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Question: I was recently in hospital to have some fibroids removed. It seemed there were a million people checking me out at each appointment! Who were all these people? I was told that it had to do with the fact that I was at a teaching hospital. What is a teaching hospital; does it mean a student might operate on me instead of the “real surgeon”?
Answer: You’re not the first person to ask this question. Many people feel uneasy about the thought of a novice involved in their care and treatment.
But studies show that patients at teaching hospitals receive care that’s just as good, and possibly better, than those treated at other medical centres.
Of course, it is true you may be asked the same questions by a lot of different people while you are at one of these hospitals. They’re the next generation of health care professionals at various stages of their training, and they include:
- Medical students who are studying to be doctors. Most of those you see in the hospital will be in their final two years of medical school training.
- Residents who have graduated from medical school and are now acquiring expertise to practise in their chosen fields such as family medicine, surgery or oncology. Residency training can last from two to five years, depending on the field.
- Fellows who have completed residency training and are undergoing additional study in a sub-specialty of their discipline. For instance, a surgeon may decide to focus on the heart.
- In addition to medical students and doctors-in-training, you will likely encounter students from other health-related professions such as nursing, physiotherapy, pharmacy and social work.
All trainees learn through an incremental process in which they are closely supervised at each step of the way. After they have demonstrated competency in a particular task, they are then permitted to do it on their own, says Dr. Mary Anne Cooper, a gastroenterologist who is director of undergraduate medical education at Sunnybrook Health Sciences Centre.
Medical students start off by learning basic skills, such as listening to a patient’s heartbeat with a stethoscope, or taking a blood pressure reading.
They don’t play a significant role in surgery until they have graduated from medical school and have begun working on their residency requirements.
“An undergraduate student is never participating in surgery alone without extensive oversight and supervision and their role would be to assist, not to conduct the actual surgery,” says Dr. Ari Zaretsky, Psychiatrist-in-Chief and Vice-President of Education at Sunnybrook.
“I remember when I was a medical student, I had to stand for hours scrubbed up and observing,” in the operating room, he recalls. The most responsibility he was given at that time involved holding a retractor – a tool used to pull back skin in order for the surgeon to gain access to underlying tissues and organs.
Surgery residents start their hands-on training by doing a small component of a much larger operation. As they master each skill, they are given more to do. By the time they have completed their residency – which takes five or more years – they are capable of performing an entire procedure without staff supervision.
It’s also important to keep in mind that surgery is a team effort and there are lots of experienced people in the operating room.
You may also be relieved to learn that doctors-in-training often practice on dummies and artificial body parts before cutting into a live human being.
Huge advances have been made in operating-room simulations in recent years. The artificial hearts and parts often look like the real thing. These training exercises are similar to the learning processes for commercial jet pilots who practice take-offs and landings on flight simulators.
Throughout their training, the residents, fellows and medical students work under the watchful eyes of staff clinicians who remain ultimately responsible for the patients.
“Obviously, they have their reputation and everything else on the line,” says Dr. Zaretsky. “They are not going to download responsibility without thinking. They are going to be very cautious.”
As they gain more experience, the residents assume a larger role in caring for patients admitted to hospital or recovering from surgery. It is the residents who you will often see working the grueling overnight shifts.
With the residents involved in daily patient care, staff clinicians can devote more of their time to research, says Dr. Cooper, who is an Associate Professor of Medicine at the University of Toronto.
In fact, one of the benefits of going to a teaching hospital is that the staff physicians are often at the forefront of medical innovation. They also tend to be the doctors who are willing to take on patients with complex conditions.
Over the years, researchers have done numerous studies that compared teaching hospitals with community medical centres. These studies are difficult to do properly because the patient populations are not always comparable. In particular, the teaching hospitals tend to be magnets for difficult medical cases.
“Despite the fact that teaching hospitals consistently take care of sicker patients, outcomes – including satisfaction outcomes – are typically as good as or better in teaching hospitals than community ones,” says Dr. Kevin Imrie, Sunnybrook’s Physician-in-Chief.
So, in general, you should expect to receive top-notch care at a teaching hospital.
But there is a catch: It may take a little longer to get through each procedure because there are additional people involved. Every patient examination is viewed as another learning opportunity for the group.
For instance, you likely saw a whole gang of trainees gathered around your bedside during morning rounds when the physician in charge of your care assessed your condition and drew up a treatment plan for the day.
Or, you have been questioned by a resident, and shortly thereafter, quizzed by a staff physician about the very same issues.
Some patients may find this repetition a bit annoying. But it is part of the teaching process and, to some extent, it is one of the safeguards to make sure nothing is missed.
