- Email: [email protected]
Parent attitudes toward resident involvement in their child's strabismus surgery
Parent attitudes toward resident involvement in their child’s strabismus surgery Hans Andrews, BS,a Ajay Soni, MD,b Michael Green, MD, MS,a Amanda Ely, MD,b and David Quillen, MDb PURPOSE
To explore patterns in parents’ understanding and preferences related to ophthalmology resident participation in their child’s strabismus surgery.
METHODS
Over a 4-week period, a survey was distributed at a suburban, academic eye center to English-speaking parents of children with strabismus who have not previously undergone, or were not being scheduled for, strabismus surgery.
RESULTS
All of the 64 eligible parents participated in the survey. For a resident to assist or perform the surgery, 80% and 97% of parents, respectively, indicated it was important or extremely important to be asked permission beforehand; 69% indicated the attending surgeon should ask permission for the resident to perform the surgery, whereas only 11% believed a standard written consent was sufficient. Of the 64 respondents, 77% indicated that they would agree to a resident assisting with their child’s operation; 36% would agree to a resident performing the surgery.
CONCLUSIONS
Nearly all parents in our study indicated that they would want to be informed of resident involvement by the attending surgeon. The vast majority would consent to having an ophthalmology resident assist in their child’s strabismus surgery, and more than onethird would consent to having the resident perform their child’s strabismus surgery. Obtaining informed consent prior to resident involvement increases transparency and highlights the importance of ophthalmology residency education. ( J AAPOS 2018; -:1-4)
trabismus affects 2%-3% of US children.1,2 Strabismus treatment depends on the etiology of the condition, but surgery may be indicated. In academic ophthalmology programs, ophthalmology residents are involved in all aspects of patient care, including participation in surgery performed under the direct supervision of an attending surgeon. The degree of participation by ophthalmology surgical residents depends on the level of training and the residents’ ability to perform the surgical maneuvers as determined by the attending surgeon. The Accreditation Council for Graduate Medical Education (ACGME) for Ophthalmology requires ophthalmology residents to perform at least 10 strabismus surgeries during their 3 years of residency training.3 According to data published by the ACGME, the average number of strabismus surgeries performed by a graduating ophthalmology resident is 24.7 surgeries. Given that approximately 450 ophthal-
S
Author affiliations: aPenn State College of Medicine, Hershey, Pennsylvania; bPenn State Eye Center, Hershey, Pennsylvania Submitted October 1, 2017. Revision accepted March 4, 2018. Correspondence: Ajay Soni, MD, Penn State Eye Center, 500 University Drive, HU19, Hershey, PA 17033 (email: [email protected]). Copyright Ó 2018, American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved. 1091-8531/$36.00 https://doi.org/10.1016/j.jaapos.2018.03.008
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mology residents graduate each year,4 on average more than 11,000 extraocular muscles are operated on annually by resident surgeons. The safety of ophthalmology residents performing ocular surgery under direct faculty supervision is well established.5-9 For strabismus surgery, the overall success rates of trainee- and attending-performed surgeries do not differ significantly.5,6 Nevertheless, parents may have concerns regarding the level of resident involvement in their child’s strabismus surgery. Guffey and colleagues10 found that patients were misinformed about resident involvement in surgery: 28% falsely believed an ophthalmology resident can perform medical procedures without direct supervision, and 22% were unsure. The current study explored patterns in parents’ understanding and preferences related to ophthalmology residents’ participation in pediatric strabismus surgery. We addressed the following questions: What are parents’ attitudes toward resident involvement in their own child’s strabismus surgery? How likely are parents to agree to have residents involved in their child’s strabismus surgery? How likely are parents to seek treatment elsewhere if residents were to be involved in their child’s surgery?
Subjects and Methods With approval of the Pennsylvania State University Institutional Review Board, this survey-based study polled subjects between
1
2
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May 8, 2017, and June 1, 2017, at the Penn State Eye Center in Hershey, Pennsylvania. The Penn State Eye Center is based in a large academic health center in central Pennsylvania that has 18 full-time faculty members representing all major ophthalmic subspecialties. The pediatric eye care team consists of 2 pediatric ophthalmologists, 1 pediatric optometrist, and 2 full-time and 1 part-time orthoptists. The survey was designed and used in a previous study regarding resident involvement in cataract surgery11 but was modified by the authors to address related issues in pediatric strabismus surgery. During the study period, parents of children with a diagnosis of strabismus presenting for a new patient or routine follow-up examination with the pediatric eye care service were asked to participate in a survey during their visit. Patients were excluded if they were being scheduled for strabismus surgery or had a history of strabismus surgery. All parents were approached whose child met the study criteria. Subjects had the option to complete the survey orally as an interview or in writing. A fourth-year medical student was present during all office hours (Monday-Friday, 8 AM to 5 PM) of the designated study period and explained and administered the surveys. Participants were first asked to review a list of definitions including the following terms: medical student, ophthalmology resident, attending physician, strabismus surgery, assisting in surgery, and performing surgery. The medical student asked the respondents whether they had any questions or needed clarification on the definitions listed. Parents were then prompted to consider a hypothetical situation in which their child needed strabismus surgery and to answer questions related to informed consent for resident involvement in that surgery (using a five-point Likert scale). In particular, participants were asked about the importance of seeking consent for residents to be involved in their child’s surgery, the best way to obtain consent for resident involvement, and their likelihood of allowing residents to be involved. Basic demographic information was also elicited. Survey questions are provided in the eAppendix. All responses were summarized and expressed using frequencies and percentages.
