Among surgeons, it’s pretty common knowledge that residents and other providers may perform non-critical parts of a patient’s procedure. This not only helps residents and other trainees gain valuable surgical experience, it also gives patients better and faster access to high-demand surgical expertise.

The question is this: How well are surgeons explaining these facts to their patients?

Recent guideline updates by the American College of Surgeons (ACS) underscore the need for surgeons to proactively and fully explain how other providers might be involved in a procedure. Informed consent discussions provide physicians with an opportunity to talk with patients about why they may not be present for the entire surgery, as well as which other team members might participate. A well-executed consent form can both guide the conversation and support its proper documentation.

Four scenarios

It’s the responsibility of a primary surgeon to educate patients about other providers’ participation during surgery, their respective roles, and the benefits their participation brings. The following four scenarios show how surgeons can complement the language found on well-designed consent forms to enhance patient understanding:

1. Physicians other than the operating practitioner. Explain to patients the specialized skills of the other physicians involved. A thoracic vertebral procedure, for example, might include a thoracic surgeon to expose the spine for an orthopedic surgeon or neurosurgeon — the primary surgeon. This conversation might occur in conjunction with informed consent language that reads:

Physicians, other than the operating practitioner, including but not limited to residents, will be performing important tasks related to the surgery, in accordance with the facilities’ policies and, in the case of residents, based on their skill set and under the supervision of the responsible practitioner.

2. Residents. Discuss how important it is to expose residents — who are medical doctors — to actual surgical practice. Describe how hands-on experience allows them to safely participate in operations under the direct supervision of experienced teaching surgeons. This can be conveyed in consent language such as:

It is anticipated that physicians in specialty training (residents) who are in approved post-graduate residency training programs, will perform portions of the surgery, based on their availability and level of competence. It will be decided at the time of the surgery which residents will participate and their manner of participation, and that this will depend on the availability of residents with the necessary competence; the knowledge the operating practitioner has of the resident’s skill set; and your condition. Residents performing surgical tasks will be under the supervision of the operating practitioner. Based on the resident’s level of competence, the operating practitioner may not be physically present in the same operating room for some or all of the surgical tasks performed by such residents.

3. Qualified medical practitioners. Talk about the important roles played by other providers who deliver care in the OR — such as nurse anesthetists who provide moderate sedation or surgical techs who close simple incisions so the operating surgeon can concentrate on more complex tasks. Consent language could include:

Qualified medical practitioners who are not physicians may perform important parts of the surgery or administration of anesthesia. Those qualified medical practitioners will perform only tasks that are within their scope of practice, as determined under State law and regulation, and for which they have been granted privileges by the facility.

4. Overlapping procedures. Be transparent about how, in some cases, the primary surgeon might not be physically present in the OR but must be accessible to the OR team if needed. To explain such situations, a consent might say:

This procedure may be a sequenced procedure where the primary surgeon may initiate and participate in another operation on another patient after he/she has completed the critical portions of your procedure and at a time when his/her presence in the operating room is not essential to completion of  the final phase of the your operation. A qualified practitioner will be physically present in your operating room and will perform these non-critical components of your operation. The primary surgeon, or a designated backup surgeon, will be immediately available to return to your operating room if required.

Total team understanding

A useful analogy when articulating the benefits of some of the above scenarios is to note that surgery is always a team effort. Each member of the team brings unique skills and experience. A specific example might be to comment that nurses can typically insert IVs faster and with less pain and trauma than many other skilled care providers; since IV insertion is something nurses do many times each day, they excel at that task. Patients also appreciate that teams can provide care to more patients than single individuals.

Primary surgeons should further explain to patients that every team has a captain — the one individual with overarching responsibility for ensuring patient safety and the best possible patient outcome. The captain is the primary surgeon; ultimate responsibility rests with that individual regardless of the participation of others.

Descriptive language on a consent form must support and complement the discussions that physicians have with their patients. If a physician is unsure whether a patient comprehends these concepts, a confirmation technique such as repeat back may be useful. By expanding the informed consent discussion and using appropriate consent language to explain the value of involving other providers, primary surgeons can help patients appreciate those participating in their care team as well as how each member contributes to an overall positive outcome.

Aaron Fink is a professor emeritus of surgery, Emory University, Atlanta, GA.

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