In my time at Sunnybrook, I have had an opportunity to follow some doctors on their morning rounds and the experience has bolstered my confidence in how the teaching system works. The trainees are eager to do their best. And, I think, senior staff benefit from the stimulating discussions with the students, residents and fellows. When they are reviewing a patient’s case, all the care options are carefully weighed and considered. It’s fascinating to watch.
I hope this explanation of a teaching hospital puts your concerns to rest. You may still feel tempted to ask the senior staff physician to perform your entire surgery – and not let the trainees touch you.
However, if you make such a request at a teaching hospital, don’t be surprised to encounter some resistance.
“Teaching is part of the mandate of our hospital,” says Dr. Cooper. “This is what we do here.”
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor
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I hope after procedure performed by a resident, ending in unintended, damaging complications, should give patient a right to request next to be done by specialist. Things happen, but should I subject myself to a riskier one, or should simply forget about essential care just because it’s a teaching hospital.
Great article.
But my question is, is there a report of form that is mandatory for staff to filled if they were present during a surgery? As an example if had a surgery and a student came in an operated on you. The name of that student should be mentioned somewhere in the medical file?
Shud Yur Opthamologist tell you that an intern or resident will be doing cateract surgery prior to operating? I was informed;led to believe my dr would be doing the operation after telling me she had 22 yrs of experience.Please respond back! The operation was done at baskin Palmer a teaching hospital with great reviews which I no longer trust after having an eye infection,getting no response to my questions nor getting a call back until I called several numbers complaining abt having a problem with eye 4 wks now. Attitudes frm coordinator were rude.Messages were made to my ill husband never to me which they were directed to do frm the beginning.No notes were taken & getting run around trying to get authorization frm medical records.No one can answer or you get message machine with no call back I never authorized another person whether intern or resident to do. Now eye problems an only interest was do I want lasix when specifically I told dr prior to op & written dwn, I don’t want can’t afford. Mess left with sick husband 2-3x ref to this, an asking when to schedule next eye to remove Cateracts.Common sense if u can’t see frm eye done clearly & bothersome still, I wouldn’t be able to see when other eye was done! I was never contacted! His ph number was for ER calls only.No messages to me at all though claiming to have done. I’ve saved all calls -none frm UHealth plantation Fl. They don’t retn calls!!!
I write on my patient intake form “NO STUDENTS/RESIDENTS”. I cannot choose another hospital; my insurance only covers one. I teach medical students so their participation in my care is A CONFLICT OF INTEREST. I learned the hard way when I declined their “care” and had my medical records copied, photographed, and distributed among a few students. Please don’t comment and tell me my copied/distributed records did not happen. THEY DID. Students in my class were commenting on my child’s birth and that the opioids given to me didn’t work (2D6 polymorphism…very old news). No one else could have known that. The only sanction the students received was a threat that they could lose X practice site for violating HIPPA, my rights, my privacy, my sanity, and ultimately my health as I have refused “medical care” for the past 25 years (NONE; don’t argue with me…it is none). If you deny this reality, you are the problem. If you are angry at me because I am not whining and petulant and saying how this emotionally scarred me, LAY OFF. We all handle violent intrusions differently. I have to stay angry to avoid these manipulative, arrogant entitled people who BELEVE I exist for them to touch, handle, prod, laugh at, make fun of, share stories about, etc. THIS OCCURRED. DO NOT ATTEMPT TO ARGUE THAT IT DID NOT. That the hospital took their side by keeping my humility high and their punishment low is evidence that this DOES happen again and again. It is happening now. It will not stop happening. AGAIN. do not argue with me, attempt to tell me how this was. I am telling you. LEARN FROM IT.
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Yes students will operate on you at a teaching hospital.I had to have a second surgery 3 days later,I almost lost my leg.It had turned black from my foot up to the top of my leg,with big blisters,and I now have no feeling in my foot and leg,In fact these four students told me did my surgery.
If you are having an examination, procedure, test or surgery, you may want to insist on no contact with interns, trainees, students, observers, etc, because of germs and infections, mistakes, distractions, privacy and confidentiality issues. When a patient is unconscious it is assumed they are giving “implied consent” to almost anything a caregiver wants to do to them. In 90% of states, doctors, nurses and medical students are legally allowed to give unnecessary urinary catheters, pelvic, breast, rectal, testicular, prostate exams and other unnecessary procedures on patients who are under anesthesia without being given “explicit consent” to do so. Often multiple times by many students or interns for training purposes or any other reason. Also, multiple observers is sometimes common. https://www.elle.com/life-love/a28125604/nonconsensual-pelvic-exams-teaching-hospitals/ You may want to avoid a teaching hospital for multiple reasons.
