 the younger surgeons. This is the group that you've all been waiting for. I know the first person that I'm gonna introduce is Dr. Melanie Sir. I mentioned Melanie a few minutes ago. She's currently assistant professor of surgery at Mount Sinai Health System. Melanie came here as a surgical oncology fellow, and if that wasn't enough, she also did a medical education fellowship and a fellowship in the McLean Center. And she's really done some phenomenal work. And I must say, for me, there's nothing better than seeing how great the people that I at least had a small part in training have done as they've left the University of Chicago. So Melanie, welcome. Thank you. What a pleasure to be back. So just a heads up, I think there is gonna be a good amount of overlap, I think, between my talk and Dr. Langermansom. We've worked together in the past, but maybe I can give you a little bit of the young attending view, since I'm not that seasoned. I have two months of seasoning as an attending surgeon. So, we'll start with the case. So a 54-year-old man who's recently admitted to University Hospital for acute cholecystitis or an infection of the gallbladder. So he's admitted under the care of Dr. Lee, who's a well-known minimally invasive surgeon. The patient is otherwise healthy, so antibiotics are administered and he's scheduled to have a laparoscopic removal of his gallbladder. Before the surgery, the surgical chief resident approaches the patient at the bedside to obtain informed consent, which is quite common at any academic institution for the trainee to be the one actually sort of obtaining that informed consent signature. But as the resident goes on to introduce herself and the role within the team, the patient interrupts, you know, it's nice to meet you, but I hope you understand, I only want Dr. Lee to do the operation. So this is a situation that is quite familiar to the surgical resident and I think is sort of the basis for some of the ethical issues that we see in surgical education. So I think as a background, it's important to first to go back and recognize that there has been sort of a fundamental role of apprenticeship in the history of medical and particularly in surgical education. So in the United Kingdom, the barber surgeons of the 17th century sort of, this is where surgery began, the barbers were the ones that have the tools, the scissors to be able to start doing small procedures for their patients or clients. The barber surgeons, their training was characterized by the apprenticeship model as opposed to going to the academic setting that the medical doctors went to. And that's actually the basis for using the title mister for surgeons in England as opposed to doctor, they're not referred to as doctors, they're called, you know, mister or miss. So that was really an important aspect of the history of surgery. And if you look to the beginning of the 20th century, it really also was important for people like William Halstead who sort of formalized the apprenticeship model into formal surgical residencies. So Halstead is seen here with his, one of his mentees, Harvey Cushing. So if you think about all the surgeons practicing in America today, we essentially all have a lineage of mentor mentees and can really trace our lineages back to these founding fathers of surgery. And now certainly the ACGME, the American Board of Surgery, they're both sort of in charge of making sure that programs are standardized across the board, making sure that residents have some sense of graduating having completed some certain competencies. And of course they have to go through a rigorous written and oral board exam. So the problem with surgical education as Dr. Langerman has alluded to is that we have to have trainees directly involved in operations. So there's no way to get around that. We don't think that didactics alone or simulation alone is gonna be enough to train a surgeon for operating independently. So there's sort of two challenges that come from that. Number one, allowing less experienced physicians to participate in surgery obviously has a potential for increased risk to patient safety, which is obviously very important. Number two, it's not clear to what extent patients would really have this ability to actively consent or actively refuse trainee participation. So the social goal or societal level goal of physician training and making sure that patients of today and patients of the future have access to adequately trained surgeons may be at odds with patient safety, which is fundamentally about doing no harm and doing the best for the patient, as well as patient rights, respecting patient autonomy and understanding that ultimately no person should not be able to have the ability to sort of control what happens to their bodies. So I think it's useful to think about this problem sort of considering each of the stakeholders in surgical education. I think the first is the resident surgeon who has an obligation to care for patients and obviously to do no harm, but also to do their best to learn to care for future patients and be prepared for the day that comes when they are the attending. Some of the challenges here is that surgery is a physical act. And so for whatever reason, participation is seen as something that is more intrusive and more consequential really than medical decisions. So I've certainly never heard of a case and we have certainly non-surgeoned physicians in the room and let me