Results During the 4-week study period, 67 individuals were approached, of whom 64 (51 females) were eligible and agreed to participate. The median age of the parent was 36 years (range, 21-62 years). The median age of the child was 6 years (range, 1-18 years). In response to questions on the importance of being consulted in advance about resident participation in strabismus surgery (eFigure 1), 80% of respondents indicated it was important or extremely important to be asked before residents would assist with surgery, and 97% said it was important or extremely important to be asked before residents would perform the surgery. If the resident was in the operating room during the surgery and the parents’ permission had not been sought, 55% of parents said they would not be upset at all, and 16% indicated they would be extremely upset. However, as resident involvement in the procedure increased, so did parent desire for prior consent: 50% indi-
cated they would be moderately or extremely upset if they found out after surgery that the resident assisted with the procedure; 83% would be moderately or extremely upset if they found out the resident had performed the surgery. Asked whether being a patient at an academic health center implies that resident physicians will be involved in all aspects of a patient’s medical care, 56% agreed or strongly agreed; only 16% disagreed or strongly disagreed. The remainder were neutral or unsure. However, regarding the process for obtaining informed consent, 64% of respondents indicated that the attending surgeon was the most appropriate person to ask permission for the resident to assist, and a minority (19%) believed that the standard written consent form was adequate for approval of residents assisting with the surgery (eFigure 2). Similarly, 69% of respondents indicated that the attending surgeon was the most appropriate person to ask permission for the resident to perform the strabismus surgery, whereas a minority of parents (11%) believed a standard written consent was sufficient. Finally, asked whether they would allow residents to be involved in their child’s surgery if permission had been sought (eFigure 3), 77% indicated they would definitely or likely agree to a resident assisting their child’s operation (11% would likely or definitely disagree), and 36% would definitely or likely agree to allowing a resident to perform their child’s operation (39% would definitely or likely disagree). Furthermore, 18% said they would be likely to seek treatment elsewhere if the resident were to assist in the surgery, while 25% would do so if the resident were to perform the surgery (eFigure 4).
Discussion Previous studies have investigated ophthalmology resident involvement in surgery but have largely focused on adult cataract surgery.11-15 Wisner and colleagues11 served as the model for our study. They reported that 83% of patients surveyed would be agreeable to having a resident assist in cataract surgery, whereas 49% of patients would likely consent to a resident performing their cataract surgery. The results of our study on parents’ attitudes toward resident involvement in their child’s strabismus surgery reveal a similar trend: 77% of parents would be agreeable to having a resident assist, whereas 36% of parents would likely consent to a resident performing the operation on their child. With increasing level of involvement, parents expressed a greater reluctance to consent to resident’s participation in their child’s surgery. The overwhelming majority of parents in this study wanted to be informed if a resident were to assist (80%) or perform (97%) their child’s surgery. Likewise, a study at another pediatric ophthalmology clinic showed that 76% of parents wanted to be asked to allow trainee participation in their child’s eye care.12 This data also aligns with the study by Wisner and colleagues11 and the general surgery literature, according to which 80%-96% of patients desire to
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Volume - Number - / - 2018 know whether a resident will be participating in their surgery.16,17 To our knowledge, there is no explicit requirement or recommendation by the American Medical Association or the American Academy of Ophthalmology for consent regarding trainee participation in surgery, although both organizations encourage an ethical and transparent consent process.18,19 The current patterns of ophthalmology programs in the United States suggest the large majority do not have an established policy on disclosing the level of resident involvement to patients undergoing ophthalmic surgery. Chen and colleagues20 reported that 74% of 53 programs had no established policy about disclosing resident involvement. Our findings suggest that parents overwhelmingly want to be made aware of resident involvement in their child’s eye care, indicating the potential need for a standardized disclosure process. Our study exposes a potential challenge for ophthalmology training programs. Parents desire disclosure of resident involvement in their child’s strabismus surgery but express a decreased likelihood of consenting when informed of resident involvement in the surgery. With consent rates declining as transparency about trainee participation increases,17,21,22 the process could potentially lead to a reduction of surgical cases for residents. Nevertheless, training programs and attending ophthalmologists have an ethical duty to be honest and transparent to patients (or their parents) about who will be doing the surgery, how residents will be involved, and the level of supervision this entails. It is our hope that, with an open and transparent approach, the public will acquire a greater appreciation of the goals of academic medical centers and entrust their personal or their family members’ care to physicians in a supervised training environment. The fact that a large majority of parents are agreeable to having an ophthalmology resident assist in their child’s strabismus surgery suggests that they are willing partners in the process of training future ophthalmologists provided they are adequately informed by the attending surgeon. Greater disclosure of the likely presence of an ophthalmology resident and the extent of resident involvement may alleviate the parents’ concerns while preserving the important role of ophthalmology resident education. Both the current study and the previous study by Wisner and colleagues11 suggest that the best way to disclose resident involvement is by the attending surgeon and patients or parents communicating directly. This is congruent with the views of US ophthalmology program directors, who indicate the primary responsibility for informing the patient about the level of resident involvement falls to the attending surgeon.20 Our study also highlights that being an academic medical center alone is not sufficient to assume that the patient or parent is agreeable to resident surgical participation through a standard written consent. This study has several limitations. First, the survey sample size is small and therefore may not be representative of the population as a whole. Furthermore, the study was
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3
completed at a single site, and the results may not be generalizable to other academic centers in urban areas. A weakness of the survey itself is that it did not stress the fact that in strabismus surgery an assistant is an obligatory member of the surgical team, and if a resident does not assist, a surgical technician would assume that role. Although our study results already show that a majority of parents would agree to a resident assisting in surgery, there may be an underestimation due to this omission. Inherent in all surveybased research is the risk of social desirability bias, in that respondents provide answers that they believe the researchers want to hear. Hopefully, the anonymous nature of the survey minimizes this bias. Finally, there is always a potential for selection bias in research such as this; however, because no patients refused the survey, voluntary response biases and nonresponse biases are minimized.
