The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 95, Issue 6

The Orthopaedic Forum | March 20, 2013

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

J Bone Joint Surg Am, 2013 Mar 20;95(6):e36 1-9. doi: 10.2106/JBJS.K.01439

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Abstract

Background:

Little is known about the moral reasoning utilized by orthopaedic surgery residents when resolving moral dilemmas.

Methods:

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.

Results:

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.

Conclusions:

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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Moral Reasoning

Moral decision-making is the act of deciding between right and wrong when confronted with a moral dilemma. Some scenarios do not have clear right or wrong answers. Therefore, the decision-making process is more insightful than the decisions themselves. Rational deliberation, or moral reasoning, is one way to evaluate moral dilemmas. This deliberation weighs factors such as obligations of the involved parties, areas of conflict between parties, consequences of choosing certain actions, and relevant moral principles raised by the dilemma¹.

Kohlberg described a theory of moral development in which people progress through well-defined stages of moral reasoning^2-5. Rest expanded this theory and developed a comprehensive model of moral behavior based on four psychological capacities: moral sensitivity, moral reasoning, moral motivation, and moral implementation^6-11 (Table I). Rest et al. replaced Kohlberg’s stages of development with three overlapping schemas labeled personal interest (PI) schema, maintaining norms (MN) schema, and postconventional (P) schema^12,13 (Table II). It is helpful to think of these schemas as a moral reasoning strategy. People utilize all three of the schemas to some degree in their moral reasoning. Theoretically, as people develop more sophisticated reasoning strategies, utilization of the PI and MN schemas decreases, whereas utilization of the P schema increases. Principled reasoning has been shown to increase with higher educational attainment, especially if the curriculum specifically addresses moral decision-making^14,15.

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TABLE I Psychological Capacities

Psychological Capacities^6-11	Definition
Moral sensitivity	The capacity to interpret ambiguous clues indicating moral dilemmas in real-life settings
Moral reasoning	The capacity to analyze moral issues and provide justifications for decisions
Moral motivation	The capacity to internalize and give priority to moral values
Moral implementation	The capacity for empathetic interaction and problem solving when faced with a moral dilemma

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TABLE I Psychological Capacities

Psychological Capacities^6-11	Definition
Moral sensitivity	The capacity to interpret ambiguous clues indicating moral dilemmas in real-life settings
Moral reasoning	The capacity to analyze moral issues and provide justifications for decisions
Moral motivation	The capacity to internalize and give priority to moral values
Moral implementation	The capacity for empathetic interaction and problem solving when faced with a moral dilemma

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TABLE II Developmental Schemas

Developmental Schemas^12,13	Definition
Personal interest schema	Right action is based on personal interest and/or maintaining one’s loyalty to family and friends
Maintaining norms schema	Right action is based on maintaining existing laws, rules, and/or societal norms
Postconventional schema	Right action is based on either procedural justice or the universal moral principles or ideals on which conventions, norms, rules, and laws are based

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TABLE II Developmental Schemas

Developmental Schemas^12,13	Definition
Personal interest schema	Right action is based on personal interest and/or maintaining one’s loyalty to family and friends
Maintaining norms schema	Right action is based on maintaining existing laws, rules, and/or societal norms
Postconventional schema	Right action is based on either procedural justice or the universal moral principles or ideals on which conventions, norms, rules, and laws are based

Moral reasoning can be measured and analyzed. Rest et al. developed the Defining Issues Test (DIT), which asks respondents to resolve vignette-based moral dilemmas and rate and rank issue statements that are important to their decision-making¹⁶. One example can be seen in Fig. 1. Many measures of moral reasoning are calculated, including the respondent’s utilization of the PI, MN, and P schemas^12,13,17. The DIT is a reliable, validated, and widely used measure of moral reasoning^16,18,19. The DIT-2, an updated version, is administered over the Internet.

Fig. 1

This sample DIT dilemma presents a moral dilemma about the protagonist, Heinz, and whether or not he should steal a lifesaving but unaffordable drug from a local pharmacist to save his dying wife. The dilemma is presented in the same SurveyMonkey format that our residents viewed when they took the DIT-2. (Reproduced, with permission from, the Office for the Study of Ethical Development, The University of Alabama, Tuscaloosa, Alabama.)

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Orthopaedic Surgery

Baldwin et al. administered the DIT to orthopaedic surgeons. One study examined fifty-three private practice surgeons. Surgeons with fewer than 0.20 malpractice claims per year demonstrated significantly greater utilization of the P schema compared with surgeons with more than 0.40 malpractice claims per year²⁰. A subsequent study divided surgeon’s scores into quintiles based on their utilization of principled reasoning. The lowest quintile utilized principled reasoning no more than 32% of the time, which is equivalent to normative data collected from high school seniors. Surgeons in the top quintile utilized principled reasoning more than 53% of the time, which is equivalent to normative data collected from individuals with graduate degrees²¹.

The DIT or DIT-2 has never been used, to our knowledge, to evaluate the moral reasoning strategies of orthopaedic residents, which may prove valuable to orthopaedic graduate medical education (GME) programs because moral decision-making plays an important role in the Accreditation Council for Graduate Medical Education’s (ACGME) professionalism competency. The ACGME states that “residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles,” especially the principles of “privacy” and “autonomy”²². Furthermore, residency influences the clinical, academic, and professional behavior of orthopaedic surgeons for the remainder of their careers.

Our institution sponsors a large orthopaedic surgery GME program with sixty-three residents and twenty fellows. As part of a new professionalism and ethics initiative, we administered the DIT-2 to our residents to describe and analyze their moral reasoning strategies and establish baseline data prior to any curriculum changes. We present our DIT-2 results, discuss their implications and limitations, and suggest directions for future research.

