Elsevier

Current Surgery

Volume 60, Issue 6, November–December 2003, Pages 615-622
Current Surgery

Original report
The effect of standardized patient feedback in teaching surgical residents informed consent: results of a pilot study

https://doi.org/10.1016/S0149-7944(03)00157-0Get rights and content

Abstract

Purpose

The purpose of this pilot study was to determine the effectiveness of using feedback from a standardized patient (SP) to teach a surgical resident (SR) informed consent (IC) protocol.

Methods

Four general case types of increasing difficulty were tested in a longitudinal experimental design format. The four types of cases were appendectomy, cholecystectomy, colorectal cancer, and breast cancer. Eight SRs of varying years of completion in medical school served as subjects—four in the experimental group (received performance feedback from an SP) and four in the control group (received no SP feedback). Both the control and experimental groups participated in two patient encounters per case type. The first patient encounter served as the pretest, and the second patient encounter was the posttest. In each encounter, an SP rated the resident on 14 measures using an open-ended seven-point rating scale adopted and modified from the Brown University Interpersonal Skill Evaluation (BUISE). Each resident also reviewed a videotape of an expert giving IC between pretest and the posttest for basic instructional protocol. Random stratified sampling was used to equally distribute the residents by postgraduate years. A total of 16 SPs were used in this study. All patient/SR encounters were videotaped.

Results

There was a statistically significant overall change—pretest to posttest and across cases (p = 0.001). The group effect was statistically significant (p = 0.000), with the experimental group averaging about 10 points greater than the control group.

Conclusions

Standardized patient feedback is an effective modality in teaching surgical residents informed consent protocol. This conclusion is tentative, due to the limitations of sample size. The results of this study support continued research on the effects of standardized patient feedback to teach informed consent to surgical residents.

Introduction

Teaching surgical residents (SR) how to deliver informed consent is a complex behavioral and medical/legal subject. Very little in the literature informs the surgical educator what instructional protocol is best for orienting the resident to this area of content. Other than the apprenticeship model, little evidence is found for teaching this subject. The apprenticeship model does not address the issues of standardization (does everyone get the same experience?), nor does it lead the resident into the process without directly involving a real patient.

Informed consent (IC) is a complex process that represents an interaction between a physician and a patient. The process may be a verbal discussion or a written document that allows patients to make the best possible judgment regarding the treatment of their disease process. This interaction between the physician and patient should satisfy the physician's moral and legal responsibility while increasing the patient's satisfaction with, respect for, and trust in the physician. The desired results can minimize the frequency of malpractice suits and at the same time enhance physician–patient relationships.

The discipline of surgery is especially vulnerable to medico-legal concerns. Surgical intervention can bring about a variety of risk factors that range from a simple infection to mortality. This opens the door for potential litigation from an unsatisfactory patient result. With the advent of important surgical advances in the treatment of any disease, such as breast cancer, rectal cancer, and the use of endoscopic procedures, it is more important than ever to stress appropriate IC.

How then, do surgical residents (SR) learn about giving patients appropriate IC? There is little in the literature regarding this question. Few articles are published on the actual teaching of informed consent. Coles et al published a clinical brief on a proposed method for teaching IC to residents but have not yet reported their findings.1 A survey conducted in 1997 by Downing et al stated that at least 76% of the general surgery residency programs offered little or no formal ethics training that included the topic of informed consent. Yet it is interesting to note that 94.3% of the surgery program directors that responded to this survey agreed that it was important to teach IC in the surgical curriculum.2 In 1999, Angelos et al sought to develop and evaluate a medical ethics curriculum designed specifically for surgical residents. The instructional methods used to address IC education were case debate, formal presentation, and game simulation.3 Although the confidence levels of the residents improved significantly from pretest to posttest, it did not appear that the residents had an opportunity to apply the conceptual framework in the practice setting.

In addition, anecdotal evidence reinforces that surgical residents are most often working in the operating room and surgical floors (inpatient setting), rather than evaluating patients in the preoperative period in the outpatient setting. “As a result, surgical residents may have little opportunity to witness the difficult discussions and decisions that are made regarding the care of a patient, because these discussions are frequently occurring in the ambulatory setting.”3 At the very most, residents serve as apprentices during the informed consent process and tend to model behaviors of the attending surgeons regarding this issue. Thus, few residents get the chance to visit the patient to address IC issues in a supervised environment. Lack of this exposure naturally leads to inexperience, which subsequently may lead to patient dissatisfaction as the resident progresses on a continuum throughout the resident's career. Thus, there has been little formal or systematic attention given to this instruction.

The adult teaching and learning process is a “delicate human transaction.”4 To facilitate learning in the theoretical framework of adult learning, residents should be given opportunities for direct experiences in giving informed IC in a safe environment. Such an environment would not only shelter the resident from any legal ramifications sought by the patient but also provide the SR with feedback from both the SP and their surgical trainers.

The role of experience and learning has been a theme in the adult education literature beginning with Dewey's seminal work5 (see also Bateson6 and Usher et al7). Merriam and Caffarella8 describe how context affects learning and how it can serve as an important method in the teaching/learning transaction. They describe three teaching modalities that adult educators utilize to organize learning from experiences. They are reflective practice, cognitive apprenticeships, and anchored instruction. While containing aspects of each of the three modalities, the teaching method employed in this research to instruct surgical residents informed consent most closely resembled anchored instruction. The role of anchored instruction is to “create situations in which learners, through sustained experiences, can grapple with the problems and activities that experts encounter.”8

To date, Des Moines University-Osteopathic Medical Center (DMU) provides no structured intervention for teaching IC to the residents. Again, residents must rely on the apprenticeship model to incidentally learn the knowledge and skills necessary for performing IC. Although incidental experience may have historically been sufficient, it is not satisfactory for the future, given the increasing complexity of surgical procedures. Therefore, a structured educational experience is necessary.

The purpose of this pilot study was to determine the effectiveness of using feedback from a standardized patient (SP) to teach a surgical resident (SR) informed consent protocol. The pilot functioned to validate the use of SP encounters as a regular feature of the DMU residency-training program. From this experience, a protocol is being developed that can be used as a template for adding SP encounters to the general surgery program as well as to other programs in the postgraduate track.

The specific aims of the project were to (1) develop a protocol to teach SR informed consent using SPs, (2) produce four videotapes of an expert giving IC to an SP, and (3) test the effect of SP feedback given to the residents immediately after a SP encounter. The expert videos served as the formal instructional piece for the SRs participating in the project.

Section snippets

Methods

Four general case types of increasing difficulty were tested in a longitudinal experimental design format. The four types of cases were appendectomy, cholecystectomy, colorectal cancer, and breast cancer. Eight SRs in postgraduate years two through five served as subjects—four in the experimental group and four in the control group. Random stratified sampling was used to distribute the residents equally over the groups by number of postgraduate years. A total of 16 SPs were used in this study.

Results

The results were divided into results (1) by each of the four case types using pretest/posttest data, (2) over all four case types using pretest/posttest data, and (3) over all four case types using only posttest data.

Discussion

This was a small pilot study consisting of eight surgical residents (four in each group). The standardized patients were mixed and matched with the SR to provide the assessments (both groups) and feedback (treatment group). The purpose of the study was to assess the effectiveness of using SP feedback in teaching the IC protocol to surgical residents. The conclusions are tentative, due to the limitations of sample size. There was a statistically significant group difference over all cases, with

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