To The Editor:
I read with great interest "Ethics in Practice: Residency Training"
(82-A: 1356-1357, Sept. 2000), by Capozzi and Rhodes. The authors have
provided the readers of The Journal with an excellent
scenario relative to ethics in the practice of orthopaedic surgery
at an academic institution. The scenario presented in the manuscript
raises several questions that open some of the authors' conclusions
to variable interpretation. In this scenario, the patient's surgery
lasted forty minutes longer than the attending physician's usual
surgical time and the blood loss was 300 millimeters greater. Would
it not have been better to view this scenario in light of the surgeon's
range of surgical time and range of blood loss for comparable procedures?
If one views this scenario in terms of range, the surgical time
and blood loss may well fall within the surgeon's range for comparable
procedures and, hence, the interpretation of this scenario would be
that the patient did receive acceptable care. In addition, the scenario
proposed by the authors does not take into account the considerable
variability that exists among individual surgeons, even those who
are experts in the index procedure. One could only imagine that
the variability with respect to surgical time, blood loss, and component
placement would be great, not only within institutions but among
institutions. Another point of concern is that this scenario raises issues
relating to resident supervision that would be particularly troublesome
to nonsurgeons who read The Journal. Readers of
the article should be aware that the guidelines of the Residency
Review Committee for Orthopaedic Surgery clearly outline the supervisory
status of all aspects of patient care in residency training programs.
Furthermore, readers should be aware of the supervision of residents
required for reimbursement. The authors should be congratulated
on raising an extremely important issue that faces all physicians
working in an academic medical center and all patients who receive
their care in these centers.
Stuart L. Weinstein, M.D.
Department of Orthopaedic Surgery
University of Iowa Hospitals and Clinics
200 Hawkins Drive
Iowa City, Iowa 52242-1009
To The Editor:
After reading the article entitled "Ethics in Practice: Residency
Training," we realized that little has been written regarding the
ethics of using trainees for care1,2.
Capozzi and Rhodes present a persuasive case that patients should
be allowed the meaningful choice of whether or not to receive their
care after being informed of exactly who on the surgical team (consisting
of residents and staff surgeons) will be doing what during the proposed
procedure. It is hard to argue against meaningful choice, but the
underlying question is whether the variation in care among practitioners
with different levels of training is greater than that among established
practitioners. At a larger level, we are really talking about the
practice of medicine - please allow us the latitude to reinforce
the word practice.
Most ceremonial affirmations recited at the time of medical school
graduation, including the Hippocratic oath, the Declaration of Geneva, and
Maimonides' prayer for the physician, involve ethical decision-making
based on the following principles: nonmalfeasance (doing
no harm), beneficence (applying one's ability solely
for the patient's well-being), autonomy (respecting
the patient's independence), justice (treating
all patients equally and avoiding prejudicial biases), veracity (being
truthful with oneself and one's patients), and confidentiality (respecting
the patient's privacy)2. Professional
boundaries are essential in order to protect the patient's level
of comfort and to establish a sense of safety as well as to ensure that
the patient's best interests always remain the overriding concern.
From the time that we leave residency, we jump on a learning
curve for each type of procedure that we undertake. What does this
curve look like? Does it vary from procedure to procedure or from
surgeon to surgeon? Although we rely heavily on our teachers and
mentors to get us started on this path or "curve" of learning, it
is left to the individual surgeon to finally reach the plateau where
the procedure is perfected and performed meticulously. When does
the developing surgeon attain this plateau? With the continuous
advent of new technologies and the incessant infusion of information
into the literature, most practicing surgeons never reach it.
This article suggests that it is unethical, when obtaining consent,
not to report "the learning status of the person who is providing
treatment." If we apply this principle more broadly, we would like
every patient to have information about his or her surgeon's expertise
and track record. In an ideal world, patients would have access
to case-mix-adjusted data on surgical outcomes - both overall (aggregate)
and for each individual surgeon. Based on this information, patients
would be able to choose the surgeon best qualified to perform the
procedure.
However, many factors stand in the way of such a program. Obviously,
everyone cannot receive his or her care from the very best practitioner. Logistics
alone make that impossible. Nonetheless, patients are entitled to
better information. If we believe that the learning curve is important and
that the amount of training that a surgeon has received is at least
a crude indicator of proficiency, we have an obligation to provide
that information to patients before they choose a surgeon.