References 1. McKean-Cowdin R, Cotter SA, Tarczy-Hornoch K, et al., Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia or strabismus in asian and non-Hispanic white preschool children: multiethnic pediatric eye disease study. Ophthalmology 2013;120:2117-24. 2. Friedman DS, Repka MX, Katz J, Giordano L, Ibironke J, Hawse P, et al. Prevalence of amblyopia and strabismus in white and African American children aged 6 through 71 months the Baltimore Pediatric Eye Disease Study. Ophthalmology 2009;116:2128-34. e1-2. 3. ACGME Review Committee for Ophthalmology. Required minimum number of procedures for graduating residents in ophthalmology. Available at: www.acgme.org/Portals/0/PFAssets/Program Resources/240_Oph_Minimum_Numbers.pdf. Accessed May 31, 2017. 4. ACGME Department of Applications and Data Analysis. Ophthalmology: National Resident Report. 2014. Available at: https://www. acgme.org/Portals/0/Opthalmology_National_Report_Program_Ve rsion.pdf. Accessed May 31, 2017. 5. Mehta VJ, Utz VM, Traboulsi EI, Rychwalski PJ. Outcomes of strabismus surgery with or without trainee participation as surgeon. Ophthalmology 2014;121:2066-9. 6. Wisnicki HJ, Repka MX, Raab E, et al. A comparison of the success rates of resident and attending strabismus surgery. J Pediatr Ophthalmol Strabismus 1993;30:118-21. 7. Mehta VJ, Perry JD. Blepharoptosis repair outcomes from trainee versus experienced staff as the primary surgeon. Am J Ophthalmol 2013;155:397-403.e1. 8. Khatibi A, Naseri A, Stewart JM. Rate of rhegmatogenous retinal detachment after resident-performed cataract surgery is similar to that of experienced surgeons. Br J Ophthalmol 2008;92:438. 9. Lois N, Wong D. Pseudophakic retinal detachment. Surv Ophthalmol 2003;48:467-87. 10. Guffey R, Juzych N, Juzych M. Patient knowledge of physician responsibilities and their preferences for care in ophthalmology teaching clinics. Ophthalmology 2009;116:1610-14. 11. Wisner DM, Quillen DA, Benderson DM, Green MJ. Patient attitudes toward resident involvement in cataract surgery. Arch Ophthalmol 2008;126:1235-9. 12. Zeller M, Perruzza E, Austin L, et al. Parental understanding of the role of trainees in the ophthalmic care of their children. Ophthalmology 2006;113:2292-7. 13. Nguyen TN, Silver D, Arthurs B. Consent to cataract surgery performed by residents. Can J Ophthalmol 2005;40:34-7. 14. Gan KD, Rudnisky CJ, Weis E. Discussing resident participation in cataract surgery. Can J Ophthalmol 2009;44:651-4.
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15. Sharda RK, Sher JH, Chan BJ, Kobetz LE, Mann KD. A comparison of techniques: informed consent for resident involvement in cataract surgery. Can J Ophthalmol 2012;47:113-17. 16. Kempenich JW, Willis RE, Blue RJ, et al. The effect of patient education on the perceptions of resident participation in surgical care. J Surg Educ 2016;73:e111-17. 17. Porta CR, Sebesta JA, Brown TA, Steele SR, Martin MJ. Training surgeons and the informed consent process: routine disclosure of trainee participation and its effect on patient willingness and consent rates. Arch Surg 2012;147:57-62. 18. Code of Ethics of the American Academy of Ophthalmology. Available at: https://www.aao.org/ethics-detail/code-of-ethics;. Accessed May 25, 2017.
Volume - Number - / - 2018 19. American Medical Association, American Medical Association. Council on Ethical and Judicial Affairs, Southern Illinois University at Carbondale. School of Medicine, Southern Illinois University at Carbondale. School of Law. Code of Medical Ethics of the American Medical Association. Chicago: American Medical Association; 2017. 20. Chen AJ, Scott IU, Greenberg PB. Disclosure of resident involvement in ophthalmic surgery. Arch Ophthalmol 2012;130:932-4. 21. Santen SA, Hemphill RR, McDonald MF, Jo CO. Patients’ willingness to allow residents to learn to practice medical procedures. Acad Med 2004;79:144-7. 22. Gaeta T, Torres R, Kotamraju R, Seidman C, Yarmush J. The need for emergency medicine resident training in informed consent for procedures. Acad Emerg Med 2007;14:785-9.