If I am paying for a procedure or surgery I don’t want that to take longer because students take extra time here and there….I am charged for my operating room by the quarter/hour and want only the experienced doctor and a PA to do the work. No disrespect, but if I’m to be worked on by students, why am I asked to pay the full bill? ANd the medical students should always ask the patinet and not just show up expecting the free show.
If I am ever told that I can take students or cancel the procedure, I WILL walk out.
Please focus learning on those patients who are not paying.
This is an update for the 2014 thread: Will I be operated on by a student…”
It follows from a question I received from a viewer so I am adding this as my “updated response” because I believe I can add value to this earlier conversation.
“I have just reread the 2014 article which outlines “some” facts about the training process professionals go through but the article overlooked a very important patient rights issue in the context of this article.
For example: At this 2020 juncture in health care and considering patients rights, I have not observed or witnessed any hospital’s need to “inform patients” about the following real possibilities that infringe on “their right to know” about the care they should expect to receive and their right to choose who will perform their surgery. So I’ve outlined some further thoughts to consider.
Example: How many patients would ask or even think to ask the following questions?
1. Re: Orthopaedic surgery: If you need a hip replacement, as many elderly patients do; has your surgeon and the person who is obtaining your consent to treatment for your surgical procedure outlined your options? For example, you might qualify for the “anterior approach” instead of the “old” posterior approach that is still most commonly provided.
2. Why should we be informed about options for care? Because many surgeons are not updated regularly on the latest protocols or procedures. It is incumbent on both the surgeon and those obtaining consent to “inform patients about choices for which they would qualify.” Whether the hospital has updated their surgeons with the “latest” equipment should not determine “how they” will choose to inform or withhold information for patients requiring surgery. It is always the patients right to know and their right to choose their care and, patients should understand it is their right to know as well as: it is a patient’s right to refuse. Today patients are often better informed, not necessarily by their doctor but by having access to getting up to date and reliable information online. (Mayo Clinic, Web MD are two examples)
3. As a professional you have the obligation to inform patients. Example: As a former nurse, I had a young patient who required surgery for an internal injury. I could tell his parents felt insecure about the local surgeon doing his operation. Sensing their insecurity, I said: “If he were my son, I would take him to Sick Kids in Toronto.” They told me “we’ve already suggested this to the surgeon but he said: I am perfectly capable of doing his surgery.” Several years later I happened to be seated at a social event and this mother told me: “I’ve never forgotten what you did for our son.” ( they took him to Sick Kids).
I think it is very important for professional staff to involve themselves to do what is right for their patient, and not leave it to the “unprofessional” doctors who “think” they will make the decision for the patient or the parents of their children. When I trained, we were never taught how to deal with situations like this and I don’t think there is much done today. My comments might be going beyond the “theme of this article” but I believe the comments on this thread and related threads could be better addressed if we could see the benefit of “conflict resolution” as an integral course that was mandatory for all levels of professionals to enable everyone in the health care professions to both recognize and understand how to engage in these matters so we prevent the types of issues that are discussed online.
Hi Paul,
I appreciate your view and it was well delivered and received. As a recent Patient at a teaching hospital in Boston, Massachusetts I had a recent gynocological surgery namely a Hysterectomy. All my tests were in order and I attended my surgeon’s office pre approintments as dictated. We discussed the surgery and she explained the anatomy of the operation and we went over my recovery necessities. My only issue is this, I could have used more information at my presurgery appointments on “how and who will be in the operating room during my surgery and the responsibilities of each attendee. I was very unaware of how this teaching institute run their surgical department until the day of my surgery. I found out who would be in attendance when one of the residents said she would be assisting my designated gynocological surgeon. My surgeon was not bedside and hadn’t arrived yet. I think before the day of surgery, my surgeon should have informed me ahead of time how their institution work their surgical department. Discussion ahead of surgery would have alleviated my fears and I could then feel free to ask questions without the other learning students present. I came across as untrusting to this resident at introduction time and felt guilty. I felt this is my body and I have the right to know before the day of surgery. I went through with the operation of course and it went smoothly, but I went in to surgery with a BP of 200 which required a few relaxation pills prior to surgery and profusely apologizing for my knee jerk reaction. Knowing more how the operating room works would have lessoned my anxiety especially during a time of the COVID-19 virus circumstances going on at the time of my surgery. Is it worth mentioning this to my doctor at my follow up appointment or should I just except the circumstances as “Business as usual” at a teaching institutions. Response welcomed.
All patients need to be well informed before they sign their consent to treatment form. Hospitals have neglected to protect patients.
