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Moral Reasoning Strategies of Orthopaedic Surgery Residents
John J. Mercuri, MD, MA1; Raj J. Karia, MPH1; Kenneth A. Egol, MD1; Joseph D. Zuckerman, MD1
1 Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, 301 East 17th Street, Room 1402, New York, NY 10003. E-mail address for K.A. Egol: Kenneth.Egol@nyumc.org
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Investigation performed at the Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Mar 20;95(6):e36 1-9. doi: 10.2106/JBJS.K.01439
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Little is known about the moral reasoning utilized by orthopaedic surgery residents when resolving moral dilemmas.


Sixty-three residents in an accredited program took the Defining Issues Test-2, an online examination designed to measure and analyze moral reasoning. Scores approximate how often residents utilize three schemas in their moral reasoning: personal interest, maintaining social norms, and postconventional. Scores were analyzed for differences among years of training, previous literature, and established norms.


Approximately 9.5% of residents utilized personal interest heavily in their moral reasoning, 27% utilized maintaining norms, and 63.5% utilized postconventional reasoning. There were no significant differences between years of training. The fourth-year (R4) class recorded the highest utilization of principled reasoning, while the fifth-year (R5) class recorded the lowest. The range of principled reasoning scores narrowed from the first year (R1) to R5. The principled reasoning scores of residents were significantly lower than previously reported scores of professional degree-holders and medical students, and empirically lower than previously reported scores of orthopaedic attendings and medical students.


Residents utilized principled reasoning less frequently than expected for physicians. It remains unclear as to what factors contributed to high utilization of principled reasoning in the R4 class but low utilization in the R5 class. Our cross-sectional data suggest that each year of training homogenizes toward a class-specific utilization of principled reasoning. It remains unclear why residents utilized principled reasoning less than orthopaedic attendings, medical students, and other professional degree-holders.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Joseph D Zuckerman MD and Kenneth A Egol MD
    Posted on May 30, 2013
    Emphasis on gender oversimplifies the issues
    NYU Hospital for Joint Diseases, New York, NY, USA

    Although it is true that the R4 class exhibited a higher level of moral reasoning than the other resident years and it is also true that the R4 class had a greater number of women than other years, Dr. Healy’s conclusion is, at best, oversimplified. Orthopaedic residents in any training program should be taught the fund of knowledge and the surgical skills needed to be an orthopaedic surgeon. Equally important is our commitment to teaching the professionalism needed to practice orthopaedic surgery. The development and maturation of moral reasoning skills is an important component of professionalism and should be part of the curriculum of our residency programs. Our goal is to select well-qualified students to enter our residency programs. The students must have the ethical foundation needed to be a physician. To that ethical foundation we should be adding the professionalism required of an orthopaedic surgeon just as we teach orthopaedic knowledge and surgical skills. Selecting the right individuals to train continues to be challenging, with many factors to consider. Dr. Healy’s emphasis on the importance of gender greatly oversimplifies the issues being discussed.

    John H. Healey MD FACS
    Posted on March 28, 2013
    The Moral Solution
    Stephen McDermott Chair in Surgery & Chief of Orthopaedic Surgery, Memorial Sloan-Kettering Cancer Center; Professor of Orthopaedic Surgery, Weill Medical College of Cornell University, New York,

    Mercuri, et al. present a provocative, important topic to the orthopaedic community, and orthopaedic educators in particular. If the goal is to improve the moral reasoning of orthopaedic residents, the authors’ data show the answer. Simply follow the example of the R4 class and accept more women into orthopaedic programs.

    [The author has no relevant financial conflicts of interest to disclose.]

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