As the above case illustrates, however, additional ethical dilemmas arise
when a resident-in-training performs poorly. Patient care and safety may be
compromised above and beyond an acceptable level. Hospitals and their staff
face potential costly litigation as well as damage to their reputations.
Patients may become distrustful of the medical institution or even of the
medical system in general. Attending physicians may refuse to continue working
with a particular resident when they are no longer confident that they can
safely supervise his or her training.
Residency training programs recognize that varying degrees of expertise,
competency, surgical skills, and intelligence exist. Given that range, the
goal of any program is to produce orthopaedic surgeons who can be certified as
trustworthy to perform at a basic level of competency. Talented residency
directors find ways to maximize the abilities of each resident while also
strengthening the trainee in areas of weakness and remedying deficiencies. In
the process, residency directors also have an obligation to ensure the safety
and well-being of the patients entrusted to the program's care. Residents
learning new procedures and providing treatment should be well supervised.
Cases should be assigned as appropriate to the resident's training level.
Patients should be informed regarding exactly who will be providing their care
and the level of expertise of that individual.
All residents require training, supervision, coaching, correction, and
mentoring. They all are given multiple opportunities to learn from their
mistakes and to improve their clinical and surgical skills. Nevertheless,
there is a limit to a program's obligation to do all that it can to instruct
its young physicians. That limit is set by the program's obligation to ensure
patient safety.
Residents with major uncorrectable deficiencies in clinical or surgical
skills are not helped by being retained in a program for which they ultimately
will not qualify. A program does no favor to a resident who lacks the
necessary talents for the field. For everyone's sake, the resident's time and
energy will be better spent elsewhere. The resident and his or her future
patients are better served by prompt decisions and clear, unambiguous
communication. Residency directors owe them this as well as career counseling
and assistance in finding placement in another, more appropriate sort of
training program.
Residents with major professional or character deficiencies present an
entirely different sort of problem and require a totally different response.
The response to egregious unprofessional behavior, such as lying, disregard
for patient safety, lack of surgical preparation, failure to care for
patients, or falsifying medical records, is clear. If such behavior is not
immediately explained and rectified, dismissal is the appropriate response.
Character runs deep. When someone at this level of training reveals a
willingness to behave in such ways, the person cannot be trusted to forswear
unethical behavior in the future. Maintaining them in a training program is a
hazard for the program and its patients. Ultimately providing so flawed a
person with medical credentials and allowing him or her to practice without
close supervision puts future patients in peril.
The more difficult situation arises when the poor behavior is not glaring
and dramatic but is subtle, insidious, and repetitive. Rarely is there a
single irrefutable catastrophic incident. More typically, there are a number
of chronic, somewhat equivocal, seemingly unprofessional behaviors and events.
They may occur over a prolonged period of time and in a variety of locations.
Since most training programs rotate their residents through various services
and often through several different hospitals, it may be very difficult to
establish a clear pattern of behavior that warrants dismissal. Then, programs
are reluctant to terminate residents on grounds of character and
professionalism even after a well-documented pattern of unprofessional
behavior has been identified. Program directors fear the litigation that may
ensue. Also, residents are often responsible for a large portion of the
patient care delivered at an institution. Dismissing a resident can have a
serious impact on the call schedules and workloads of the other residents. All
of these issues must, however, take a back-seat to a program's primary
responsibility for the care and safety of patients today and in the future. If
a resident continues to perform at a level that is below an acceptable
standard and if multiple opportunities to correct the behavior have failed to
rectify the problems, then that resident must be terminated from the training
program.
There are several reasons why it is important to dismiss residents who fail
to meet professional standards of expertise and character. These reasons are
the same as those cited for intervening when a physician is impaired.
The primary reason for dismissing a resident with major clinical or
behavioral deficiencies is to prevent harm to patients. Training programs are
responsible for the actions of their residents and ultimately are responsible
for patient well-being. As Kapp explained, because of their supervisory
positions, faculty members, medical schools, and health care institutions are
legally liable for harm resulting from residents'
actions3. Likewise,
Keyes reported that those charged with monitoring a resident are held liable
for the resident's
negligence4. Because
of their obligation to protect patients from harm, programs are, therefore,
required to take measures to ensure the safety of current and future
patients.