This mean patients need to know “who” will do their surgery and their surgeons tell them whether it is they or others who will do the surgery.” This might seem like a no brainer: but, since you’ve seen the surgeon who recommended your procedure and in your case you had your questions answered it is a brach of trust and protocol when they don’t normally “disclose” this information. You could have any number of people observing, you could have someone other than your surgeon do all or part of the surgery and so on. This is not “informed consent” and you have signed a form (in good faith) that didn’t give you all this information. If you go online, look for the Boston Globe article: “Spotlight: All in the name of care.” It reveals how surgeons were going back and forth between operating rooms”without, of course, patients being aware and, leaving unfinished tasks for others to complete!
Now…that is certainly an example of “doctors not understanding the protocols for informed consent.
This was the most blatant example I’ve publicly read but I’m sure this is only the tip of the iceberg!
I attended a teaching hospital in Boston Massachusetts knowing it was a “teaching hospital”. What I really question was the fact that a very important discussion never took place at any previous appointments. The topic is to explained to me (the patient) about how a teaching hospital runs their surgery department with resident doctors/iinterns and attending surgeons. The first time I learned (or suspected) was when the resident came up to me bedside awaiting surgery and introduced herself as a resident assisting in my surgery (my attending dr a surgical gynocologist was not even present). I was very nervous about a resident in the operating room and how much involvement they would have in my hysterectomy. I felt extremely uneasy even more so because of COVID-19 world epidemic and having an elder (93yr old dad) living with me when I returned home. I went through my operation feeling apologetic for questioning this procedure but, if a discussion happened ahead of time,I could have had some adequate time to process and ask questions to alleviate my fears. The operation went well and I am six days into my recovery at home. If your a physician or resident or intern reading this… I hope it will be part of your discussion with your patients before a consent form is put in front of a waiting surgical patient.
it was for fibroid s so there should not of bean several people checking her out it is obvious they were practicing on her
I had surgery at a teaching hospital and was not advised there would be several residents in the or and I did not find out until I read the surgical report there was 13 people in the or for plastic surgery, on listed a visitor. As a woman I have been left feeling violated and will never be able to trust a surgeon or that hospital again. I have had numeros medical complications after the surgery. It’s 6 months later and it has left me permanently disfigured.
The question was not answered. Can a patient in a treatment hospital still refuse to be seen by a student and be refused care and reasonable follow up?
The answer is Yes! However, the process and dynamics of any hospital situation such as the one you describe needs to change. Change is a process and takes time. If you see no change and you need help you might want to consider an out of town hospital where you hear others speak highly of the care they’ve received.
The main concern of any hospital should be the patient not the students. That has not been our experience. At every point of my husband’s treatment, he has been treated as a practice dummy. Unfortunately we have not been recipients of the benefits of being treated by innovative, bright, fresh students mentioned above. At every point, I had to battle so that medical students did not touch my husband. The surgeon screamed at me in the presence of my convalescent husband because I was not allowing her students to “do their job”. She said “Who is going to care for me when I am sick”. The many residents, interns and students have not made his treatment innovative and better but created a lack of continuity which has caused serious mistakes.
Your comments suggest the hospital where your husband had his surgery is not providing leadership to protect patients. If you are up to it you might want to get on the Hospital Board or even become a patient advocate within the hospital setting. Most hospitals today have PFAC’s set up in which patients are valued as part of the initiative to discuss the types of problems you and your husband faced. You would be perfect for this type of position since you understand from the patient’s family perspective, how things can go wrong and how things need to be changed.
I don’t know whether this thread is still functional as it started in 2014!
The response to Paul’s article has generated much attention given the comments.
I would like to add that anyone who is interested in knowing more about the issues the consent to treatment process raises can contact me: erankin@kent.net
I’ve developed content that is beyond what I have in my book. I presented my work in August to medical educators (AMEE) in Basel Switzerland. My presentation was titled: Consent to Treatment in the era of the e-Patient.
My question was if a hospital or surgeon could let a student do your surgery without consulting the patient first to see if they would prefer not to have a student do a complicated surgery. A patient should be asked first.
Elizabeth, students would not do surgery but they can and do observe. Residents do surgery but it would be under the supervision of the Surgeon. There could be some locales where there are different practice standards. Unfortunately, it is up to “smart patients” to become well informed before they sign any consent to treatment form.
I am a physician. 2 decades ago I was one of chief residents in my department at Duke University Medical Center so I am familiar with academic medicine and it’s modus operandi. If I ever have to have a surgery, I will go to a premiere teaching medical facility ( I live in Chicago ) and I will unabashedly request that an attending physician performs my ENTIRE surgery. I certainly will not be surprise to encounter resistance . But I know my rights as a prospective patient/customer who pays $2000.00 per month for my individual coverage.
Good to have a physician’s response to this important topic.
Patients as you know, do have rights. Good for you for exercising yours!
