R. C. is an orthopaedic resident in a teaching program. At
the orthopaedic clinic, he examines an elderly, otherwise healthy
patient who requires a total hip replacement. He presents the patient
to his covering attending physician, who agrees to supervise the
joint replacement surgery. The resident discusses the surgery with
the patient. The procedure, risks, goals, benefits, and alternatives
are presented. The patient agrees to proceed with the surgery.
The resident performs the surgical procedure with the attending
physician's assistance. The surgery lasts forty minutes longer than
the attending physician's usual surgical time, and the blood loss
is 300 milliliters greater. Postoperative radiographs demonstrate
a well positioned press-fit acetabular component and a cemented femoral
component in 6 degrees of varus.
Whenever a resident who is at the beginning of a learning curve
performs a procedure that could have been done better by someone
else with more experience, the learner and the teacher who permits
it are not acting for the good of their patient. Since the patient
is subjected to a greater risk of harm and discomfort than necessary,
they are violating the dictum "do no harm." Furthermore, respect
for patient autonomy requires that we avoid treating patients merely
as a means to an end, as useful tools for our own purposes. Taken
together, these considerations suggest that patients should not
be used as learning tools.
Considering the issue from another perspective, however, we have
to acknowledge the common desire for good health. Reasonable people
understand that, at some point in the future, they or their loved
ones are likely to need medical attention. Everyone would want to
have trained, skilled physicians available to administer appropriate
medical care when it is needed. Because programs of medical education
involving patients are a necessary means of achieving the desired
medical expertise, training programs that use patients in education
must be morally acceptable. Teaching with use of patients is, in fact,
essential to the transmission of clinical skills and techniques,
and every individual has an ethical responsibility to do his or
her fair share to participate in the education of our society's
future medical experts. This is essential so that we may each have
access to their knowledge and skill when they are needed for ourselves
or our loved ones. This insight, however, does not complete the
picture of the ethical obligations that are involved in residency
training.
Because medicine is committed to the goals of acting for the
good of patients and doing them no harm, programs of medical education
must be carefully designed and vigilance must constantly be exercised.
Through its careful attention to candidate selection, methods of sequential
learning, supervised practice, discussion, evaluation, and review,
academic medicine does an excellent job of protecting patients' health
during the process of resident education. The requirement for such
continued vigilance must be recognized as an ethical duty.
Residents learning new techniques or procedures should only perform
them under the supervision of an experienced attending surgeon.
This policy avoids unnecessary risks to the patient and provides
the resident with the training that justifies any increase in risk.
Adequate direction and instruction are required to protect the patient and
to provide a learning experience for the resident. The supervising
surgeon's intervention is required at any point when the resident
encounters difficulties. Ready intervention minimizes the risk of
complications for the patient and provides crucial education for
the resident.
In our case presentation, the slight increases in surgical time
and blood loss pose no significant additional risk to the patient.
The final position of the components is slightly imperfect but certainly
acceptable. The patient should have a well functioning hip replacement
with normal component longevity. The resident has had an opportunity
to improve in the surgical technique of joint replacement surgery
and also an occasion to learn about preoperative decision-making
and postoperative care.
These considerations do not, however, exhaust the ethical concerns
that have to be taken into account. Physicians have additional ethical commitments
to patients that go beyond avoiding harm. Physicians also are required
to respect patients as autonomous beings by allowing them to make
their own choices and by taking their perspective into account when
making decisions about what would be best. Respect for the autonomy
of patients requires more than a charming bedside manner and a polite
demeanor; it demands that patients be honored as people by being
told the truth about who is being asked to do what for whom. Patients
have a right to know who will be performing examinations and invasive
procedures and what additional risks, if any, that this may present.
If patients ask questions about the experience of those who will
be involved in their procedure, they should be given honest answers.
If they don't ask, they still need to be given the information that
is relevant to making an informed choice that reflects their values
and priorities. Those who are clever enough to ask questions do
not have more of a right to be treated with respect than do those who
are silent. Furthermore, those who are inadequately informed of
risks (including resident involvement) cannot give informed consent,
and those who are responsible for conveying relevant information
are legally liable for failure to do so.
Informing the patient of the learning status of the person who
is providing treatment allows the patient the opportunity to fulfill
the moral duty of participating in the training of society's future physicians
and to enjoy the rightful pride and pleasure of that contribution.
The physician's honest communication also promotes the view of patients
as heroic partners in the socially important activity of training
our future expert doctors.
The orthopaedic surgeon's position on the learning curve and
the need to inform patients about it are obvious concerns for residents.
The same issues also have to be considered by any surgeon who has
not yet mastered a new technique or the use of a new appliance,
tool, or material. Peer assessment, as well as self-assessment,
should be standard features of readiness. The measure of adequate
preparedness cannot simply be personal comfort, which may reflect
ego and eagerness rather than skill. The standard for informing
patients cannot stop at the need to know; the process must reflect
respect for the person being used for skill enhancement. In general,
an orthopaedic surgeon should not proceed with a planned therapy
that is new for that surgeon without being prepared to explain that
fact honestly to the patient. Again, this forthright approach reflects
compliance with the legal and ethical standards for informed consent.
James D. Capozzi, M.D.
Department of Orthopaedics
Mount Sinai Medical Center
1065 Park Avenue
New York, N.Y. 10128
Rosamond Rhodes, Ph.D.
Director of Bioethics Education
Mount Sinai School of Medicine
One Gustave Levy Place
New York, N.Y. 10029
Further Reading
Brunetti, L. L., and Stell, L. K.: Informed
consent. In A Physician's Guide to Legal and Ethical Aspects
of Patient Care, pp. 41-66. Charlotte, North Carolina,
Charlotte-Mecklenberg Hospital Authority, 1994.
Lo, B.: Ethical issues facing students and housestaff.
In Resolving Ethical Dilemmas: A Guide for Clinicians, pp.
320-327. Baltimore, Williams and Wilkins, 1995.
Williams, C. T., and Fost, N.: Ethical
consideration surrounding first time procedures: a study and analysis
of patient attitudes toward spinal taps by students. Kennedy
Inst. Ethics. J., 3: 217-231, 1992.