A second reason for dismissing a poorly performing resident is the issue of
professional self-regulation. It is implied that a resident completing a
training program has achieved, at the very least, some basic measure of
competency in his or her field of training. Allowing an incompetent resident
to complete a training program and to obtain credentialing undermines the
trust that society has placed in the medical profession to police itself and
to protect society from harmful practitioners. This failure at self-regulation
invites criticism of the profession, increased public scrutiny, and additional
regulations imposed by outside sources.
Third, failing to dismiss a poorly performing resident sets an adverse
example for the other residents in the program. Often, they will be left in
the burdensome position of having to cover for a colleague's poor performance,
sloppy work, and failure to meet responsibilities. The residents who have to
pick up the slack are likely to either become resentful of their unfair
hard-ship or learn to ease their own workload by emulating the bad behavior.
Although terminating a resident may create workforce issues for a program, it
relieves the remaining residents' sense of frustration and eliminates a
deleterious example. Furthermore, the timely dismissal emphasizes the
program's commitment to clinical excellence, patient safety, professionalism,
and self-regulation.
Finally, although programs fear litigation over the dismissal of a
resident, when the decision follows a due process, it is the prudent course.
Irby and Milam pointed out that, when due process is followed, program
directors can expect the courts to appreciate the importance of upholding
professional and academic
standards5.
Similarly, Parrott reported, in the nursing literature, that when public
safety is at issue, faculty have the responsibility to dismiss trainees on the
basis of clinical
performance6. When
due process has been served, the courts have repeatedly upheld dismissal
decisions made by higher-education
faculty6.
In light of human variability, the difficulty in selecting appropriate
trainees on the basis of inadequate evidence, and residency programs'
professional and legal responsibilities, there will inevitably be occasions
when programs have to dismiss a resident. Whenever a resident's behavior
suggests that there is a problem with either clinical skills or character, and
before dismissal is seriously contemplated, programs should take measures to
ensure that they are treating their residents fairly and also to protect
themselves from litigation following a resident's termination. All incidents
of poor clinical performance or unprofessional behavior should be documented.
This is a burdensome responsibility that needs to be shared by all faculty in
a department and at all sites covered by a training program.
At the same time, the resident in question must be treated fairly and
equitably. In other words, no resident should be expected to meet standards
that are not applied to others and no resident should be singled out as the
sole object for incident reporting. When a concern about a resident's behavior
is noted, effort should be invested in communicating with the resident about
the problems and in correcting the skills or behavior. Program directors
should consider instituting a scheduled review of all trainees. When
appropriate, outside counseling should be offered. All of these efforts should
be documented.
Unfortunately, it is difficult to be more specific with regard to the due
process of resident evaluations and reviews. Each program needs to tailor its
review process to what seems to be appropriate for that particular program.
The process will undoubtedly be defined by the number of residents, available
faculty, hospital geography, and time constraints. It is also imprudent to be
specific with regard to the number of incidents that should be tolerated
before dismissal is considered. Each offense and each trainee must be
evaluated on a case-by-case basis with regard to the gravity of the offense,
the resident involved, past experiences, and patient harm. There are no hard
and fast rules or schedules to follow. Finally, when a decision to dismiss has
to be made, it should be reached through a discussion and consensus of the
department's faculty, which, again, needs to be carefully documented.
In contemplating dismissal decisions, it is appropriate for medical faculty
to recall that the proper responsibility of a training program is to provide
competent and trustworthy medical practitioners for society. Certifying that
someone is worthy of the credential is bestowing an honor that the unworthy
are not entitled to have. Medical faculty are entrusted with the power for
both giving and withholding the credentials of the field. Unless they are
prepared to deny an inappropriate certification, they cannot properly wield
that decision-making authority. Consequently, those involved in making
decisions about retention and dismissal of residents need to keep in mind that
they are not meting out punishment but acknowledging accomplishment and
granting responsibility.