Maybe you could take your concern on patient’s rights and integrate it into a course on ethics for your hospital and your university!
Hi,
I had trigger finger surgery at a VA hospital. I researched the surgeon to be sure he had the experience I was expecting and he did. I researched all the malpractice and complaints involving this Dr. and found all was well. It was going to be local anesthetic and I was relieved because I wanted to be awake during the surgery so I could be aware of all that took place. They coerced me into allowing fentanyl to relieve the pain during the procedure. I was not expecting this and so I remember nothing of the surgery, it affected my memory and that was the reason I wanted to stay awake. Later, I found that a student did my surgery, not the very experienced surgeon. I still have pain and swelling, the stitches did not dissolve as expected and well, isn’t there something that needs to be done when a student is doing the surgery, like a consent? Or do they just do what ever they want in a VA hospital. The surgeon is also a teaching professor at the local medical school that is within walking distance of the VA hospital. I never thought he would just use me as a teaching prop. This bothers me, but now what do I do? I still need care, my hand is not healed yet. I was hoping the surgery would help me have more normal use of my right hand, but it is worse, weak and still very painful even after 6 weeks. Did the student cut too deep, too much or not enough? Did she suture the incision incorrectly or use the wrong material as the sutures? I read in my medical records that they claimed I had signed a consent for a student to perform my procedure, if there was to be a student performing this procedure, but I did not. I asked the student if she or the DR. performed my surgery, she said, they both did. If I did give consent, it was after I was drugged and I don’t remember it. I believe this as wrong. But I also believe there is nothing I can do about it.
Thank you for your input. I had done research to find the best ortho for foot surgery in my area. I was disappointed to find he was associated with a hospital that I wasn’t thrilled with. However, when I had a consult with him about a botched up bunionectomy on my foot and he examined it, he said it could be fixed. He told me everything that had been done wrong in the previous surgery could be fixed but it was to be very precise and complicated. I never saw him again after that consult. No one saw me before surgery and no one saw me after surgery. It was performed the
23rd of March 2016. He was never present at any of my checkups. Until I requested a surgery report, I was never made aware that he had not even done my surgery. He let a student do it. Had that been told to me, l would have walked away. My foot is now constantly numb. Numbness even goes up my leg. Still is painful.Like trying to walk with a club foot.
Cindy, You can not consent undertake influence of medication!
Old post here but that’s ok.
I’m a medical student so I’m biased, but I’ve also been a patient and a relative of a patient so I do feel I know what I’m talking about here.
I’ve often treated physicians as patients too and NONE of them has ever declined a medical student.
It’s understandable to want the ‘staff’ doctor for yourself. But it seems you aren’t clear about a few things.
1) Medical students don’t “do surgery”. Senior residents do. Most of the time students do nothing significant in surgery, at most they will hold things, cut strings, and close the skin under 100000% supervision. You are entirely uninformed if you think students are “doing surgery”.
2) Even community hospitals have some residents sometimes.
3) Staff doctors are not perfect either. There are a lot of factors at play.
4) Residents are physicians with the right to prescribe and order tests in hospitals. Residents RUN teaching hospitals, don’t let anyone tell you otherwise. After 5 pm? TRUST me, you are being cared for by students and residents in the majority of large Canadian hospitals whether you know it or not. Everyone wants and needs competent residents. Where do you think they come from? Do they hatch?
5) Medical students actually help provide better care.
a) We spend more time with you.
b) we are the ONLY ones who have read your entire file and taken a whole history. I have made important contributions to patient care by taking up to 2 hours to fully understand a complex patient. No one else does that. You benefit from that and you don’t even see it.
c)Staff also try to be on their better behaviour in front of medial students for many reasons.
d) more time is spent thinking about you if you are being ‘reviewed’ by 2-3 people.
e) Our documentation is almost always better so that will help you later.
6) Most patients have no idea how LITTLE a staff does in their care, especially for patients who are hospitalized. The staff may spend a few minutes a day with each patient. The rest of the work is all the trainees.
7) Some people don’t offer patients the chance to say ‘no’ to students because its not exactly your right. The government pays for your care and our training and the whole system. You don’t get to ask for a nurse with 5 yrs experience vs 2 yrs experience- you get the nurse who is on. Similarly, you don’t get to ask for the ‘full’ doctor- you only get the doctor (or trainee) who is scheduled.
Hi Jack:
Thanks for your thoughtful comments. They help add additional context to what I originally wrote.
Paul Taylor
Hi Paul,
You might like to know I have just published a book: April 2016
THE PATIENTS’ TIME HAS COME
The subtitle: Listening to Patients will Redefine Health Care Safety and Revitalize Service Delivery
The thread from this article will interest many.
