As another resident at a large teaching hospital, I would tend to agree here. In general surgery, as long as there's a fellow or a senior (3rd-5th year depending on procedure complexity), the attendings usually don't even scrub in for routine procedures. If they do scrub, they are basically sitting on the stool with arms folded and chatting with the OR staff - yet available in case the resident/fellow gets "stuck" and needs a pointer. The resident has seen the attending do the procedure, the attending has observed the resident do it, and it's time for the senior to teach his junior residents. The attending might take a mental break, round on a few inpatients, grab a coffee, etc before his next case.
Yes, the attending definitely needs to be there for the key components of the procedure (fracture fixation, anastamosis of vessels, inserting total knee components, patching of hernia, etc... but it's not uncommon for the attendings to run 2+ ORs in order to be more efficient and save turnover time, esp if they have a chief or fellow in one of the rooms.
For pod, I think it's a bit irresponsible for attendings to leave the OR before the joint capsule is closed. However, as long as they discussed the gameplan at the scrub sink, oversaw the key aspects of the procedure, are working with residents they know to be competent based on same or highly similar procedures, and will be available in the doctors lounge or by pager afterwards, then I see nothing wrong with letting residents close, splint, etc. I've had attendings jokingly ask "do I even need to scrub in today?" when it's a slower surgery schedule day and they walk into the room and see a 2nd or 3rd year resident present for stuff like hammertoes, bunions, TMA, etc. Especially for inpatient I&Ds, Apligrafs, toe amps, etc... there's really no way to make the patient "worse" and there's reason not to let a [competent] resident struggle - so long as the attending takes a look and voices approval before the bandages go on.
Feli,
Once again, this has nothing to do with the competency of the residents or the confidence I have in the residents. In my opinion, it's simply the responsibility I have to my patient to be present. The patient's safety is my responsibility and I'm captain of the ship.
The patient did not come to my office to be treated by you or any other resident. The patient came to my office to be treated by me. Yes, the consent form states that the procedure will be performed by me or whoever I designate, yada, yada, yada, but I have a private practice and my patients come for my expertise and reputation, not for the resident that happens to be scrubbing that day.
Yes, of course I allow the resident to perform parts of the procedure in conjunction with the skill level and attitude of the resident. But I NEVER leave the room. I don't need to take a "mental break", go to the lounge to get a cup of coffee or mingle with the other docs, etc. I have dedicated my time to my patient, no matter how long the case takes. If I get bored, I shouldn't have booked the case. If I decide to allow an amazing resident to perform a case skin to skin, that's also great, but I will be in the room 100% of the time.
I believe it's my moral obiligation, and once again has
nothing to do with resident competency. When you are in practice, there are a lot of things you can do that are "OK", but then there are things you will do simply because you feel it's the "right thing" to do. And I believe that staying in the OR with my patient is the right thing.
And if you really want to look at this from another perspective, forget about academic/hospital based practices regarding general surgical practices. Let's talk about private podiatric practices for a minute.
I am consulted on a regular basis to defend podiatric malpractice cases, and in these cases, everyone involved gets "cold feet" and looks to point fingers at everyone else named in the case. It can get
very ugly. When depositions are taken, they often depose everyone that every looked at the patient, including scrub nurses, circulating nurses, residents, anesthesia personell, etc.
If and when it comes up in deposition that an attending of a private practice patient was down the hall, performing rounds, getting a cup of coffee, etc., and NOT in attendance until the completion of a case, there will be ramifications. Because everyone in that room will have a different account of when the attending left the room. Someone will say after the skin incision, someone will say during the osteotomy, someone will say prior to fixation, someone will say during closure, etc., etc. Regardless of whether or not that anything to do with the outcome, it certainly will not look good in court and it will always be tough to answer "why" you felt the need to leave the OR. There is no correct answer.
So, even if you don't follow my philosophical belief that it's simply the "right thing" to do, since your patient expects you to be there, then at least think of the medical-legal ramifications when you are an attending.
But most importantly, is there REALLY a
valid reason to leave the OR?