Informed Consent
A 34 yo G1 at 38 weeks requests a primary cesarean delivery, citing concern for perineal tearing (she reports her sister had a 4th degree laceration) despite no current medical contraindications to vaginal birth. The physician is personally uncomfortable with elective surgery in this scenario but acknowledges the patient is well-informed and emotionally distressed by the prospect of vaginal birth.
According to ACOG guidelines, what is the physician’s primary ethical obligation in this scenario?
A. Recommend against cesarean and document informed refusal of trial of labor
B. Decline to offer cesarean, but offer to refer the patient elsewhere for a second opinion
C. Respect the patient’s autonomous decision and provide non-coercive support
D. Petition the hospital ethics committee for override based on resource stewardship
E. Require a formal psychological evaluation before proceeding
C. Respect the patient’s autonomous decision and provide non-coercive support
Respecting autonomy remains central even if the clinician has personal reservations. While shared decision making allows the provider to express clinical concerns, the patient’s informed choice should be honored, especially when emotionally significant.
During a routine laparoscopic salpingectomy, a trocar injury to the inferior epigastric artery causes significant hemorrhage, requiring slight extension of one port site to identify and ligate the artery and intraoperative blood transfusion. The injury is identified and managed intraoperatively. Postoperatively, the patient is stable and recovering well. The surgeon is hesitant to disclose the complication because the outcome was favorable.
According to ACOG, what is the most appropriate next step?
A. Disclose the event only if the patient asks
B. Document the event but avoid discussing it due to lack of long-term harm
C. Discuss the injury openly, including its cause, management, and possible future implications
D. Defer the discussion to risk management to try to avoid future litigation
E. Withhold immediate disclosure because the complication is a known risk of the procedure
C. Discuss the injury openly, including its cause, management, and possible future implications
Patients have the right to know what happened in their care, even if the complication was anticipated or did not result in long-term harm. Disclosure fosters trust and is an ethical imperative.
A PGY2 is nearing the end of a 24-hour call shift and is asked to assist with an emergent postpartum hysterectomy. She feels cognitively foggy and emotionally reactive but is reluctant to speak up for fear of appearing weak.
What is the most appropriate next step?
A. Proceed with the case because fatigue is expected during residency and the attending is supervising
B. Notify the attending of her fatigue and request a substitution due to concern for patient safety
C. Decline participation and leave the hospital to rest
D. Accept the assignment but work only in a limited observational role
E. Report herself to the program director after the case to avoid punitive action
B. Notify the attending of her fatigue and request a substitution due to concern for patient safety
Fatigue is a form of impairment that can compromise patient safety. Physicians have a responsibility to self-assess and communicate limitations, particularly when participating in high-risk care.
A 30-year-old OB/GYN resident in her third year has recently started to arrive late, avoid clinical responsibilities, and describe patients as “difficult” or “pointless cases.” She denies being “depressed” but feels numb and detached from work. She has not taken any time off.
According to validated burnout frameworks (Maslach), which of the following best characterizes her clinical presentation?
A. Depression with psychomotor slowing
B. Primary insomnia from chronic stress
C. Emotional exhaustion and depersonalization
D. Poor time management and professional immaturity
E. Situational anxiety triggered by cognitive overload
C. Emotional exhaustion and depersonalization
Maslach’s triad of burnout includes: emotional exhaustion, depersonalization, and reduced personal accomplishment. Detachment and cynicism toward patients strongly suggest depersonalization, a core feature.
An attending obstetrician is scheduled to perform a repeat cesarean at 9 AM. A nurse observes the physician behaving inappropriately and slurring speech before entering the OR. The anesthesiologist raises concerns to the chief resident.
What is the primary ethical obligation in this moment?
A. Proceed with surgery but assign an experienced resident to assist
B. Delay surgery and ensure the physician is evaluated for impairment before proceeding
C. Allow the physician to proceed if they deny substance use and appear functional
D. Have the anesthesiologist monitor the attending during the procedure
E. Report the incident only after the case concludes to avoid disrupting patient care
B. Delay surgery and ensure the physician is evaluated for impairment before proceeding
Physicians must be fit for duty, particularly when performing high-risk procedures. Immediate removal from clinical care and evaluation is needed when impairment is suspected, prioritizing patient safety over workflow concerns.
Which of the following strategies is most consistent with ACOG's recommended approach to informed consent?
A. Providing a standardized consent form describing all risks and requesting a signature
B. Asking the patient to restate their understanding of key concepts and decisions
C. Presenting risks using only statistical terms to reduce emotional bias
D. Limiting discussion of rare risks to avoid patient overwhelm
E. Ensuring documentation includes only the most likely outcomes
B. Asking the patient to restate their understanding of key concepts and decisions
ACOG emphasizes that informed consent is a process, not a form. Checking understanding—often via "teach-back"—is essential to ensure the patient is informed and engaged.