Please feel free to visit my website: ElizabethRankin.com
My book can be purchased through my website as well as at some selected bookstores.
I can be contacted at: medawarepublications@gmail.com
I’ve followed your work for many years and appreciate how you’ve helped others express what they’ve needed to share.
My book covers the issues every patient and professional confronts and it outlines the issues all hospitals have with the current consent to treatment they provide to patients. The book addresses how administrators, policy and governing organizations must become proactive. I provide ready to use tools and templates (including a proposal for consent to medication treatment & a recommendation and an inclusive outline of what to revise ( include content) from the current “implied general consent” for surgical treatment to one that is “a defined level of care that is permuted by patients” that will help patients, professionals and administrators, because they all need help!
PARTICIPATORY MEDICINE . DEFINED CONSENT . TRANSPARENCY
best describes the contents of this book.
I’ve written my book to help anyone understand how to become part of the process to help to facilitate the reform process that is needed to change our health care system so both patients and professionals have efficient working partnerships .
If you like what your read and would like to share your thoughts on my book I’d appreciate anything you can do to get the message out to empower everyone who identifies with what the book offers its readers so we can bring about the change that is so badly needed in our health care system.
This book stresses, that the system doesn’t require more money, it requires rethinking and reworking what we have to work with because we have good people in our system, they just don’t have the systematic tools they need that would provide them the efficiency they need (clinical appropriate checklists that cover the known risks to patients that can be prevented), and helps them become informed about various methods of collaboration they need, including a proposal for rethinking the education model for medical-nursing students in the health care professions
Regards,
Elizabeth Rankin, BScN
Well, here in the United States, we pay dearly for our health insurance and copays. So, I am not obligated to the government or anybody else in regards to decisions about my body and medical care.
This is a reply to an old post so it may not get through The subject of teaching hospitals and trainee participation along with the patient’s obligation to participate in trainee education is a bit of a sore point with me.
Not very long ago, I had cataract surgery in a downtown Toronto teaching hospital. The Doctor came highly recommended and had, in fact, done a previous very successful surgery on my right eye. The second time around the results were less than stellar. Yes, this can always happen, there are risks, but when I pulled both my files for left and right eye cataract surgery, I found that a trainee had been involved in my surgery the second time around. There were also medical students, trainee anesthetists etc swarming around the pre op room. It was like kids day at the Ex! I found it very unnerving.
I signed the generalized consent form, after the IV was already placed by an inept student, and of course, I failed to read the fine print. When we sign surgical consent forms, we must read them carefully. Try to get a copy WELL BEFORE the surgery date! These consent forms pretty much allow hospitals to do whatever they please and in the case of teaching hospitals, there is often plenty of hands on care by not only residents but first and second year medical students, student nurses, even shadowing done by kids considering medical school, ( though maybe less of this in Canada than in the United States.)
A frank and full discussion with your surgeon well ahead of the surgery is the only way to know if he/she is planning to delegate all or some of the surgery to trainees. Surgeons do not always tell patients about this unless the patients specifically asks about it. If the patient asks, the surgeon is legally obliged to answer truthfully. Even in a teaching hospital, a patient can request that the surgeon of their choice perform the most crucial parts of the surgery him/herself. Google the procedure to find out what these parts are. If you request that the attending surgeon perform all of the surgery, he/she of course has the right to refuse and then you must look elsewhere. At least inform yourself of all the facts before you enter the operating room. It is your surgery and you do have the right to refuse the so called “care” of all medical students on your “Team” and even residents although at that point, you may be advised that the surgery cannot be done at a teaching hospital. In Toronto, we are pretty much out of luck as almost all hospitals are somehow affiliated with medical schools.
I never did like the idea of “TEAM” as applied to patient care. Too often, it is just a way of providing an educational experience to a trainee while offering the patient no personal benefit. This is particularly the case when trainees fail to identify themselves as such and masquerade as full fledged attendings which is what most patients think they are anyhow.
Hopefully you find an outpost hospital somewhere where no one trains. You’ll definitely find the best surgeon ever there (not). But at least you won’t have a trainee holding a retractor.
Heather,
Your excellent points are well taken!
I did ask these very points when my husband required surgery. Everyone thinks if they go to the teaching hospitals they’ll get the best care! Not necessarily.
Your issues are a prefect example.
You might like to read the response I’ve just provided to Paul Taylor and if you are interested you can go to my website and read more information.
Elizabeth Rankin, BScN
Seems most of the hospitals around here a “Teaching” hospitals. Your article is well written but I still do not want a Medical Student in any way ,shape or form. And should I require surgery I expect that my wishes be carried out to the letter. I don’t want a Med. Student (The Team) doing ANY EXAMS that I have not specifically discussed or consented to while I am anesthetized.
