By Stacey Kusterbeck
Residents often are tasked with obtaining informed consent from patients, and must become proficient in this important skill. According to the American Association of Medical Colleges, obtaining informed consent is a core entrustable professional activity for residents.1
“The paradigm for assessing competence as a clinician is evolving toward the use of entrustable professional activities,” says Peter Yoo, MD, a transplant and general surgeon, the chief academic officer of Hartford HealthCare, and the former program director of the Yale Surgical Residency. With this approach, as trainees become more competent, supervising physicians entrust the trainee with certain professional activities that they can do at a greater scale of autonomy. For example, a brand-new medical resident may observe a physician reviewing a patient’s medications, then does it with direct supervision and documents the information. After some more experience, the resident can review medications with the patient independently. “That’s a standard rubric for gaining clinical skills. But does that work for informed consent?” asks Yoo.
Yoo and colleagues surveyed 85 attending surgeons in 2020 about the informed consent process and current entrustment practices.2 Some key findings:
- Most attending surgeons view informed consent as an ethical obligation that cannot be entrusted to trainees. Most (68.2%) stated that they never granted responsibility for the informed consent conversation to a trainee.
- Whenever a trainee obtained informed consent, the vast majority (91.4%) of surgeons indicated that they repeated the informed consent conversation themselves.
- Ethical duty and the patient/physician relationship were the most common reasons for physicians retaining responsibility for consent. Less than half of surgeons said they retained responsibility because of concerns about trainee competency.
- Almost all surgeons believed residents should receive formal training in informed consent. Less than half of physicians felt they would change their current entrustment practices even if residents had additional training, however.
“We determined that practicing surgeons believe that consent really has two general aspects to it. One is the establishment of that covenant. It’s the eye-to-eye conversation, the laying of hands, the establishment of trust, the human contact that has to take place,” says Yoo.
The other aspect of informed consent is documentation, which is commonly delegated to trainees. Even if trainees have had an informed consent discussion, the surgeon typically goes back and has the conversation themselves with the patient. “They will not delegate that aspect of the conversation except under emergency circumstances. If a surgeon is unwilling to delegate aspects of the task of obtaining informed consent to a nearly fully trained chief resident with over 1,000 operations to their credit, do we think it’s likely they’re going to delegate that task to a medical student? Probably not,” says Yoo.
This calls into question whether graduated autonomy and entrustable activity, the dominant paradigm in clinical training, is applicable to informed consent. Informed consent is a clinical skill, and an important task from a regulatory or medical/legal standpoint. “Yet it is unique from other clinical skills in that it also represents a critical event that must take place between the patient and physician,” says Yoo. “In the moment of an informed consent discussion, there is a covenant that takes place between the patient and their doctor that is particularly heightened in the setting of surgery. It’s a human connection of trust, and true human connectiveness, that cannot be delegated by doctors to somebody else.”
This raises questions about how to ensure that trainees can acquire this important skill. Residents often do not receive formal instruction in obtaining informed consent.3,4 “The question of how to teach informed consent is a ubiquitous, perennial issue in medical education. The educational experiences that lead to true confidence with that skill — and it is a skill that needs to be developed — are very variable. One important variation is that some people don’t really get taught to do it much at all, and just pick it up out of necessity,” says Yoo.
In Yoo’s view, a new model for teaching consent is needed — one that takes into consideration that some aspects of the informed consent discussion cannot be delegated. “If you can’t use a proxy to do this, then a different construct has to be arrived upon to provide proper education. New approaches need to be developed,” says Yoo.
Consent is one of the largest components of the surgeon-patient relationship, and is necessary for shared decision-making, for a patient to truly understand what they are agreeing to in their most vulnerable time, observes Steven D. Schwaitzberg, MD, FACS, chair of the Department of Surgery at the Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo. Yet the teaching of this skill has not yet been formalized in any consistent way. “It was apparent from the literature that there was no best practice in how to teach informed consent. At most institutions, this appears to be part of the on-the-job ‘hidden curriculum,’” says Schwaitzberg.
Schwaitzberg and colleagues conducted a study to see what the measurable improvement would be for informed consent skills, after a year of experience as a surgical trainee.5 The researchers surveyed 10 post-graduate year 1 and eight post-graduate year 2 residents about their experience and confidence in obtaining informed consent. Next, the researchers assessed the residents obtaining informed consent for a right hemicolectomy. An extra year of clinical experience did not improve the year 2 residents’ ability to obtain informed consent if they lacked formal informed consent education.
“We were actually quite stunned to note that the residents with a year of experience performed, overall, no better than residents fresh out of medical school,” says Clarise A. Cooper, MD, MSHPEd, FACS, another of the study authors and clinical assistant professor of surgery and associate program director of the General Surgery Residency Program at the Jacobs School.
Most residents had performed or confirmed at least 50 consents on patients. The resident consent discussion typically is duplicative of the attending discussion with the patient and is done as a formality to get the paperwork signed. “However, eventually these residents will be independent surgeons themselves. It would be best for them to learn to do this well from the beginning,” asserts Cooper.
From a patient’s perspective, there can be substantial confusion, discomfort, and loss of trust if the resident and the attending are having conflicting conversations. The study findings are important to raise awareness from an educational standpoint, says Cooper: “We need to improve how we teach this skill — both formally in curriculum creation but also informally, as we model it and include our trainees on the job.” This means residents must be in the room when informed consent discussions take place between surgeons, patients, and families. “Informed consent has become one of the educational themes of our department as an important soft skill, in conjunction with the hard skills of dissection, cut, sew, and tie,” reports Schwaitzberg.
References
1. Obeso V, Brown D, Aiyer M, et al. Toolkits for the 13 core entrustable professional activities for entering residency. Association of American Medical Colleges; 2017. https://www.aamc.org/what-we-do/mission-areas/medical-education/cbme/core-epas/publications
2. White EM, Esposito AC, Yoo PS. Should obtaining informed consent be considered an entrustable professional activity? Insights from whether and how attendings entrust surgical trainees. Acad Med. 2024;99(8):897-903.
3. Koller SE, Moore RF, Goldberg MB, et al. An informed consent program enhances surgery resident education. J Surg Educ. 2017;74(5):906-913.
4. Gaeta T, Torres R, Kotamraju R, et al. The need for emergency medicine resident training in informed consent for procedures. Acad Emerg Med. 2007;14(9):785-789.
5. Lamb M, Woodward JM, Quaranto B, et al. Do interns learn on-the-job how to obtain proper informed consent for surgical procedures? J Surg Educ. 2024;81(9):1215-1221.
Residents often are tasked with obtaining informed consent from patients, and must become proficient in this important skill. According to the American Association of Medical Colleges, obtaining informed consent is a core entrustable professional activity for residents.
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