Guidelines Concerning the Ethical Practice of Attending Physicians
and Fellows, Residents and Interns
Explanation of the nature and risk of an operation to the patient or to the patient’s representative is essential.
Before surgery or an invasive procedure is performed, informed consent should be obtained from the patient in accordance with the policies of the health care entity. Patients should understand the indications for the surgery or invasive procedure, the risk involved, and the result that is hoped to be attained. In the instance of a minor or a patient who is incapable of making an informed decision on his own behalf or is incapable of communicating such a decision due to a physical or mental disorder, the legally authorized person available to give consent should be informed and the consent of the person documented. An exception to the requirement for consent prior to or during the performance of surgery or an invasive procedure may be made if a delay in obtaining consent would likely result in imminent harm to the patient.
Under the usual and customary arrangement with patients, and with reference to the usual form of consent to surgery or an invasive procedure, it is the attending physician to whom the patient grants consent and who is obligated to perform the surgery or invasive procedure. With the consent of the patient or another legally authorized person available to give consent, it is ethical for the attending physician to delegate the performance of some or all aspects of the surgery or invasive procedure to the fellow, resident, intern or assistant provided this is done under the physician’s supervision as described in the supervising policy of the Accreditation Council for Graduate Medical Education (ACGME). If some or all of the surgery or procedure is to be delegated to another health care provider or if care of the patient is to be turned over to another attending physician, the patient or the legally authorized person available to give consent is entitled to be so informed and to give documented consent.
It is unethical to mislead a patient as to the identity of the doctor who performs the surgery or invasive procedure. If the identified attending physician cannot perform the surgery or invasive procedure due to any unusual or emergency reasons, the patient or another legally authorized person available to give consent must be fully informed and given another opportunity to accept or reject the replacement physician.
Supervision of trainees (fellows, residents and interns) by attending physicians
The attending physician has both an ethical and a professional responsibility for the overall care of the individual patient and for the supervision of any trainee involved in the care of the patient. Although senior trainees require less direction than their junior counterparts, even the most senior must be supervised. A chain of command that emphasizes graded authority and increasing responsibility as experience is gained must be established. Judgments on this delegation of responsibility must be made by the attending physician who is ultimately responsible for the patient’s care; such judgments shall be based on the attending physician’s direct observation and knowledge of each trainee’s skills and ability.
To ensure the fulfillment of these responsibilities, the following principles of supervision must be operative within a training program.
- Supervision of trainees must be specified in the bylaws, policies, procedures, rules and/or regulations of the department which must not be less demanding that those of the institution.
- Evidence that adequate supervision exists within a program must be provided in the form of signed notes in the patient charts and/or other such records.
- Proper supervision must not conflict with progressively more independent decision-making on the part of the trainee; thus, the degree of supervision may vary with the clinical circumstances and the training level of the trainee. However, to exercise their responsibilities properly, members of the teaching staff always must be immediately available for consultation and support.
For the purposes of this guidance document, “invasive procedure” shall mean any diagnostic or therapeutic procedure performed on a patient that is not part of routine, general care and for which the usual practice within the institution is to document specific informed consent from the patient or surrogate decision-maker prior to proceeding.