Maybe it’s just me but release forms are vague and open to much interpretation.
Ed, Please refer to my latest comment today in regard to an earlier article.
Now, in regard to your concern, I totally agree: Release forms are vague and ope to much interpretation.”
While we know med students have to train and start somewhere it is the patient who has the right to not accept “their questioning or examination.” However, we also need to be prepared for what it is the “student” will ask of us. They come into the room and inform you their name and status and then often ask: can I ask You some questions about your medical status, or, can I listen to your heart sounds?” But, if you feel insecure or simply feel you don’t want them to “examine” you in any way it is your right to tell them, “No!” You don’t have to “let them” do what they intend to do. Most patients will allow the student to talk to the and examine them, largely “because they are afraid what will happen” if they don’t!
I’m not sure what the answer is because students do need to get training and while they get much better lab training with simulators (& patient dummies) it isn’t the same as the human response and the human interaction. They can “pay” patients to be examined and in some cases they have these “paid patients” to allow students to “examine them” and maybe the is what they need to do rather than expect patients to grant them “free” reign over their body. How would patients gauge what is appropriate or not appropriate in terms of there request to examine the patient?
Having multiple people coming in and out of your room can be quite confusing. Especially when they tell you things and then later you find out that this was not accurate. If a student/resident with a medical badge comes into a patients room and gives them advise or reports on their condition, it should already have been reviewed by a qualified medical provider and be accurate. When a patient is left with students/residents telling them all sorts of things like “they will start an antibiotic” and you are waiting for an antibiotic only to find out that you do not have an infection and will not need an antibiotic after all. I would highly suggest writing down the names of anyone that enters your room and what they say to you so that you can report any discrepancies appropriately.
Something that isn’t covered here (not surprising as you work in a teaching facility) is “Can patients request to be non-teaching?”
By what you’ve written here you lead the reader to believe they don’t have a choice. That they must be a teaching patient if they want care in a big teaching hospital because that’s the “mandate” of the facility.
So, can a patient request to be non-teaching and still receive care in a teaching facility?
I have had coronary arterie disease for over 35 years. My angina has seldom followed those described in text books. Cardiologists would not listen to my full symptoms, sayng they could not be heart related. While in a teaching hospital, I finaly had a student doctor who did listen. However when the theaching group later gathered around my bed, the student doctor gave a decription of my symptons to the group. The description could have been copied out of a text book, and had no relation to what I had described. My conclusion was that it was more important to student to get the approval of the teaching doctor than to report honestly.
After 3 bypass operations 3 angioplasties, I have met enough cardiologists to know enough not to try to describe my symptoms while in hospital. It appears that they have learned well and do not want to hear symptoms that differ from text books.
Am I correct that a student doctor is judged on how close their report on symptom compairs with “standard” symptoms, rather that an honest report?
Bingo!
Medical training is less about performing rightly and more about buttering up superiors.
Those of us that don’t fail to get good positions and are left doing things in medicine we do not enjoy, feel no pride to do, and are not adept in.
I am sorry that the resident/student who interviewed you didn’t have the balls to stand up and tell the truth. I bet he’s doing better than me with his career too.
Hi Louise:
It does sound like you felt pressured to give consent. Patients and families deserve a fuller explanation of the process – well before the patient is on the way to the operating room.
It may be worthwhile having a conversation with the surgeon who was responsible for the operation.
Most hospitals have an office that handles patient and family concerns. (At Sunnybrook, for instance, it’s called The Office of Patient Experience.)
The patient office can help arrange a meeting with the surgeon. Use the meeting to achieve two goals: a) find out why the surgery wasn’t successful; and b) what can be done for follow-up.
Extensive notes are usually taken during an operation. The doctor should be able to tell you who did what. Ask about the normal success rates and potential complications from the procedure.
You may find that the outcome of surgery reflected specific aspects of your son’s case, rather than who was doing various parts of the procedure.
As well, the surgeon may be able to suggest another operation that could correct the problem. Sometimes, in growing children, there are certain ages when surgery is recommended, or will have a potentially better outcome.
If you still feel uncomfortable with the idea of trainees being involved in your family’s care, you may want to consider a non-teaching hospital the next time you’re dealing with a scheduled surgery. The challenge may be finding a community hospital that does the operation. If it’s an uncommon procedure, a teaching hospital may still be your best choice.
Patients can and should request a copy of their medical record, even if things went well for them. It is smart patient practice to have your medical history. In the future it might become standard practice as all medical records are electronically used and it is a simple click to forward to the patient at their request. (for a cost I might add!)
In this case, unfortunately this patient suffered at the hands of an inexperienced doctor. Moreover, the “parents were not informed” or advised there would be someone other than the surgeon with whom they’d “contracted” to do the surgery.