A gynecologic oncologist performs a radical hysterectomy during which the ureter is inadvertently transected. Upon discovering the complication postoperatively, she speaks with the patient and expresses regret, clearly explains what occurred, and outlines the next steps for repair and follow-up.
Which of the following best reflects ACOG’s recommendation regarding disclosure of adverse events and apology?
A. Avoid apologizing, as it may be interpreted as admission of guilt and increase liability
B. Use vague language to reduce legal exposure
C. Provide factual information but refer all emotional concerns to the hospital’s risk management team
D. Acknowledge the event clearly and offer a sincere, non-defensive expression of empathy
E. Delay disclosure until all internal reviews are complete
D. Acknowledge the event clearly and offer a sincere, non-defensive expression of empathy
ACOG encourages prompt, transparent disclosure that includes a sincere expression of empathy. This is not equivalent to admitting legal liability but rather upholding ethical responsibility and supporting patient trust.
A large medical center has experienced a rise in near-miss events during handoffs between overnight and daytime OB teams. An internal audit reveals that most of these events occur after 20–28 hours of continuous duty for OB attendings.
According to ACOG recommendations, which of the following institutional strategies would best address this safety concern?
A. Increase use of caffeine and nutrition stations to boost alertness
B. Mandate power naps for all attendings at the 20-hour mark
C. Implement formal duty hour limits for attendings, protected rest periods, and standardized handoff protocols
D. Require all attendings to undergo monthly simulation training for emergency fatigue scenarios
E. Encourage peer-to-peer fatigue checks during long shifts
C. Implement formal duty hour limits, protected rest periods, and standardized handoff protocols
System-level interventions, including duty hour limits, fatigue-mitigation strategies, structured handoffs, and protected rest periods, are most effective to reduce risk associated with fatigue.
Which of the following statements best reflects the evidence regarding the prevalence and contributors to burnout in medical residents?
A. Burnout rates are significantly lower among residents than attending physicians due to greater institutional oversight
B. Lack of coping skills is a stronger predictor of burnout than total work hours alone
C. Female residents consistently report lower burnout scores across specialties
D. Burnout in residents is most strongly associated with poor Step 1 scores and academic pressure
E. Residents with burnout are more likely to disclose their symptoms and seek help proactively
B. Lack of coping skills is a stronger predictor of burnout than total work hours alone
While long work hours contribute to burnout, maladaptive coping styles (e.g., avoidance, denial) and low social support are stronger predictors. Institutional and personality-level contributors play major roles.
A resident discloses to the program director that they are struggling with alcohol dependence and want help. The program director wants to support them but is unsure how much information should be shared with the clinical team.
Which of the following best describes the ethical framework for responding to this disclosure?
A. Confidentiality should be waived to ensure full transparency
B. Information should be shared only if the resident poses a risk to patient safety
C. All supervising physicians must be informed immediately
D. The resident must be removed from training permanently
E. Anonymous reporting to the National Practitioner Data Bank is mandatory
B. Information should be shared only if the resident poses a risk to patient safety
Resident physicians should be provided confidential access to treatment, with disclosure limited to cases involving active impairment that threatens patient safety. Stigma must be reduced, and confidentiality upheld unless safety is at stake.
A 41 yo nulliparous patient with complete previa at 36 weeks states she wishes to attempt vaginal delivery. After extensive counseling, she expresses mistrust of surgery and declines a scheduled cesarean despite understanding the risks.
Which of the following best reflects the physician’s ethical and professional responsibility?
A. Proceed with vaginal delivery under close monitoring
B. Seek judicial authorization to proceed with cesarean delivery
C. Continue respectful dialogue while documenting the informed refusal
D. Notify hospital administration and transfer care
E. Initiate emergency guardianship evaluation due to high-risk refusal
C. Continue respectful dialogue while documenting the informed refusal
Even when the clinician disagrees with the patient’s choice, coercion is unethical. The physician must respect informed refusal and ensure clear documentation of the discussion and decision.
A junior attending discloses a retained surgical sponge following a cesarean section. The institution initiates a root cause analysis, revealing gaps in OR communication and handoff processes.
Which of the following best reflects ACOG's view of institutional responsibility in adverse events?
A. The surgeon should bear primary accountability, as the error occurred during their case
B. Focus should be placed on disciplining the nurse responsible for the count
C. Disclosure to the patient is only necessary after full legal review
D. Institutions should support disclosure and focus on systems improvement over blame
E. Root cause analysis should remain confidential and not influence patient communication
D. Institutions should support disclosure and focus on systems improvement over blame
ACOG endorses a just culture—one that emphasizes learning and systemic improvement over punitive action. Institutions should support clinicians through disclosure processes and promote safety-oriented reform.