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eAppendix. Strabismus surgery Parent Survey Since your child has been diagnosed with strabismus, we would like to know more about your attitudes about the participation of trainees in surgical care. Please answer the following by marking the single best answer to each question. For this survey, assume your child is a patient in a teaching hospital, which is a facility where medical students and
a. assist in the strabismus surgery (under the direction and supervision of the attending physician) b. perform the strabismus surgery (under the direction and supervision of the attending physician)
If your child was scheduled to undergo strabismus surgery, 1. How important to you is it to be asked permission in advance for an ophthalmology resident to. ,2 A little important
,3 Important
,4 Extremely important
, Not sure
,1 Not at all important
,2 A little important
,3 Important
,4 Extremely important
, Not sure
Definitions: Medical student: A college graduate enrolled in a fouryear program culminating in the awarding of an MD degree. Medical students are not licensed physicians and are therefore unable to write prescriptions or work unsupervised in a medical setting. Ophthalmology resident: A medical-school graduate enrolled in a four-year, specialized training program in the field of ophthalmology. Ophthalmology residents are trained based on a system of increasing responsibility appropriate to their level of skills and education. Once a resident has completed his or her residency, that person is qualified to practice ophthalmology independently. Attending physician: A medical doctor who has finished residency and holds the ultimate responsibility for patient care. Attending physicians in the Department of Ophthalmology supervise medical students and residents. Strabismus surgery: An operation on one or more of the muscles that control eye movements in order to straighten the eyes. Assisting in surgery: In a teaching institution, a resident often assists an attending physician in surgery. The degree of resident involvement in surgery depends on his or her experience and skill in that particular operation, and involves irrigating the eye with drops and minimal direct participation. Resident assistance in surgery is provided under the direction and supervision of the attending physician.
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Performing surgery: The performing surgeon is responsible for executing the majority of an operation. When the resident has attained a sufficient level of training and expertise, he or she may perform strabismus surgery. Resident performance of surgery is provided under the direction and supervision of the attending physician.
,1 Not at all important
residents (licensed physicians in training) receive their medical education.
a. .was in the operating room during your child’s strabismus surgery b. .assisted in the strabismus surgery (under the direction and supervision of the attending physician) c. .performed the strabismus surgery (under the direction and supervision of the attending physician)
4.e1
,1 Not at all upset ,1 Not at all upset ,1 Not at all upset
2. Who should ask your permission for the ophthalmology resident to assist in the strabismus surgery (appropriately supervised by the attending physician)? a. best choice (check only one) A standard written consent form , a nurse , the ophthalmology resident , any licensed physician , the attending surgeon , other ______________ ,
b. acceptable choice (check all that apply) , , , , , ,
, No one needs to ask.
3. Who should ask your permission for the ophthalmology resident to perform the strabismus surgery under the direction and supervision of the attending surgeon? a. best choice (check only one) A standard written consent form , a nurse , the ophthalmology resident , any licensed physician , the attending surgeon , other ______________ ,
b. acceptable choice (check all that apply) , , , , , ,
, No one needs to ask.
4. If your permission had not been asked, how upset would you be if you found out that an ophthalmology resident. ,2
,3
,4
,2
,3
,4
,2
,3
,4
,5 Extremely upset ,5 Extremely upset
, Not sure , Not sure
,5 Extremely upset
, Not sure
4.e2
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5. How much do you agree or disagree with the following statements:
a. Being a patient at a teaching hospital implies that resident physicians will be involved in all aspects a patient’s medical care. A standard consent form is all that is needed to elicit informed consent for residents to. b. .be in the operating room during your surgery c. .assist in the strabismus surgery (appropriately supervised by the attending physician) d. .perform the strabismus surgery (under the direction and supervision of the attending physician)
you be to seek treatment elsewhere, at a place where residents were not involved?
,1 strongly disagree
,2 disagree
,3 neutral
,4 agree
,5 strongly agree
,1 strongly disagree ,1 strongly disagree
,2 disagree ,2 disagree
,3 neutral ,3 neutral
,4 agree ,4 agree
,5 strongly agree ,5 strongly agree
,1 strongly disagree
,2 disagree
,3 neutral
,4 agree
,5 strongly agree
6. If asked in advance, how likely would you be to agree to have an ophthalmology resident assist in your child’s operation (under the direction and supervision of the attending physician)? , Definitely agree , Likely agree , Not sure , Likely disagree , Definitely disagree 7. If asked in advance, how likely would you be to agree to have an ophthalmology resident perform your child’s operation (under the direction and supervision of the attending physician)? , Definitely agree , Likely agree , Not sure , Likely disagree , Definitely disagree 8. If your child was scheduled to have strabismus surgery and you found out that an ophthalmology resident would assist in the surgery (under the direction and supervision on the attending physician), how likely would you be to seek treatment elsewhere, at a place where residents were not involved? , Very likely , Somewhat likely , Not sure , Somewhat unlikely , Very Unlikely 9. If your child was scheduled to have strabismus surgery and you found out that an ophthalmology resident would perform the surgery (under the direction and supervision of an attending physician), how likely would
, , , , ,
Very likely Somewhat likely Not sure Somewhat unlikely Very Unlikely
10. By choosing to have care in an academic medical center like Penn State Hershey Medical Center, I assume medical students and or residents will participate in the care of me or my family members. , Definitely agree , Likely agree , Not sure , Likely disagree , Definitely disagree Your age ________ Age of your child _______ Your Gender , Male , Female Your Child’s Gender , Male , Female Has your child had eye surgery in the past? , Yes , No Have you ever had a bad experience with a medical student or resident? , Yes , No Thank you for you time and effort in completing this survey.
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eFIG 1. Response rate to the question, How important to you is it to be asked permission in advance for an ophthalmology resident to assist in/perform the strabismus surgery (under the direction and supervision of the attending physician)?
eFIG 2. Response rate to the question, How much do you agree or disagree with the following statement? A standard consent form is all that is needed to elicit informed consent for residents to: be in the operating room (OR); assist in the surgery (appropriately supervised by the attending physician); perform the surgery (appropriately supervised by the attending physician).
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4.e3
eFIG 3. Response rate to the question, If asked in advance, how likely would you be to agree to have an ophthalmology resident assist in/ perform your child’s operation (under the direction and supervision of the attending physician)?
eFIG 4. Response rate to the question, If your child was scheduled to have strabismus surgery and you found out that an ophthalmology resident would assist in/perform the surgery (under the direction and supervision on the attending physician), how likely would you be to seek treatment elsewhere, at a place where residents were not involved?
