When Chryssa McAlister, MD, was learning to remove cataracts, she trained under some cranky doctors who didn't hesitate to bark critiques. But a few of her supervisors maintained a purposeful silence, soundlessly mouthing their words. It was obvious that they wanted to conceal from the patient, awake under local anesthesia, that the instruments had changed hands.
McAlister found the experience disturbing, she recalled in an . She coined a term for the practice: the "silent switch."
The silent switch seemed to violate the bond of trust between patients and their doctors, McAlister wrote. "It's very difficult being in a scenario where you feel like, perhaps the patient doesn't necessarily fully know," McAlister, who is now an ophthalmologist in Kitchener, Ontario, and a professor at McMaster University, told 鶹ý. "It makes you uncomfortable, so it's something that kind of stayed with me."
McAlister's experience is far from unique. Experts say that many surgeons at teaching hospitals -- possibly even the majority -- do not explicitly tell their patients when trainees will be holding the scalpel. And a more egregious kind of deception can occur when a surgeon leaves an anesthetized patient completely in a junior doctor's hands and moves to another room to begin a new operation. After a 2015 exposé of surgical double-booking in the , the American College of Surgeons (ACS) to clarify that "concurrent or simultaneous" surgeries, in which a lead surgeon manages the critical components of two procedures at once, are inappropriate, whereas "overlapping surgeries," in which the critical components are staggered, are acceptable.
Still, patients are when surgeries overlap -- for instance, when a trainee sews up the incision while their supervisor starts a new procedure in another room -- but a released in 2016 found that doesn't always happen.
"For the average hospital that does simultaneous surgery, or the average doctor who does it, it's an efficient use of their time, so they really don't want to change it," said orthopedic surgeon James Rickert, MD, president of the , who is on the clinical faculty at Indiana University School of Medicine. "I just think it's much easier to use language that's a little bit more oblique."
The federal government has increased its scrutiny of hospitals that, in the quest for profits, routinely double- and triple-book top surgeons. In February, Massachusetts General Hospital agreed to a $14.6 million settlement that included a commitment to revise its patient consent forms to clearly explain that the head surgeon may not always be present.
And increasingly, surgeons themselves are urging their colleagues to be more transparent. James R. Hupp, MD, who was until recently the editor-in-chief of the Journal of Oral and Maxillofacial Surgery, advocated "" in an editorial, and said in an interview that patients who are under general anesthesia deserve special consideration because they can't advocate for themselves.
"It's a vulnerable point in everybody's existence that has to have surgery, and that's where I think disclosure is even more important," Hupp told 鶹ý, adding that since there is no legal requirement, "it's left up in the air whether or not anyone feels compelled to do it."
The surgeons who urge more transparency say they are motivated by an ethical imperative not to hide anything from patients -- and not by safety concerns.
"When residents are involved, they ask questions. I think it brings everybody to a higher level of attentiveness," said Hupp, who added that these are personal opinions and that he does not speak for his employer, Elson S. Floyd College of Medicine at Washington State University in Spokane, where he is the senior associate dean for policy and compliance.
The available research suggests that while operations tend to be slightly longer when trainees take part, they are, on balance, equally successful. In a , investigators examined more than 600,000 surgeries performed at 234 U.S. hospitals between 2006 and 2009. Some of the hospitals utilized residents, while others did not. Complication rates were slightly higher with resident participation, but mortality rates were slightly lower.
Based on that study and others, most researchers agree that resident involvement has no significant impact on surgical outcomes.
"You need a microscope to see the difference," said Philip Goodney, MD, a vascular surgeon who directs the Center for the Evaluation of Surgical Care at Dartmouth in Lebanon, New Hampshire. Goodney added, however, that the available evidence has limitations. Teaching hospitals, where residents tend to work, have more state-of-the-art equipment and support staff than community hospitals -- factors that could boost surgical success rates and obscure problems associated with trainee participation.
There is less research, and less consensus about whether overlapping and concurrent surgeries pose additional risks to patients, Rickert said. One concern he has is that individual surgeons are left to determine the "critical components" of a procedure -- the ones they must be present for -- and can even change their minds on the fly if they want. Rickert would like to see medical associations or the federal government establish which parts of various operations require the presence of the supervising surgeon. He would also like doctors and hospitals to be crystal clear in their preoperative discussions with patients, especially when procedures will overlap.
