Resident Involvement in Plastic Surgery: Divergence of Patient Expectations and Experiences with Surgeon's Attitudes and Actions.

BACKGROUND: As surgical educators, we need to balance the training of our future colleagues against the best possible outcomes and expectations of our patients. Although the legal and ethical standards for disclosure regarding trainee involvement in delivery of surgical care are well established, it is unclear if patient experiences reflect current principles of medical ethics. The attitudes and behavior of surgeons regarding informed consent and patient expectations about resident involvement also remain uncertain. METHODS: One hundred and five patients surveyed within 6 weeks following their surgery to assess their experiences and expectations regarding resident involvement in their surgery. Three hundred and eight-three members of the Canadian Society for Plastic Surgery received online surveys concerning their attitudes and behaviors regarding the involvement of residents and fellows in trauma, elective, and cosmetic surgery. RESULTS: Only half of patients were informed that residents may be involved in their surgery and only half were aware if it occurred. This is consistent with the finding that only half of surgeons indicate that specifically requesting consent for trainee involvement during surgery is required for residents to assist or operate. If specifically asked, most patients would agree to have a resident assist in their surgery, but the majority would not agree to have the resident perform the surgery. This is contrary to the finding that more than two-thirds of surgeons report willingness for the trainee to operate independently, with supervision, on trauma or elective patients. Two-thirds of patients felt it was essential that they specifically be asked for permission regarding resident involvement and that this question should be posed by the primary surgeon. Interestingly, only half of surgeons report that patients can decline trainee involvement in their trauma or elective surgery, but the majority of surgeons reported that cosmetic surgery patients could decline resident involvement. Patients also indicated that they would be upset if they subsequently found out that residents assisted or performed their surgery without their specific consent. CONCLUSIONS: Canadian plastic surgeons indicate a clear commitment to intraoperative surgical training of residents and fellows, although this willingness declines precipitously when it involves cosmetic surgery patients. Unfortunately, the reported attitudes and behaviors of the surgeons are not consistent with the expectations of their patients, or the legal and ethical demands regarding informed consent.

Mortality & clinical characteristics of hospitalized adult patients with HIV in Pune, India.

BACKGROUND & OBJECTIVE: In India, data regarding mortality and clinical characteristics of hospitalized HIV-infected patients are sparse, which may limit the effectiveness of new hospital-based HIV programmes providing antiretroviral therapy (ART). The objective of our study was to determine mortality and clinical characteristics of hospitalized HIV-infected individuals in a high HIV prevalence region of India. METHODS: A retrospective chart review was done of known HIV-infected adults admitted to the Medical Service of a large, public hospital in Pune, India, from January 2002 to November 2003. RESULTS: A total of 655 HIV-infected patients were identified; 489 (74.7%) were male and 4 (0.6%) were on ART. The most common illnesses reported were tuberculosis (55.8%), diarrhoea (4.2%), and alcoholic liver disease (3.7%) . The inpatient mortality was 172 (26.3%). The most common causes of death of the 172 people were tuberculosis (52.9%) and cryptococcal meningitis (7.6%). In multivariate analysis, factors associated with increased mortality were male sex (adjusted odds ratio (AOR) 1.92, 95% CI: 1.08-3.41), haemoglobin level < 7 g/dl (AOR 2.75, 95% CI:1.23-6.14), length of stay < 2 days (OR 5.78, 95%, CI: 1.82-18.4), and cryptococcal meningitis (OR 4.44, 95% CI:1.19-16.6). INTERPRETATION & CONCLUSION: In the era prior to widespread ART, a high inpatient mortality of 26 per cent was found among hospitalized HIV-infected individuals. Thus, while hospitalization is an important access and referral point for HIV care and treatment, earlier identification of HIV-infected persons must occur to ensure they will optimally benefit from the government's ART programme.