To explore patterns in parents’ understanding and preferences related to ophthalmology resident participation in their child’s strabismus surgery.
METHODS
Over a 4-week period, a survey was distributed at a suburban, academic eye center to English-speaking parents of children with strabismus who have not previously undergone, or were not being scheduled for, strabismus surgery.
RESULTS
All of the 64 eligible parents participated in the survey. For a resident to assist or perform the surgery, 80% and 97% of parents, respectively, indicated it was important or extremely important to be asked permission beforehand; 69% indicated the attending surgeon should ask permission for the resident to perform the surgery, whereas only 11% believed a standard written consent was sufficient. Of the 64 respondents, 77% indicated that they would agree to a resident assisting with their child’s operation; 36% would agree to a resident performing the surgery.
CONCLUSIONS
Nearly all parents in our study indicated that they would want to be informed of resident involvement by the attending surgeon. The vast majority would consent to having an ophthalmology resident assist in their child’s strabismus surgery, and more than onethird would consent to having the resident perform their child’s strabismus surgery. Obtaining informed consent prior to resident involvement increases transparency and highlights the importance of ophthalmology residency education. ( J AAPOS 2018; -:1-4)
trabismus affects 2%-3% of US children.1,2 Strabismus treatment depends on the etiology of the condition, but surgery may be indicated. In academic ophthalmology programs, ophthalmology residents are involved in all aspects of patient care, including participation in surgery performed under the direct supervision of an attending surgeon. The degree of participation by ophthalmology surgical residents depends on the level of training and the residents’ ability to perform the surgical maneuvers as determined by the attending surgeon. The Accreditation Council for Graduate Medical Education (ACGME) for Ophthalmology requires ophthalmology residents to perform at least 10 strabismus surgeries during their 3 years of residency training.3 According to data published by the ACGME, the average number of strabismus surgeries performed by a graduating ophthalmology resident is 24.7 surgeries. Given that approximately 450 ophthal-
S
Author affiliations: aPenn State College of Medicine, Hershey, Pennsylvania; bPenn State Eye Center, Hershey, Pennsylvania Submitted October 1, 2017. Revision accepted March 4, 2018. Correspondence: Ajay Soni, MD, Penn State Eye Center, 500 University Drive, HU19, Hershey, PA 17033 (email: [email protected]). Copyright Ó 2018, American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved. 1091-8531/$36.00 https://doi.org/10.1016/j.jaapos.2018.03.008
Journal of AAPOS
mology residents graduate each year,4 on average more than 11,000 extraocular muscles are operated on annually by resident surgeons. The safety of ophthalmology residents performing ocular surgery under direct faculty supervision is well established.5-9 For strabismus surgery, the overall success rates of trainee- and attending-performed surgeries do not differ significantly.5,6 Nevertheless, parents may have concerns regarding the level of resident involvement in their child’s strabismus surgery. Guffey and colleagues10 found that patients were misinformed about resident involvement in surgery: 28% falsely believed an ophthalmology resident can perform medical procedures without direct supervision, and 22% were unsure. The current study explored patterns in parents’ understanding and preferences related to ophthalmology residents’ participation in pediatric strabismus surgery. We addressed the following questions: What are parents’ attitudes toward resident involvement in their own child’s strabismus surgery? How likely are parents to agree to have residents involved in their child’s strabismus surgery? How likely are parents to seek treatment elsewhere if residents were to be involved in their child’s surgery?
Subjects and Methods With approval of the Pennsylvania State University Institutional Review Board, this survey-based study polled subjects between
1
2
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May 8, 2017, and June 1, 2017, at the Penn State Eye Center in Hershey, Pennsylvania. The Penn State Eye Center is based in a large academic health center in central Pennsylvania that has 18 full-time faculty members representing all major ophthalmic subspecialties. The pediatric eye care team consists of 2 pediatric ophthalmologists, 1 pediatric optometrist, and 2 full-time and 1 part-time orthoptists. The survey was designed and used in a previous study regarding resident involvement in cataract surgery11 but was modified by the authors to address related issues in pediatric strabismus surgery. During the study period, parents of children with a diagnosis of strabismus presenting for a new patient or routine follow-up examination with the pediatric eye care service were asked to participate in a survey during their visit. Patients were excluded if they were being scheduled for strabismus surgery or had a history of strabismus surgery. All parents were approached whose child met the study criteria. Subjects had the option to complete the survey orally as an interview or in writing. A fourth-year medical student was present during all office hours (Monday-Friday, 8 AM to 5 PM) of the designated study period and explained and administered the surveys. Participants were first asked to review a list of definitions including the following terms: medical student, ophthalmology resident, attending physician, strabismus surgery, assisting in surgery, and performing surgery. The medical student asked the respondents whether they had any questions or needed clarification on the definitions listed. Parents were then prompted to consider a hypothetical situation in which their child needed strabismus surgery and to answer questions related to informed consent for resident involvement in that surgery (using a five-point Likert scale). In particular, participants were asked about the importance of seeking consent for residents to be involved in their child’s surgery, the best way to obtain consent for resident involvement, and their likelihood of allowing residents to be involved. Basic demographic information was also elicited. Survey questions are provided in the eAppendix. All responses were summarized and expressed using frequencies and percentages.
