Harmonizing cataract surgery training and patient‐centred care in 2020: Disclosure, consent, supervision and patient altruism

Abstract

Unquestionably, a key component in the training of ophthalmic surgeons is surgical experience; the learning curve for phacoemulsification surgery has been shown to follow an exponential pattern with major reductions in complication rates throughout phases of training. Nonetheless, even with stratification of risk, complication rates typically remain a little higher for trainees than consultant ophthalmologists in public teaching hospitals. Therefore, in the era of patient-centred care (PCC), that is, “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions,” disclosure of trainee involvement during informed consent may impact core aims of teaching hospitals to train surgeons. Indeed, practitioners may be concerned that detailed disclosure of trainee participation, by uncovering patient fears, may reduce the number of possible learning opportunities. In essence, informed consent is the communication between patients and surgeons in which the patient is provided with all the information required to provide voluntary consent to undergo a surgical procedure. This interactive process requires both full disclosure by the surgeon and comprehension of this information by the patient to allow shared decision-making. Surgeon qualities such as appropriate communication skills, empathy, honesty and respect for autonomy are required to optimize this relationship and to establish patient trust, comfort and altruism towards trainee surgeons. Internationally, all medical practitioners are legally required to abide by local codes of health/ethics and patients right to be fully informed in order to enable informed choice and consent. In New Zealand, a representative Code states that patients have the right to “Notification of any proposed participation in teaching or research, including whether the research requires and has received ethical approval.” The American Academy of Ophthalmology also instructs ophthalmologists to correctly disclose the identity, qualification and role of the doctors involved in the patient s care. Similarly, the Royal College of Ophthalmologists (UK) emphasizes the need for transparency regarding trainee involvement in surgery and the degree of participation under supervision. Thus, it is clearly essential to inform patients if trainees will be involved in their surgery, and patients clearly have the right to refuse such participation. With increasing emphasis on appropriate PCC, transparency and patient autonomy in decisions regarding their treatment are paramount. Thus, several studies have assessed patient perspectives and willingness to consent to trainee involvement in their surgery. Within the field of surgery, studies have shown that the large majority of patients are willing to have trainee involvement. Cowles et al surveyed 200 general surgery patients postoperatively, and the majority (86%) were comfortable with resident involvement in their care, but 32% did not want any trainee involvement in performing their operation. Those who agreed to trainee involvement expressed the importance of training future surgeons. Similarly, Porta et al surveyed patients undergoing surgery at a tertiary hospital in the United States (N = 316), reporting that the majority supported the training of residents and most consented to having a resident participate in their surgical procedure (94.0%). McClellan et al assessed patient willingness to consent to resident participation in bariatric surgery at a teaching hospital in the United States and also reported that most patients showed support for teaching hospitals and trainee education and involvement. Specifically, in relation to cataract surgery, several studies have assessed patient attitudes regarding the participation of trainee surgeons. The current limited literature highlights that patients typically understand the need for surgical training, and a large majority will consent to trainee participation in cataract surgery when this is explicitly discussed. Previous studies highlight that 67% to 70% of patients have positive responses to trainee surgeons performing their operation as part of their training. Wisner et al used an anonymous survey to study patient attitudes towards resident involvement in their cataract surgery in an academic ophthalmology practice in central Pennsylvania. Of 96 respondents, most agreed to resident assistance (83%), and nearly half agreed to resident performance (49%) of their cataract surgery. Importantly, without prior consent, many of the patients would be upset if the resident assisted in (45%) or performed (74%) their cataract surgery. Nonetheless, relatively few indicated they would seek treatment elsewhere if they knew a resident would be DOI: 10.1111/ceo.13614