"If you're a surgeon, you don't want to be like a thief in the night trying to get away with something. You want to be going to the patient saying, 'I'm going to be running two rooms. I won't be in the room for the whole surgery,'" Rickert said. "And you want to tell the person that with time to ask questions. Because I would think the average person would have questions about that."
Multiple studies suggest that patients want to know when the surgeon they met with -- the one carefully chosen based on experience and reputation -- won't be wielding the instruments the entire time. Yet physicians are often less than candid about the role helpers play.
In a conducted at an academic children's hospital in Toronto, for example, doctors cited many reasons they avoid describing to parents how trainees would participate in their children's surgeries. Lead surgeons mentioned being pressed for time during consultations, not wanting to overwhelm patients with information, and a belief that patients who seek care at an academic hospital know that by definition teaching will occur during surgery. Surgical trainees, meanwhile, said they were purposefully vague about their role, in part to reduce parents' anxiety but also because they feared eliciting objections that might cost them training opportunities.
"There's a lot of stuff that if people knew, they would decline the surgery. And the hospitals are aware of that," said Helen Haskell, founder of Mothers Against Medical Error, a nonprofit advocacy group. As long as secrecy around trainee participation remains the norm, it will foster dangerous practices, she added. "I think it would decrease risk if patients knew the role of residents and were able to push back on things they thought were unsafe. But a lot of patients, probably most patients, don't even know about it."
Jean Kestner, 68, a retired insurance underwriter, expected a speedy recovery when she had her gallbladder removed at a University of Pittsburgh hospital a few years ago. It was a minimally invasive surgery that didn't require an overnight stay. But two and a half weeks later, she was admitted to the hospital with a raging internal infection that almost caused her kidneys to shut down.
Kestner's infection was the result of a bile duct injury -- an error to which inexperienced surgeons are more prone. Kestner had chosen a veteran for her procedure, but when she obtained her hospital records after the fact, she was disquieted to learn there was a second doctor in the operating room, a relative newbie still honing his surgical technique.
Kestner can't be certain who botched her surgery because, as is typically the case, the records are not explicit. What she does know is that nobody ever told her that a surgeon-in-training would be handling any part of her operation, a lapse she found troublesome.
There are two parts to the informed consent process for elective surgeries. The first is a conversation in which, along with describing the operation and potential complications, the surgeon is supposed to explain the roles of all participants, . That often doesn't happen, Rickert, Hupp, and others said. The second part is a hospital consent form that patients must sign on the day of the procedure. At that point, it's hard to back out. "When you're five minutes away from being wheeled into an OR, you probably aren't taking time to read the sixth paragraph," Kestner quipped.
Kestner said that she understands the need for surgical training and probably would have agreed if asked. But many other patients balk at the idea of trainees operating. In one of 108 patients contemplating weight-loss surgery, 86% said they would be comfortable having residents observe, but only 56% were okay with having apprentices assist, and just 14% would agree to having a trainee perform the surgery under supervision. In a , 35% of patients said they would rather put off knee surgery for a month or more than be operated on by a resident.
In the traditional teaching hospital model, the lead surgeon is in the room for the entire surgery, directing and overseeing -- stepping outside only to nurture the independence of the most experienced trainees. Christopher R. Porta, MD, who has conducted two studies on patient hesitance toward resident care, says although it may seem counterintuitive to many doctors, being open with patients about the role of junior surgeons can actually relieve their concerns. The key, he said, is to take the time to explain about the rigorous oversight of trainees and their gradual process of skills acquisition.
"We don't just flip 'em a scalpel and say, 'Hey, good luck, I'm going to be down the street drinking a beer,'" he tells his patients. "We're going to be assisting their every step and watching every single move under a microscope."
Over time, the oversight becomes less intense, until eventually the senior surgeon is just an observer, said Porta, a general surgeon at Madigan Army Medical Center in Tacoma, Washington. "You're just slowly backing your way out of the room, because at the end of the day they have to graduate fully comfortable and confident," he said. "That's what I owe to my future patients. That's what I owe to society, to train a competent surgeon."