Fellow-in-Training Perspective
Establishing the Role of Fellow and Building Patient Trust
By Callie Hill, MD, Fellow-in-Training Board Observer
Mohs surgery is an incredible field to train in. While other surgical specialties are conducted under general anesthesia, we have the privilege of performing precise surgery on cosmetically sensitive areas of our awake patients. This adds an extra level of complexity and sensitivity in our learning environment. On occasion, I have sensed reluctance when a patient asks, “What exactly is a fellow?” or “How involved in my care will you be?” On the rarer occasion, I have been told the patient expects the attending to exclusively perform the Mohs surgery and reconstruction. This experience is likely relatable for most. It is important to consider how the patient perceives the fellow’s role. In understanding this, we may practice ways to optimize success for each patient-fellow relationship.
Trust is built with time spent getting to know our patients. During the pre-operative period, I seek to understand each patient’s baseline knowledge of his/her skin cancer and the procedure. I then mark the surgery site and discuss expectations for the day. I consider this fundamental in developing rapport. As we are preparing for surgery, my attending may say, “Dr. Hill is my fellow, meaning she is a board-certified dermatologist who is spending an extra year with us learning Mohs surgery.” These words seem to validate my presence in the surgery to the patient. When residents are present, I ensure they are introduced and their training level is also clear. I encourage patients to let me know if they are unsure of who is present in the room. Whenever possible, I act as a liaison for the patient, updating family members and relaying information to the surgery team. At the point of reconstruction, I discuss repair options with each patient, keeping in mind the individual’s goals, functional status, and level of support at home. Throughout these interactions, I aim to build trust and therapeutic alliance with each patient, positioning myself as one of their surgeons.
In speaking with other fellows about how they navigate this situation, Dr. Elliott Campbell, Mohs surgery fellow at Mayo Clinic in Rochester, Minnesota, says, “A team-based approach is crucial for a fellow’s success. …Our nurses emphasize the fellow's integration into the team, highlighting them as a board-certified dermatologist pursuing an optional surgery year. This introduction sets the stage.” Dr. Campbell framed the fellow as the “initial physician,” discussing how individuals will gravitate towards the first surgeon they meet. Dr. Campbell considers this first patient interaction to be pivotal, during which time “extensive consenting and information exchange is crucial in leveraging the fellow's expertise in tumor biology, surgery-specific anatomy, and reconstructive options.” He further acknowledged the important role of the attending physician in echoing the fellow’s board certification.
Dr. Lauren Crow, Mohs surgery fellow at the University of Pittsburgh, also views the pre-operative process as an opportunity to take the lead. Through guiding each patient in discussions of risks, benefits and details of the procedure, the patient can rest assured that the fellow is knowledgeable of their case and has experience in the procedure. Dr. Crow emphasizes clear communication and the central role of our attendings. “It is important to never try to trick the patient into thinking that the attending is operating when they are not, as this breaks the patient’s trust. When I am working on a patient I have never met before, my attending is always assisting me and essentially has hands on the patient, even if she is not the one operating.”
There are several points throughout the surgery day at which the fellow can take the lead. As Drs. Campbell and Crow agreed, the pre-operative moments with the patient are key. Attending physicians, nurses, and other support staff are helpful in emphasizing the fellow’s years of training and board certification. Awkward moments may still arise when patients express reluctance or question the fellow’s involvement. In these instances, we should pause to clarify their concerns, educate, and define the level of participation they are comfortable with. I am grateful for patients who entrust me with their care and for the mentorship of the Washington University Mohs surgeons. As we enter the remainder of fellowship, let us take advantage of every opportunity to invest in our patients and our learning.