Results During the 4-week study period, 67 individuals were approached, of whom 64 (51 females) were eligible and agreed to participate. The median age of the parent was 36 years (range, 21-62 years). The median age of the child was 6 years (range, 1-18 years). In response to questions on the importance of being consulted in advance about resident participation in strabismus surgery (eFigure 1), 80% of respondents indicated it was important or extremely important to be asked before residents would assist with surgery, and 97% said it was important or extremely important to be asked before residents would perform the surgery. If the resident was in the operating room during the surgery and the parents’ permission had not been sought, 55% of parents said they would not be upset at all, and 16% indicated they would be extremely upset. However, as resident involvement in the procedure increased, so did parent desire for prior consent: 50% indi-
cated they would be moderately or extremely upset if they found out after surgery that the resident assisted with the procedure; 83% would be moderately or extremely upset if they found out the resident had performed the surgery. Asked whether being a patient at an academic health center implies that resident physicians will be involved in all aspects of a patient’s medical care, 56% agreed or strongly agreed; only 16% disagreed or strongly disagreed. The remainder were neutral or unsure. However, regarding the process for obtaining informed consent, 64% of respondents indicated that the attending surgeon was the most appropriate person to ask permission for the resident to assist, and a minority (19%) believed that the standard written consent form was adequate for approval of residents assisting with the surgery (eFigure 2). Similarly, 69% of respondents indicated that the attending surgeon was the most appropriate person to ask permission for the resident to perform the strabismus surgery, whereas a minority of parents (11%) believed a standard written consent was sufficient. Finally, asked whether they would allow residents to be involved in their child’s surgery if permission had been sought (eFigure 3), 77% indicated they would definitely or likely agree to a resident assisting their child’s operation (11% would likely or definitely disagree), and 36% would definitely or likely agree to allowing a resident to perform their child’s operation (39% would definitely or likely disagree). Furthermore, 18% said they would be likely to seek treatment elsewhere if the resident were to assist in the surgery, while 25% would do so if the resident were to perform the surgery (eFigure 4).
Discussion Previous studies have investigated ophthalmology resident involvement in surgery but have largely focused on adult cataract surgery.11-15 Wisner and colleagues11 served as the model for our study. They reported that 83% of patients surveyed would be agreeable to having a resident assist in cataract surgery, whereas 49% of patients would likely consent to a resident performing their cataract surgery. The results of our study on parents’ attitudes toward resident involvement in their child’s strabismus surgery reveal a similar trend: 77% of parents would be agreeable to having a resident assist, whereas 36% of parents would likely consent to a resident performing the operation on their child. With increasing level of involvement, parents expressed a greater reluctance to consent to resident’s participation in their child’s surgery. The overwhelming majority of parents in this study wanted to be informed if a resident were to assist (80%) or perform (97%) their child’s surgery. Likewise, a study at another pediatric ophthalmology clinic showed that 76% of parents wanted to be asked to allow trainee participation in their child’s eye care.12 This data also aligns with the study by Wisner and colleagues11 and the general surgery literature, according to which 80%-96% of patients desire to
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Volume - Number - / - 2018 know whether a resident will be participating in their surgery.16,17 To our knowledge, there is no explicit requirement or recommendation by the American Medical Association or the American Academy of Ophthalmology for consent regarding trainee participation in surgery, although both organizations encourage an ethical and transparent consent process.18,19 The current patterns of ophthalmology programs in the United States suggest the large majority do not have an established policy on disclosing the level of resident involvement to patients undergoing ophthalmic surgery. Chen and colleagues20 reported that 74% of 53 programs had no established policy about disclosing resident involvement. Our findings suggest that parents overwhelmingly want to be made aware of resident involvement in their child’s eye care, indicating the potential need for a standardized disclosure process. Our study exposes a potential challenge for ophthalmology training programs. Parents desire disclosure of resident involvement in their child’s strabismus surgery but express a decreased likelihood of consenting when informed of resident involvement in the surgery. With consent rates declining as transparency about trainee participation increases,17,21,22 the process could potentially lead to a reduction of surgical cases for residents. Nevertheless, training programs and attending ophthalmologists have an ethical duty to be honest and transparent to patients (or their parents) about who will be doing the surgery, how residents will be involved, and the level of supervision this entails. It is our hope that, with an open and transparent approach, the public will acquire a greater appreciation of the goals of academic medical centers and entrust their personal or their family members’ care to physicians in a supervised training environment. The fact that a large majority of parents are agreeable to having an ophthalmology resident assist in their child’s strabismus surgery suggests that they are willing partners in the process of training future ophthalmologists provided they are adequately informed by the attending surgeon. Greater disclosure of the likely presence of an ophthalmology resident and the extent of resident involvement may alleviate the parents’ concerns while preserving the important role of ophthalmology resident education. Both the current study and the previous study by Wisner and colleagues11 suggest that the best way to disclose resident involvement is by the attending surgeon and patients or parents communicating directly. This is congruent with the views of US ophthalmology program directors, who indicate the primary responsibility for informing the patient about the level of resident involvement falls to the attending surgeon.20 Our study also highlights that being an academic medical center alone is not sufficient to assume that the patient or parent is agreeable to resident surgical participation through a standard written consent. This study has several limitations. First, the survey sample size is small and therefore may not be representative of the population as a whole. Furthermore, the study was
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completed at a single site, and the results may not be generalizable to other academic centers in urban areas. A weakness of the survey itself is that it did not stress the fact that in strabismus surgery an assistant is an obligatory member of the surgical team, and if a resident does not assist, a surgical technician would assume that role. Although our study results already show that a majority of parents would agree to a resident assisting in surgery, there may be an underestimation due to this omission. Inherent in all surveybased research is the risk of social desirability bias, in that respondents provide answers that they believe the researchers want to hear. Hopefully, the anonymous nature of the survey minimizes this bias. Finally, there is always a potential for selection bias in research such as this; however, because no patients refused the survey, voluntary response biases and nonresponse biases are minimized.