know if you think otherwise, but I've certainly never heard really of a patient saying, stop, sir, I don't want a trainee, deciding what antibiotics I should be on. I don't want a trainee writing my admission orders or my rate, my IV fluid rate. But people have much more resistance to the idea of a trainee participating in an operation compared to a trainee participating in their overall medical care. There's also this long history of public distrust. So certainly we know about the Boston Globe expose on concurrent surgery, but this has gone on really, or I should say started over 20 years ago or over 30 years ago in the 1970s when there was a notorious sort of 60 minutes expose looking at how surgeries were performed. And essentially they interviewed a patient who was really sure that he had had the best surgeon do his, I think it was a hernia repair and behind the door behind the closed doors it was really the chief resident who essentially had done the operation independently. And so this was labeled, this is the title of that episode was called ghost surgery. And Dr. Sligo and Dr. Angelos and I have been talking about, well, what is really ghost surgery? I think traditionally we think of it as one surgeon being substituted for another without the patient's consent. And does trainee participation really constitute ghost surgery? I think technically no because it's not that one surgeon has been replaced 100% but I think the slope is slippery. From the patient's perspective, obviously any level of not knowing who's doing what could be seen as sort of deceitful. But so this question of does resident participation truly harm patients? It seems logical, they're less experienced but fortunately we actually have quite a number of studies that have looked at this through NISQIP data, through a variety of sources. And in general the trend is that resident participation and operations seems to increase sort of slightly increase the rate of minor complications and definitely increases operative time I think for obvious reasons. However, in general there tends to be a protective effect against mortality. And we think, although it's really hard when you're looking at these large numbers to try to identify what that is from, it would make sense that this might be through improved rescue from complications that sort of the price of having a trainee close up your wound maybe that they're also gonna be there in the middle of the night when the attending is not there to pick up on your desaturation and I diagnose a PE and get you taken care of. So I think there is this trade off and certainly one of the things I looked at when I was a fellow was this level of involvement of trainees and sort of speaking up about their patient's care and making changes potentially to their patient's care. So I think there is a role for that. For the attending surgeon, the obligation obviously number one is to maintain that responsibility for patient care and safety but all attendings do have responsibilities to teach as well. So the challenges here I think are this need to disclose from the attending really and explain resident participation to gain the patient's trust and ideally this is done in the elective setting but unfortunately the few studies that we have suggest that up to 80% of attendings surveyed don't routinely disclose the role of trainees. Now these are like small studies, you know I wouldn't necessarily generalize that to everybody but that's sort of the data that we have that there's not necessarily routine disclosure. Interestingly, where I am right now I actually don't have trainees in a hospital where I'm most commonly but I do have physician's assistants and house stocks and on the back of our consent form is a list of all the names and a separate signature that the patient has to sign to acknowledge that there will be someone else helping them in the operation. And of course at first I was like oh my goodness like one more piece of paperwork, one more signature but I realized even sitting here that what it forces me to do is that for any patient that I'm operating on I have had that one sentence or two sentences where I'm saying hey, as you know, I can't do this by myself I'm gonna have someone helping me and these are their names and these are their degrees and so I think there is value to that and I think that might be one of the ways that we work towards gaining public acceptance and actually giving them information about who are the residents and what are their qualifications, what milestones have they accomplished. The surgeon is also responsible, the attending surgeon is also responsible for sort of tailoring their didactic strategies to the trainees abilities and goals in order to sort of balance these education and patient safety goals. So actually I'll give an example Dr. Langerman is very good at this so when I was on his service rotating as a surgical oncology fellow we often had other rotating trainees from ENT, from plastic surgery and one of the things that he did very well was sort of actually tailor his teaching of different parts of the operation to the different specialties so maybe focusing on the vascular reconstruction aspects for the plastic surgeon and focusing more on the oncologic aspects for the cancer fellow. So I think that you have to tailor what kind of teaching you're doing to the trainee and then finally we should recognize that although we talk about this as sort of an issue