A senior attending frequently performs complex gynecologic surgeries after being awake overnight from labor and delivery call. The attending boasts about stamina and insists that “fatigue is just part of the job.” Residents express admiration but also anxiety about expectations.
Which of the following best reflects ACOG’s stance on this professional behavior?
A. Acceptable, as it reflects dedication and resilience
B. Problematic, as it normalizes unsafe behavior and sets a harmful precedent
C. Ideal from a resource perspective, provided patient outcomes remain excellent
D. Acceptable only if the attending discloses fatigue to the surgical team and patients
E. Encouraged, as it fosters a strong work ethic in training programs
B. Problematic, as it normalizes unsafe behavior and sets a harmful precedent
ACOG discourages the glorification of fatigue, as it undermines safety culture and can perpetuate unsafe norms. Physicians must model behaviors that prioritize patient safety and professional responsibility.
A PGY2 resident with recognized burnout begins to demonstrate reduced clinical documentation accuracy, impaired teamwork, and increasing conflict with nursing staff.
Which of the following is the most well-documented consequence of unaddressed resident burnout?
A. High rates of professional liability claims
B. Increased patient satisfaction due to greater resident autonomy
C. Higher rates of diagnostic testing and resource overuse
D. Decline in professionalism and higher rates of medical error
E. Improved stress tolerance and long-term resilience shown later on in independent practice
D. Decline in professionalism and higher rates of medical error
Burnout is associated with decreased professionalism, greater rates of error, poorer patient care, and lower empathy. Unaddressed burnout undermines both patient safety and resident development.
A senior resident notices that a fellow colleague has been increasingly disheveled, missing chart documentation, and showing up late to rounds smelling of mouthwash and acting erratically. The colleague brushes off their concerns and attributes it to stress.
What is the senior resident’s most appropriate course of action?
A. Continue monitoring discreetly unless a sentinel event occurs
B. Confront the colleague directly during a quiet moment
C. Report the behavior to appropriate institutional leadership or a physician health program
D. Discuss the issue anonymously on a group messaging platform to gauge consensus
E. Submit an anonymous evaluation reporting the unprofessional behavior
C. Report the behavior to appropriate institutional leadership or a physician health program
Physicians have a professional and ethical duty to protect patient safety and support impaired colleagues. Reporting to institutional authorities or a Physician Health Program (PHP) is the appropriate first step—not silent observation or informal confrontation.
A 25 yo with severe endometriosis and infertility is considering definitive management with hysterectomy. She is highly informed and aware of future reproductive implications but is repeatedly discouraged from proceeding by her gynecologist, who insists on preserving fertility due to her age.
According to ACOG’s stance on shared decision making, which of the following best characterizes this interaction?
A. Collaborative decision making based on reproductive potential
B. Beneficent guidance grounded in clinical best practices
C. Informed consent with appropriate clinical skepticism
D. Inappropriate paternalism undermining patient autonomy
E. Standard preoperative counseling for irreversible procedures
D. Inappropriate paternalism undermining patient autonomy
Overriding a competent patient’s preference based on clinician values, rather than facilitating shared decision making, constitutes inappropriate paternalism, even when well-intentioned.
During an emergency cesarean delivery, a near miss event occurs in which the patient is almost administered a drug to which she has a documented allergy. The error is caught and corrected before any drug is given. The patient is unaware that anything happened.
According to ACOG, how should this be handled?
A. No disclosure is necessary since no harm occurred
B. Disclose the event as part of an open safety culture and ethical practice
C. Wait until discharge to discuss the error in the context of a broader quality report
D. Refer the issue solely to the institutional safety team without patient discussion
E. Document internally, but do not record the event in the medical record
B. Disclose the event as part of an open safety culture and ethical practice
ACOG states that near misses — even without harm — may still warrant disclosure, particularly if the patient was affected or at risk. Transparency is essential to preserving trust and promoting safety culture.
A physician admits post-call fatigue but is the only available gynecologic surgeon for an emergency ovarian torsion in a rural hospital. The hospital has no formal fatigue policy.
According to ACOG guidance, what is the physician’s most ethically justifiable course of action?
A. Proceed with the case while implementing personal fatigue countermeasures
B. Delay the case until rest is obtained
C. Cancel the surgery and arrange for transfer regardless of delay
D. Refuse to operate, citing impairment and document the refusal
E. Notify administration and proceed only after legal counsel approves
A. Proceed with the case while implementing personal fatigue countermeasures
In unavoidable circumstances where urgent care is required and no alternatives exist, ACOG acknowledges that physicians may need to proceed while taking steps to mitigate fatigue-related risk (e.g., double-checks, checklists, increased communication).
