"Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent

Should Obtaining Informed Consent Be Considered an Entrustable Professional Activity? Insights From Whether and How Attendings Entrust Surgical Trainees

PURPOSE

Because residents are frequently delegated the task of obtaining consent early in their training, the American Association of Medical Colleges describes "obtaining informed consent" as a core entrustable professional activity (EPA) for medical school graduates. However, prior studies demonstrated that residents frequently perform this task without receiving formal instruction or assessment of competency. This study sought to understand how attending physicians decide to delegate obtaining informed consent for surgical procedures to trainees.

METHOD

The authors conducted a survey of attending surgeons at a university-based health care system of 6 affiliated teaching hospitals (October-December 2020) to collect data about current entrustment practices and attendings' knowledge, experience, and attitudes surrounding the informed consent process. Summary statistics and bivariate analyses were applied.

RESULTS

Eighty-five attending surgeons participated (response rate, 49.4%) from diverse specialties, practice types, and years in practice. Fifty-eight of 85 (68.2%) stated they "never" granted responsibility for the consent conversation to a trainee, and 74/81 (91.4%) reported they typically repeated their own consent conversation whenever a trainee already obtained consent. The most common reasons they retained responsibility for consent were ethical duty (69/82, 84.1%) and the patient relationship (65/82, 79.3%), while less than half (40/82, 48.8%) described concerns about trainee competency. Reflecting on hypothetical clinical scenarios, increased resident competency did not correspond with increased entrustment ( P = .27-.62). Nearly all respondents (83/85, 97.7%) believed residents should receive formal training; however, only 41/85 (48.2%) felt additional training and assessment of residents might change their current entrustment practices.

CONCLUSIONS

Attendings view informed consent as an ethical and professional obligation that typically cannot be entrusted to trainees. This practice is discordant with previous literature studying residents' perspectives. Furthermore, resident competency does not play a predominant role in this decision, calling into question whether informed consent can be considered an EPA.

Comparing Faculty and Trainee Evaluators of First-Year Resident Skills

OBJECTIVE

To determine if senior residents are comparable to faculty in assessing first-year resident skills on their overall assessment.

BACKGROUND

As resident training moves towards a competency-based model, innovative approaches to evaluation and feedback through simulation need to be developed for both procedural as well as interpersonal and communication skills. In most areas of simulation, the faculty assess resident performance however; in clinical practice, first-year residents are often overseen and taught by senior residents. We aim to explore the agreement between faculty and senior resident assessors to determine if senior residents can be incorporated into a competency-based curriculum as appropriate evaluators of first-year resident skills.

DESIGN

Annual surgical first year resident training for central line placement, obtaining informed consent and breaking bad news at a single institution is assessed through an overall assessment (OA). In previous years, only faculty have been the evaluators for the OA. In this study, select senior residents were asked to participate as evaluators and agreement between groups of evaluators was assessed across the 3 tasks taught during surgical first-year resident training.

SETTING

Vanderbilt University Medical Center, tertiary hospital, Simulation Center.

PARTICIPANTS

Anesthesia and surgery interns, chief residents, anesthesia and surgical faculty.

RESULTS

Agreement between faculty and senior resident assessors was strongest for the central line placement simulation with a faculty average competency score of 10.71 and 9.59 from senior residents (κ = 0.43; 95% CI: -0.2, 0.34). Agreement was less substantial for simulated informed consent (κ = 0.08; 95% CI: -0.19, 0.36) and the breaking bad news simulation (κ = 0.07; 95% CI: -0.2, 0.34).

CONCLUSION

Select senior residents are comparable to faculty evaluators for procedural competency; however, there was less agreement between evaluator groups for interpersonal and communication-based competencies.

Consent in surgery

This article will focus on obtaining informed consent from the perspective of a surgical advanced clinical practitioner (SACP). There are many considerations regarding obtaining informed consent and it is recognised that the duty of this role will vary within each NHS trust. This article will reflect on whether SACPs should obtain consent for surgical procedures.

Measuring Impact of Simulation-Based Informed Consent Training on Surgical Intern's Long-Term Confidence

OBJECTIVE

Our objective was to evaluate the outcome of a training program on long-term confidence of interns and attending physicians.

DESIGN

In this prospective cohort study, general surgery interns underwent a training program on informed consent that involved didactics, standardized patient encounters, and supplemental procedure specific guides at the start of the academic year. At the end of the academic year, we surveyed interns from the classes of 2020 (trained) and 2019 (untrained) about their experience and confidence in obtaining an informed consent. Further, we queried attending physicians on their experience and confidence in the interns at the end of each academic year.

SETTING

Single academic general surgery residency program based at 2 urban tertiary hospitals.

PARTICIPANTS

General surgery interns including unmatched preliminary residents and categorical interns from general surgery, interventional radiology, and urology.

RESULTS

Twenty-four incoming interns participated in the training program. Intern confidence discussing operation benefits improved from a median score of 4 to 5 (p = 0.03), and total confidence improved from a median score of 15 to 17.5 (p = 0.08). There was no difference in median total confidence scores (15 vs. 17.5; p = 0.21) between classes. Attending physicians had similar median total confidence scores following intervention (10 vs. 11; p = 0.87). Intern satisfaction was 80% with the didactic session, and 90% with standardized patient encounters. Twenty percent of learners used the supplemental procedure specific guides.

