Informed Consent and a Resident Performing the Case
A 62-year-old man with a 1.1 cm basal cell carcinoma of the right cheek is scheduled for Mohs surgery at an academic center. On the day of surgery, the attending introduces a dermatology resident who will perform the excision and repair under supervision. The patient becomes visibly uncomfortable and says, "I thought you were doing this. I don't want a trainee cutting on my face." The attending is double-booked and the schedule is tight. The resident has performed 40 Mohs cases.
1. How do you handle the patient's objection, balancing autonomy, education, and the schedule?
Read the worked answer
The patient's autonomy is paramount: he consented to surgery by the attending and has the right to refuse trainee involvement. Acknowledge his concern without defensiveness, explain the resident's role and level of supervision (attending present, direct oversight, 40 prior cases), and offer options: (1) the attending performs the entire case; (2) the resident performs under direct, hands-on supervision with the attending scrubbed and physically present; (3) reschedule to a time when the attending can do the case. Do not pressure or penalize him. If the schedule is tight, the ethical priority is honoring the patient's choice - reschedule or rearrange, and address the double-booking as a systems issue. Document the conversation and his decision in the chart, and obtain a revised consent reflecting who will perform which parts. This is both an ethical obligation (informed consent, honesty) and a professionalism/patient-safety matter.
2. What are the informed-consent and documentation requirements when trainees participate in surgery?
Read the worked answer
Consent must disclose who will perform the procedure and the extent of trainee participation, and the patient must agree. Requirements: (1) identify the attending as the responsible surgeon and describe the resident's role; (2) disclose supervision level; (3) document the discussion, the patient's questions, and his choice; (4) if the patient declines, record that and the alternative arranged; (5) ensure the consent form reflects the actual plan. Institutional and accreditation policies (e.g., ACGME, hospital bylaws) govern trainee involvement; patients may refuse without prejudice to their care. If the resident performs, the attending must be physically present and directly supervising, and the operative note should reflect the attending's involvement. Revisit consent if the plan changes (e.g., a different surgeon or a more extensive repair).