Which of the following best distinguishes burnout from clinical depression in residents?
A. Burnout includes somatic symptoms and anhedonia
B. Depression always occurs without external triggers
C. Burnout primarily impacts work-related identity and engagement
D. Burnout is most effectively treated with pharmacotherapy
E. Depression predictably improves with time off
C. Burnout primarily impacts work-related identity and engagement
Burnout is specific to the occupational domain, especially feelings of inefficacy or depersonalization at work. Depression is a global mood disorder that affects all domains of life and includes biological and cognitive symptoms.
Which of the following best characterizes the role of Physician Health Programs (PHPs)?
A. Primarily serve as licensing boards for impaired physicians
B. Offer punitive oversight to deter future violations
C. Provide confidential support, monitoring, and reintegration for physicians with substance use disorders
D. Are mandatory for all physicians following a mental health disclosure
E. Focus solely on evaluating competency after substance use is reported
C. Provide confidential support, monitoring, and reintegration for physicians with substance use disorders
PHPs are designed to support rehabilitation, often offering confidential treatment and monitoring, and facilitating a safe return to practice. They are not primarily punitive but emphasize recovery and patient safety.
Which of the following best distinguishes the ethical framework of informed consent advocated by ACOG from the minimal legal standard?
A. Legal standards require discussion of risks and benefits; ethical standards do not
B. Ethical standards prioritize form completion; legal standards do not
C. Ethical standards encourage dynamic, individualized dialogue with patients
D. Legal standards mandate disclosure of all complications, regardless of likelihood
E. Legal standards require shared decision making; ethical standards rely on clinician judgment
C. Ethical standards encourage dynamic, individualized dialogue with patients
ACOG's ethical model elevates informed consent beyond legal minimalism, emphasizing personalized, evolving dialogue—not just checklist-based disclosure.
Following an intraoperative complication, a resident writes in the chart: "The attending inadvertently transected the bowel due to poor visualization."
Which of the following best reflects appropriate documentation and communication of adverse events per ACOG recommendations?
A. Acceptable, as it ensures transparency about the complication
B. Inappropriate, because it assigns blame in a legally discoverable document
C. Preferred, as it clearly outlines which individual was involved and the likely reason for the injury
D. Unnecessary, as verbal disclosure to the patient is sufficient
E. Standard, as it mirrors what was discussed with the patient
B. Inappropriate, because it assigns blame in a legally discoverable document
ACOG advises that documentation be objective and factual, avoiding blame or subjective language. Charting should accurately describe events and care but not include accusatory or speculative statements.
Which of the following scenarios is most consistent with early cognitive impairment due to fatigue?
A. An attending forgetting a patient’s name on rounds and looking at their notes
B. A resident becoming emotionally dysregulated during a routine shoulder dystocia
C. A fellow declining to participate in an after-hours surgery due to family obligations
D. A junior resident requesting help with documentation after a busy clinic
E. An intern expressing boredom during a prolonged induction course
B. A resident becoming emotionally dysregulated during a routine shoulder dystocia
Early signs of fatigue impairment include difficulty with concentration, memory lapses, poor judgment, mood changes, and emotional reactivity—which may manifest subtly but impact care significantly.
A residency program is developing a wellness initiative after a needs assessment shows high rates of emotional exhaustion among trainees. Which of the following strategies has the strongest evidence for reducing burnout?
A. Mandated therapy for all residents
B. System for anonymous reporting of mood symptoms to the GME office
C. Protected time for reflection, mentorship, and peer connection
D. Removing clinical evaluations for the first three months of each year
E. Eliminating night float rotations in favor of traditional 24-hour calls
C. Protected time for reflection, mentorship, and peer connection
Programs that support peer support, mentoring relationships, and protected wellness time show the most durable improvements in resident wellbeing.
A gynecologist with a history of opioid use disorder returns to practice after completing a monitored treatment program. Six months later, they begin exhibiting signs of anxiety and fatigue and are observed borrowing sedatives from office stock.
Which of the following is the most appropriate response?
A. Confront the physician privately and request they return the medication
B. Wait to see if the physician self-reports the relapse
C. Immediately notify the practice administrator and the PHP
D. Recommend therapy and resume monitoring internally
E. Refer the physician to the medical board for immediate suspension
C. Immediately notify the practice administrator and the PHP
Relapse is a known risk with substance use disorders. Early intervention through structured support channels (e.g., PHP), rather than confrontation or informal oversight, is the best way to support physicians in such scenarios. Immediate reporting ensures safety and structured treatment.