References 1. McKean-Cowdin R, Cotter SA, Tarczy-Hornoch K, et al., Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia or strabismus in asian and non-Hispanic white preschool children: multiethnic pediatric eye disease study. Ophthalmology 2013;120:2117-24. 2. Friedman DS, Repka MX, Katz J, Giordano L, Ibironke J, Hawse P, et al. Prevalence of amblyopia and strabismus in white and African American children aged 6 through 71 months the Baltimore Pediatric Eye Disease Study. Ophthalmology 2009;116:2128-34. e1-2. 3. ACGME Review Committee for Ophthalmology. Required minimum number of procedures for graduating residents in ophthalmology. Available at: www.acgme.org/Portals/0/PFAssets/Program Resources/240_Oph_Minimum_Numbers.pdf. Accessed May 31, 2017. 4. ACGME Department of Applications and Data Analysis. Ophthalmology: National Resident Report. 2014. Available at: https://www. acgme.org/Portals/0/Opthalmology_National_Report_Program_Ve rsion.pdf. Accessed May 31, 2017. 5. Mehta VJ, Utz VM, Traboulsi EI, Rychwalski PJ. Outcomes of strabismus surgery with or without trainee participation as surgeon. Ophthalmology 2014;121:2066-9. 6. Wisnicki HJ, Repka MX, Raab E, et al. A comparison of the success rates of resident and attending strabismus surgery. J Pediatr Ophthalmol Strabismus 1993;30:118-21. 7. Mehta VJ, Perry JD. Blepharoptosis repair outcomes from trainee versus experienced staff as the primary surgeon. Am J Ophthalmol 2013;155:397-403.e1. 8. Khatibi A, Naseri A, Stewart JM. Rate of rhegmatogenous retinal detachment after resident-performed cataract surgery is similar to that of experienced surgeons. Br J Ophthalmol 2008;92:438. 9. Lois N, Wong D. Pseudophakic retinal detachment. Surv Ophthalmol 2003;48:467-87. 10. Guffey R, Juzych N, Juzych M. Patient knowledge of physician responsibilities and their preferences for care in ophthalmology teaching clinics. Ophthalmology 2009;116:1610-14. 11. Wisner DM, Quillen DA, Benderson DM, Green MJ. Patient attitudes toward resident involvement in cataract surgery. Arch Ophthalmol 2008;126:1235-9. 12. Zeller M, Perruzza E, Austin L, et al. Parental understanding of the role of trainees in the ophthalmic care of their children. Ophthalmology 2006;113:2292-7. 13. Nguyen TN, Silver D, Arthurs B. Consent to cataract surgery performed by residents. Can J Ophthalmol 2005;40:34-7. 14. Gan KD, Rudnisky CJ, Weis E. Discussing resident participation in cataract surgery. Can J Ophthalmol 2009;44:651-4.
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15. Sharda RK, Sher JH, Chan BJ, Kobetz LE, Mann KD. A comparison of techniques: informed consent for resident involvement in cataract surgery. Can J Ophthalmol 2012;47:113-17. 16. Kempenich JW, Willis RE, Blue RJ, et al. The effect of patient education on the perceptions of resident participation in surgical care. J Surg Educ 2016;73:e111-17. 17. Porta CR, Sebesta JA, Brown TA, Steele SR, Martin MJ. Training surgeons and the informed consent process: routine disclosure of trainee participation and its effect on patient willingness and consent rates. Arch Surg 2012;147:57-62. 18. Code of Ethics of the American Academy of Ophthalmology. Available at: https://www.aao.org/ethics-detail/code-of-ethics;. Accessed May 25, 2017.
Volume - Number - / - 2018 19. American Medical Association, American Medical Association. Council on Ethical and Judicial Affairs, Southern Illinois University at Carbondale. School of Medicine, Southern Illinois University at Carbondale. School of Law. Code of Medical Ethics of the American Medical Association. Chicago: American Medical Association; 2017. 20. Chen AJ, Scott IU, Greenberg PB. Disclosure of resident involvement in ophthalmic surgery. Arch Ophthalmol 2012;130:932-4. 21. Santen SA, Hemphill RR, McDonald MF, Jo CO. Patients’ willingness to allow residents to learn to practice medical procedures. Acad Med 2004;79:144-7. 22. Gaeta T, Torres R, Kotamraju R, Seidman C, Yarmush J. The need for emergency medicine resident training in informed consent for procedures. Acad Emerg Med 2007;14:785-9.
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eAppendix. Strabismus surgery Parent Survey Since your child has been diagnosed with strabismus, we would like to know more about your attitudes about the participation of trainees in surgical care. Please answer the following by marking the single best answer to each question. For this survey, assume your child is a patient in a teaching hospital, which is a facility where medical students and
a. assist in the strabismus surgery (under the direction and supervision of the attending physician) b. perform the strabismus surgery (under the direction and supervision of the attending physician)
If your child was scheduled to undergo strabismus surgery, 1. How important to you is it to be asked permission in advance for an ophthalmology resident to. ,2 A little important
,3 Important
,4 Extremely important
, Not sure
,1 Not at all important
,2 A little important
,3 Important
,4 Extremely important
, Not sure
Definitions: Medical student: A college graduate enrolled in a fouryear program culminating in the awarding of an MD degree. Medical students are not licensed physicians and are therefore unable to write prescriptions or work unsupervised in a medical setting. Ophthalmology resident: A medical-school graduate enrolled in a four-year, specialized training program in the field of ophthalmology. Ophthalmology residents are trained based on a system of increasing responsibility appropriate to their level of skills and education. Once a resident has completed his or her residency, that person is qualified to practice ophthalmology independently. Attending physician: A medical doctor who has finished residency and holds the ultimate responsibility for patient care. Attending physicians in the Department of Ophthalmology supervise medical students and residents. Strabismus surgery: An operation on one or more of the muscles that control eye movements in order to straighten the eyes. Assisting in surgery: In a teaching institution, a resident often assists an attending physician in surgery. The degree of resident involvement in surgery depends on his or her experience and skill in that particular operation, and involves irrigating the eye with drops and minimal direct participation. Resident assistance in surgery is provided under the direction and supervision of the attending physician.
