informed consent is the ethical and legal hallmark for the support of patient decision-making in medicine. Though the ethics of patient communication of facts without deceit has been part of medical consideration for generations, it wasn’t until the landmark decision Schloendorff v The Society of the New York Hospital in 1914 that informed consent became United States law. Informed consent has been also been emphasized from the aspect of medical ethics, in recent decades, as decision making has moved from physician paternalism to patient autonomy. Patients awaiting medical/surgical procedures are currently given variable content and amounts of information about their illness and the procedure itself and the risks and outcomes anticipated. Some general information is provided as a printed form and patient specific details is provided directly to the patient or surrogate by a healthcare provider, hopefully one who is a participant in the procedure.

The matter of the patient being fully informed as to the upcoming procedure may be complicated in teaching hospitals where, in addition to the attending physician and surgeon, fellows, residents, interns and medical students may be present during the procedure and actually may participate to varying degrees as part of formal training exercise. How much detail regarding this possible array of “learners” and what duties they will carry out that is withheld or actually given to the patient as part of the informed consent procedure is unknown but possibly minimal if even presented at all.

A study published in the Archives of Surgery, January 2012 by Porta, et al reports responses of 316 patients preparing for surgery within a teaching hospital of the U.S. Military Health Care System, surveyed regarding their opinion with respect to being personally attended by trainees. “…most expressed overall support of resident training: 91.2% opined that their care would be equivalent to or better than that of a private hospital, 68.3% believed they derived benefit from participation, and most consented to having an intern (85.0%) or a resident (94.0%) participate in their surgical procedure … However, when given specific, realistic scenarios involving trainee participation, major variations in the consent rate were observed. Affirmative consent rates decreased from 94.0% to 18.2% as the level of resident participation increased. Patients overwhelmingly opined that they should be informed of the level of resident participation and that this information could change their decision of whether to consent.”

One realistic scenario that could have been presented to those study patients would have involved their awareness that a subtle or at times not too subtle dilemma develops for those who teach the trainees in teaching hospitals. A description of that very personal dilemma of teaching to a trainee a medical procedure on a patient with its opposing risks vs benefits to both is beautifully presented in the “In Practice” column of the July-August 2013 issue of the Hastings Center Report titled “Patient and Trainee: Learning When to Step In” by Christy L Cummings. The goal is to provide the opportunity for the trainee, primarily an intern or resident or even a fellow physician, to adequately learn a procedure with supervision on a patient so that in the future that physician will be able to repeat the procedure on their patients effectively and safely. The goal of both the teacher and trainee is, at the time, similarly, to complete the procedure effectively and safely. This opportunity, despite the teacher observing and communicating with the trainee, nevertheless has with it the uncertainty of a procedure gone wrong, not completed and the patient about to be worse off. This was the case as Dr. Cummings was observing her trainee unsuccessfully attempt to insert an endotracheal tube into a premature baby who was at first stable but then with repeated attempts the baby’s condition deteriorated. So, if difficulties appear both in the task itself and the condition of the patient, a new uncertainty arises for the teacher. When should she intervene, put her “hands on”, taking over the task of performing the procedure and remedying any serious problems with the patient’s condition? If she intervenes too quickly, the trainee may miss a valuable opportunity to personally handle, with the teacher’s advice, a difficult situation and complication thus learning for the care of future patients. On the other hand, it is the teacher’s responsibility to attend to the safety of the patient and the completion of the goal of the procedure. When should the teacher take over?

This dilemma is not at all rare and, as such, one could reasonably ask whether these uncertainties should also be part of the information provided to the patient in a teaching hospital for truly informed consent. And If not, why not?