of training the reality is that training doesn't end on graduation day and so new surgeons also really face some of these same issues and they must continue to disclose and sort of disclose their level of experience and seek senior help as appropriate. For the current patient obviously the goal of any of us when we are a patient is to heal, to regain health, to maintain ownership over their bodies. Now you might say well there's sort of a goal of perhaps giving back to the medical system by facilitating physician education but I think we would all agree that this is clearly secondary for the patient and really cannot be mandated for them. So the challenge is in that sense I think the ultimate question is should patients be able to really refuse trainees? I think full respect for autonomy does require an explicit consent process and you might say well okay if we do that that's fine a few of them might refuse it's not a big deal but if all of them were to refuse we would have a big problem and future patients would clearly be at risk. So one compromise of course is to disclose prior to elective procedures and offer this alternative of saying well you could always go somewhere else. But I think back to my own training and remember that in some settings sort of a public or city hospital setting patients don't have any other alternatives for insurance purposes there really is no other place where they can go to and so should their rights be any different? Should it be that the patient who has a good insurance policy has the option of going to a private hospital and not having a resident involved and the patient who has no insurance is forced to have the intern do their appendectomy? Well I think we all agree that we probably shouldn't have a system like that unfortunately I think we largely do to this day because there is still in surgery I think in medicine in general this idea that well you can do more at the community hospital it's really great to have this rotation at a public hospital because you can do more. So I think that is a problem and I think it's important that we maintain this degree of training participation across healthcare settings and not allow there to be more patient autonomy just based on access. And we also have to maintain the degree of disclosure. So for the future patient obviously they're not here to talk to and it's hard to sort of keep them in mind because their needs are in the future and they have no voice right now. Certainly there is a sense that we have a projected shortage of general surgeons and it's not just an issue with numbers but also that there's an increased perception among graduating residents that they are not prepared for independent practice. We don't really know why this is. Some people think it's due to work hour restrictions. I think a lot of trainees feel like there's certainly an increasing culture of supervision and decreased autonomy. And finally there may be actually some generational attitudes so there's some thought to think that the millennials actually self-assess themselves in a more honest way than people did 50 years ago and so they're more likely to sort of say they're not ready. So I offer in closing just a few strategies for the ethical training of surgeons. I think number one, we have to obviously educate surgeons in the safest way possible. Simulation is an amazing thing that is really starting to take off but we haven't figured out how really quite to make it standardize across the board. So the idea of having an intern before they're closing that wound, maybe they've actually had to close a wound in the lab ex vivo and maybe we can actually watch them, give them sort of ratings of their skill, give them feedback, check off a box when we know that they've actually acquired that competency for certain and prior to their being involved in the patient in the operating room, we can track their milestones and actually have true data-driven graduated responsibility right now. It's a very laissez-faire sort of process where attendings are sort of judging based on their overall sense of what the trainees like but it's hard, particularly because sometimes in these academic settings, you may be getting a trainee that you've never worked with before. So how are you supposed to judge them? If we had a separate data bank of simulation, we might have a better sense of what they're capable of doing. And lastly, I would say that trainees should probably learn skills as much as possible. They should be learning skills that they are most likely to use in the future so that we're not risking patient safety without having a reasonable gain in trainee skill. From the other end, informing patients about trainee participation and gaining buy-in in the elective setting I think is very important and we talked about this a little bit earlier. I think it's important for the institution to disclose its goals, to let the patient understand the trainee qualifications and the roles of people on their team to emphasize the team approach and their commitment to safety. And finally, as I mentioned earlier, I think it is important to ensure justice and equality of access across settings. I don't think that we should be allowing a system that allows trainees to do more in the city hospitals and have the sort of more indigent population be just suffering the consequences from that. So I thank you for your time and happy to take any questions if we have any time for that.