CONCLUSIONS

Implementation of an intern targeted program on informed consent that incorporated didactics and standardized patient encounters was viewed as useful and may contribute to long-term improvements in confidence.

Perspectives on Current Attitudes, Enablers, and Barriers to Obtaining Surgical Informed Consent for Doctors-in-Training

Background Surgical informed consent (SIC) is paramount in modern-day litigious surgical practice, yet numerous complaints remain about the consenting process. This paper investigated current attitudes, enablers, and barriers to obtaining SIC in clinical practice for doctors-in-training (DiT). Methodology Self-reported SIC practice among DiT (N=1,652) across three metropolitan health service regions in Western Australia (WA) was surveyed using a de-identified 20-item multiple response ranking, dichotomous quantitative and qualitative online survey. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 27 (IBM Corp., Armonk, NY, USA). Results The response rate was 23% (n=380). There was an even distribution of key demographics across all three health regions; the median postgraduate year (PGY) was two. Only 57.4% of DiT strongly felt comfortable and confident obtaining a SIC. Of the responders, 67.4% correctly identified key SIC components. There were significant positive associations between comfort and confidence with obtaining SIC and the seniority level of the DiT (p<0.001), identification of SIC components (p<0.001), and prior training in SIC (p<0.001). Most DiTs highlighted the necessity for formal SIC training with a preference for interactive workshops supported by e-learning modules. Conclusions Most DiTs can identify the key factors that constitute a valid SIC; however, the practical conversion of this skill could be better. The key enablers to improved SIC techniques were well-supported departments, with further training and clear guidelines within the institutions. The identified barriers were time constraints, inexperience, and a lack of senior support. Future practices and interventions should address these key barriers while promoting the enablers of sustainable and efficient SIC practice.

How I Learned is How I Teach - Perspectives on How Faculty Surgeons Approach Informed Consent Education

OBJECTIVE

To understand the variability of surgical attending experience and perspectives regarding informed consent and how it impacts resident education DESIGN: A novel survey was distributed electronically to explore faculty surgeon's personal learning experience, knowledge, clinical practice, teaching preferences and beliefs regarding informed consent. Chi-square and Kruskal-Wallis testing was performed to look for associations and a cluster analysis was performed to elucidate additional patterns among.

SETTING

Single, tertiary, university-affiliated health care system (Yale New Haven Health in Connecticut), including 6 teaching hospitals.

PARTICIPANTS

Clinical faculty within the Department of Surgery.

RESULTS

A total of 85 surgeons responded (49% response rate), representing 17 specialties, both private practice and university and/or hospital-employed, with a range of years in practice. Across all ages, specialties, the most common method for both learning (86%) and teaching (82%) informed consent was observation of the attending. Respondents who stated they learned by observing attendings were more likely to report that they teach by having trainees observe them (OR 8.5, 95% CI 1.3-56.5) and participants who recalled learning by having attendings observe them were more likely to observe their trainees (OR 4.1, 95% CI 1.5-11.2).Cluster analysis revealed 5 different attending phenotypes with significant heterogeneity between groups. A cluster of younger attendings reported the least diverse learning experience and high levels of concern for legal liability and resident competency. They engaged in few strategies for teaching residents. By comparison, the cluster that reported the most diverse learning experience also reported the richest diversity of teaching strategies to residents but rarely allowed residents to perform consent with their patients. Meanwhile, 2 other cluster provided a more balanced experience with some opportunities for practice with patients and some diversity of teaching- these clusters, respectively, consist of older, experienced general surgeons and surgeons in trauma and/or critical care.

CONCLUSIONS

Surgeon's demographics, personal experiences, and specialty appear to significantly influence their teaching styles and the educational experience residents receive regarding informed consent.

In Defense of Patient Autonomy in Kidney Failure Care When Treatment Choices Are Limited

Respect for patient autonomy is a primary ethical obligation of health care providers. In kidney health care, clinical practice recommendations commonly include strategies to promote shared decision making with patients and their families about treatment options to promote patient autonomy and improve patient outcomes. However, for many people with kidney failure, treatment options may be unavailable or inaccessible. In these circumstances some clinicians may act paternalistically and withhold information from patients because of a fear of causing harm or because clinicians believe that patient autonomy is not a relevant consideration. In this article, we reflect on the concept of autonomy in the context of clinical decision making in kidney failure care, with particular attention to resource-constrained settings and the disclosure of information to patients for whom treatment may be inaccessible. We examine and address key concerns that patient autonomy may be impossible, irrelevant, or harmful in the context of limited treatment choices, and discuss factors that may influence paternalistic practices in such settings. We conclude that respect for autonomy is intrinsically and instrumentally valuable, and argue that in neglecting patient autonomy in resource-constrained settings, clinicians may exacerbate and entrench the structural inequalities and health inequities they are committed to addressing.