On the other hand, if the level of supervision is adequate, is
it the trainee's or the mentor's skills that are being applied?
There is no empirical evidence demonstrating that outcomes are affected by
which member of the operating team performs which part of the procedure.
Studies on various surgical procedures generally have not shown
a difference in outcome when the surgery was performed by a supervised
resident surgeon or by an attending surgeon3-5.
If there is no effect on the outcome of surgery, it is difficult
to argue that there is an ethical imperative to discuss the issue
with the patient.
The teacher-student relationship in the field of medicine is
an extremely important relationship. It ensures that there is continuous
and proper development of medical personnel who will one day be
able to provide care for those in need. It is mandatory that we
continue this process of developing minds - and in the case of orthopaedics,
minds and hands - to provide care for generations to come. This
issue becomes more imperative as our population ages and the demands
placed on our health-care system increase. As long as the attending
surgeon who assumes technical responsibility for the procedure is
present in the operating room, the patient is not "dishonored."
Robert L. Kane, M.D.
Khaled J. Saleh, M.D., M.Sc., F.R.C.S.(C)
Corresponding author: Khaled J. Saleh, M.D., M.Sc., F.R.C.S.(C)
Department of Orthopaedic Surgery and
Clinical Outcomes Research Center
University of Minnesota
420 Delaware Street S.E., Box 492
Minneapolis, Minnesota 55455
R. Rhodes and J. D. Capozzi reply:
We agree with Dr. Weinstein's comments that, for any given surgical
procedure, there is certainly a wide range of surgical times and
blood losses. The patient in our scenario did, in fact, receive
acceptable medical care. What we were attempting to demonstrate,
however, was that, by its very nature, a learning curve is not "acting for
the good" of that particular patient. Someone at the top of a learning
curve can, by definition, perform a procedure better than someone
at the bottom of a curve. But if that were the only standard to
which medical care was held, then all medical training would come
to a grinding halt. Learning curves are essential for the continuation
of medical training and for the delivery of medical care. We were
simply hoping to raise reader awareness regarding the importance,
and the ethical obligation, of informing patients when they are
an integral part of these learning curves.
Tucked among their many thoughtful comments, Drs. Kane and Saleh
maintain that "if there is no effect on the outcome of surgery,
it is difficult to argue that there is an ethical imperative to
discuss the issue with the patient." We would like to suggest three
arguments for that imperative.
First, while studies have supported the conclusion that patients
tend to do better in teaching hospitals, that is not the same as
finding that learner involvement never has any impact on a patient.
At best, the data support the claim that in most cases there is
ultimately no difference in long-term outcome. It is enough to present
that conclusion.
Second, considerations other than effects can contribute to the
wrongness of an action. Using someone's property without permission
can be wrong even when no damage is done. Using someone's body in
a teaching exercise without permission can be wrong even when the
individual is not harmed. To explain a procedure with the calculated
omission of a piece of information that the surgeon expects might
raise objections or concerns is to deliberately encourage a false belief.
Informed consent is impossible under these circumstances. Such a
practice also displays both a lack of respect for the patient as
a decision-maker and a lack of esteem for the patient's character.
Third, the importance of trust in the doctor-patient relationship
cannot be overstated. The practice of medicine could not take place
without some degree of patient trust. Because secrets are likely
to leak out, because patients who learn about the unauthorized use
of their bodies for medical education are likely to be displeased, and
because disgruntled patients are likely to share their dissatisfaction
by telling others, no one should discount the harm to the trustworthiness
of medicine. Patients and potential patients who worry that surgeons
may conceal the fact that patients are used as learning tools can
easily worry that other, more serious harms (for example, unnecessary
procedures, sexual molestation, and organ theft) could be perpetrated
while they are unconscious. Deception threatens the trustworthiness
of medicine. No one should gamble with anything that important.
Rosamond Rhodes, Ph.D.
James D. Capozzi, M.D.
Corresponding author: James D. Capozzi, M.D.
Department of Orthopaedics
Mount Sinai Medical Center
1065 Park Avenue
New York, N.Y. 10128