We are not inclined to sue in Canada for all the reasons there are and that process may be worse than the problem they are trying to sort out and fix. In 2020 maybe there are more avenues to pursue like 1. obtaining the your son’s medical record and a copy of your consent to treatment form.
You will have to pay for this but it is worth doing so, just for the record moving forward.
I don’t know whether there is legal recourse at this point…not likely and it may be more trouble than it is worth. That is what doctors hope anyway!
When it comes to problems like this, patients suffer and so do families who feel they have no recourse.
This is a good example and a good reason for patients to delve into knowing what they can expect, and what they can do to try and mitigate surprises such as not having the surgeon you’d seen and instead end up with a substitute.
I’m a trained patient navigator and I *still* wilted under the pressure to let an inexperienced resident MD provide my care. She was a nightmare.
It was July & I had, 1 week prior in the ED, declined to allow her to stitch a face laceration. Nothing personal! The head resident did a great job.
At the f/u the younger woman appeared alone, blustery with false confidence that quickly turned into flustered ineptness.
NOT a good patient experience! As for the outcome..? Unnecessary antibiotics — & we’ll never know if her apparent vindictiveness led to the scar on my face.
Hi Paul — I’d love your opinion on this. My son was having reconstructive surgery on his ears, which are unusually shaped due to a genetic condition. We had seen the plastic surgeon six months prior to surgery, but on the day of the surgery met for the first time a student, who had never seen my son before.
The consent I was asked to sign said that I give consent for a student to do “all” or “part” of the operation. I crossed out “all” and circled “part.” I did not want someone who had never laid eyes on my son doing the entire operation (which was not a straightforward one).
After my son went into the OR and I was upstairs waiting, I was paged throughout the hospital to come STAT (I thought he had stopped breathing). And when I ran to the nursing station of the OR I was told that my son was intubated, but they wouldn’t start the operation until I signed a new consent, without altering it.
The surgeon did not come out. What was I to do? I didn’t want the surgeon to be angry at me just as he began the surgery. I signed the new form.
As it turns out, the surgery was not successful. I will always wonder whether the participation of the student played a role.
Yes, teaching is an important part of what a teaching hospital does. But providing care that best meets the needs of patients and families — and doesn’t put them in traumatic situations like the one above — always comes first.
We also had an experience where a different minor surgery was done completely by a resident but this was never explained to us in advance. So following the surgery, when my son didn’t appear and we asked a nurse where the surgeon was, she said: “Oh, xxxx doesn’t work on Fridays.” Not knowing that the surgeon is not doing your child’s surgery is not informed consent.
Louise:
I am so sorry to read about the outcome for your son. You have every right to be concerned about the surgical outcome, the lack of informed consent, and led to believe the surgeon would be present at the surgery, after all, this is the “professional” you’d contracted with to do the surgical procedure for your son.
This is what I’d recommend you do:
1. I would get all your son’s hospital medical records so you can see who actually was present in the operating room for each of the procedures he’s had.
2. I would ask a nurse you know who can help you review the record so she [he] would know the proper protocol for what goes on or should go on in the OR setting.
3. In future take a patient advocate with you when going to doctors with your son so they can assess the doctor and ask the right questions.
4. After you have digested the process and if you want…contact the CEO to discuss your concerns. Patients and the patient’s advocate, you the parent, have a right to get the answers you need and the proper care for follow-up including perhaps a referral to someone with a better reputation.
Your feeling of thinking the surgeon might be mad and worry that he’d take it out on your son is not an uncommon worry. The book: Your Medical Mind: How To DEcide What Is Right For You, by Dr.Jerome GroopmanMD is a very good book that references issues patients have with doctors.
Best wishes,
Elizabeth Rankin
Elizabeth,
I wonder whether you could be the Betsy Rankin I knew in 1965 when you finished your nurse training at Kings College Hospital, Londonl before sailing to New Zealand to start a new job in Wellington.If so perhaps you could make contact.
Best regards,
Gavin
Is coerced consent given under duress acceptable? No. A consent agreed/signed under duress/coercion is invalid. The doctor and the hospital acted unethically. Worse, the procedure was unsuccessful which puts the doctor, the hospital and others in the position of likely being sued successfully for negligence because the consent to allow all the surgery to be done by someone other than the surgeon was given under duress.
Excellent description of a “teaching hospital”, Paul. The one thing I would add, as a physician rapidly approaching his sixth decade on this earth, is that I learn an enormous amount from the students and residents. They are bright, keen, inquisitive, and have learned the newest stuff from senior physicians at other teaching hospitals. There is no doubt in my mind that I learn as much from them as the other way around.