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Performing surgery: The performing surgeon is responsible for executing the majority of an operation. When the resident has attained a sufficient level of training and expertise, he or she may perform strabismus surgery. Resident performance of surgery is provided under the direction and supervision of the attending physician.
,1 Not at all important
residents (licensed physicians in training) receive their medical education.
a. .was in the operating room during your child’s strabismus surgery b. .assisted in the strabismus surgery (under the direction and supervision of the attending physician) c. .performed the strabismus surgery (under the direction and supervision of the attending physician)
4.e1
,1 Not at all upset ,1 Not at all upset ,1 Not at all upset
2. Who should ask your permission for the ophthalmology resident to assist in the strabismus surgery (appropriately supervised by the attending physician)? a. best choice (check only one) A standard written consent form , a nurse , the ophthalmology resident , any licensed physician , the attending surgeon , other ______________ ,
b. acceptable choice (check all that apply) , , , , , ,
, No one needs to ask.
3. Who should ask your permission for the ophthalmology resident to perform the strabismus surgery under the direction and supervision of the attending surgeon? a. best choice (check only one) A standard written consent form , a nurse , the ophthalmology resident , any licensed physician , the attending surgeon , other ______________ ,
b. acceptable choice (check all that apply) , , , , , ,
, No one needs to ask.
4. If your permission had not been asked, how upset would you be if you found out that an ophthalmology resident. ,2
,3
,4
,2
,3
,4
,2
,3
,4
,5 Extremely upset ,5 Extremely upset
, Not sure , Not sure
,5 Extremely upset
, Not sure
4.e2
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5. How much do you agree or disagree with the following statements:
a. Being a patient at a teaching hospital implies that resident physicians will be involved in all aspects a patient’s medical care. A standard consent form is all that is needed to elicit informed consent for residents to. b. .be in the operating room during your surgery c. .assist in the strabismus surgery (appropriately supervised by the attending physician) d. .perform the strabismus surgery (under the direction and supervision of the attending physician)
you be to seek treatment elsewhere, at a place where residents were not involved?
,1 strongly disagree
,2 disagree
,3 neutral
,4 agree
,5 strongly agree
,1 strongly disagree ,1 strongly disagree
,2 disagree ,2 disagree
,3 neutral ,3 neutral
,4 agree ,4 agree
,5 strongly agree ,5 strongly agree
,1 strongly disagree
,2 disagree
,3 neutral
,4 agree
,5 strongly agree
6. If asked in advance, how likely would you be to agree to have an ophthalmology resident assist in your child’s operation (under the direction and supervision of the attending physician)? , Definitely agree , Likely agree , Not sure , Likely disagree , Definitely disagree 7. If asked in advance, how likely would you be to agree to have an ophthalmology resident perform your child’s operation (under the direction and supervision of the attending physician)? , Definitely agree , Likely agree , Not sure , Likely disagree , Definitely disagree 8. If your child was scheduled to have strabismus surgery and you found out that an ophthalmology resident would assist in the surgery (under the direction and supervision on the attending physician), how likely would you be to seek treatment elsewhere, at a place where residents were not involved? , Very likely , Somewhat likely , Not sure , Somewhat unlikely , Very Unlikely 9. If your child was scheduled to have strabismus surgery and you found out that an ophthalmology resident would perform the surgery (under the direction and supervision of an attending physician), how likely would
, , , , ,
Very likely Somewhat likely Not sure Somewhat unlikely Very Unlikely
10. By choosing to have care in an academic medical center like Penn State Hershey Medical Center, I assume medical students and or residents will participate in the care of me or my family members. , Definitely agree , Likely agree , Not sure , Likely disagree , Definitely disagree Your age ________ Age of your child _______ Your Gender , Male , Female Your Child’s Gender , Male , Female Has your child had eye surgery in the past? , Yes , No Have you ever had a bad experience with a medical student or resident? , Yes , No Thank you for you time and effort in completing this survey.
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eFIG 1. Response rate to the question, How important to you is it to be asked permission in advance for an ophthalmology resident to assist in/perform the strabismus surgery (under the direction and supervision of the attending physician)?
eFIG 2. Response rate to the question, How much do you agree or disagree with the following statement? A standard consent form is all that is needed to elicit informed consent for residents to: be in the operating room (OR); assist in the surgery (appropriately supervised by the attending physician); perform the surgery (appropriately supervised by the attending physician).
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eFIG 3. Response rate to the question, If asked in advance, how likely would you be to agree to have an ophthalmology resident assist in/ perform your child’s operation (under the direction and supervision of the attending physician)?
eFIG 4. Response rate to the question, If your child was scheduled to have strabismus surgery and you found out that an ophthalmology resident would assist in/perform the surgery (under the direction and supervision on the attending physician), how likely would you be to seek treatment elsewhere, at a place where residents were not involved?