Materials and Methods

In this institutional review board-approved study, we administered the DIT-2 to sixty-three orthopaedic surgery residents. The program contained fifty-five men and eight women, ranging in age from twenty-five to forty-two years. Each of the five postgraduate class years contained twelve residents, except for the fourth-year (R4) class, which contained thirteen. The program has two residents that conduct one year of basic science research after the second year (R2). To maintain confidentiality, the scores of these residents were incorporated into the third-year (R3) class, increasing the total for that class to fourteen residents (Table III).

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TABLE III Demographics

Number		63
Mean age (SD)*		29.5 (2.9)
Sex	Men (%)	55 (87.3)
	Women (%)	8 (12.7)
Number of residents by class year	R1	12
	R2	12
	R3	14
	R4	13
	R5	12

*SD = standard deviation.

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TABLE III Demographics

Number		63
Mean age (SD)*		29.5 (2.9)
Sex	Men (%)	55 (87.3)
	Women (%)	8 (12.7)
Number of residents by class year	R1	12
	R2	12
	R3	14
	R4	13
	R5	12

*SD = standard deviation.

The DIT-2 was purchased from the Center for the Study of Ethical Development (CSED) and uploaded to a department-owned SurveyMonkey account²³. Residents provided informed consent and completed the DIT-2 independently through the web browser of a personal computer. They had a weeklong period to complete the examination in one uninterrupted sitting. Responses were recorded electronically and e-mailed to the CSED for proprietary computer scoring. Scores were returned in a spreadsheet format, and data were stored on a password-protected encrypted hard drive.

The CSED performs a series of reliability checks when it scores the DIT-2. Respondents are purged from the dataset if their responses are random, meaningless, absent, or nondiscriminatory, or if they report substantial distractions in their test-taking environment^17,23. Residents with purged results were asked to retake the DIT-2 several weeks later. If they recorded reliable scores on the second attempt, their results were included in the final analysis. If the second attempt was unreliable, then their results were discarded.

The DIT-2 score report included three relevant measures: the schema indices, the type, and the N2 score^13,16,17. The three schema indices are referred to as the PI, MN, and P scores. These scores approximate the percentage of time that respondents utilize the PI, MN, and P schemas when resolving moral dilemmas, although they are not literally percentage scores. The CSED also assigns respondents to one of seven ordered “types.” The type identifies the dominant schema used by the respondent. Types 1, 4, and 7 represent respondents who most heavily utilize the PI, MN, and P schemas, respectively. Types 2 and 3 represent respondents who rely on the PI schema increasingly less and the MN schema increasingly more. Types 5 and 6 represent respondents who rely on the MN schema increasingly less and the P schema increasingly more. Finally, the N2 score represents the extent to which respondents both favor the P schema and reject the PI schema. It is numerically comparable with the P score but with a higher statistical reliability and validity^16,17.

Statistical Methods

The final scores were analyzed with use of descriptive statistics, and they were compared with previous DIT literature and established normative data. Statistical differences were investigated between and within classes. It was acknowledged that our sample size might have been insufficient to detect such differences. N2 scores were preferred for analysis; however, the P score was used for analysis if comparative studies only reported P scores. Continuous variables were analyzed with the Student t test. Analysis of variance was used to investigate differences between or within class years. The alpha level of significance was set at 0.05.

Source of Funding

The Department of Orthopaedic Surgery, Hospital for Joint Diseases, at the NYU Langone Medical Center provided funding for this study.

Results

All sixty-three residents in the program completed the DIT-2. Because the initial results of five residents (7.9%) were unreliable, they were purged. However, all five recorded reliable scores on their second attempts, and their scores were combined with the scores of the other fifty-eight residents.

On average, our residents utilized the PI schema in their moral reasoning approximately 21% of the time, as demonstrated by a mean (and standard deviation) PI score of 21.08 (±10.64). Residents relied on the MN schema approximately 32% of the time, with a mean MN score of 31.71 (±13.60). The P schema was utilized about 42% of the time, with mean P and N2 scores of 42.19 (±14.36) and 41.12 (±13.46), respectively (Table IV and Figure 2).

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TABLE IV Scores per Class*

Class Year	Personal Interest (Mean [SD])	Maintaining Norms (Mean [SD])	Postconventional (Mean [SD])	N2 (Mean [SD])
1	24.67 (±12.69)	29.33 (±17.86)	38.00 (±17.33)	39.67 (±15.97)
2	19.83 (±11.07)	34.00 (±12.18)	44.50 (±15.98)	44.26 (±14.92)
3	22.00 (±10.67)	34.14 (±13.21)	41.00 (±12.96)	40.48 (±13.42)
4	18.00 (±10.33)	27.23 (±14.60)	49.54 (±14.43)	47.15 (±12.18)
5	22.00 (±8.44)	33.83 (±9.40)	37.50 (±8.19)	33.67 (±7.16)
Overall	21.08 (±10.64)	31.71 (±13.60)	42.19 (±14.36)	41.12 (±13.46)

*SD = standard deviation.

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TABLE IV Scores per Class*

Class Year	Personal Interest (Mean [SD])	Maintaining Norms (Mean [SD])	Postconventional (Mean [SD])	N2 (Mean [SD])
1	24.67 (±12.69)	29.33 (±17.86)	38.00 (±17.33)	39.67 (±15.97)
2	19.83 (±11.07)	34.00 (±12.18)	44.50 (±15.98)	44.26 (±14.92)
3	22.00 (±10.67)	34.14 (±13.21)	41.00 (±12.96)	40.48 (±13.42)
4	18.00 (±10.33)	27.23 (±14.60)	49.54 (±14.43)	47.15 (±12.18)
5	22.00 (±8.44)	33.83 (±9.40)	37.50 (±8.19)	33.67 (±7.16)
Overall	21.08 (±10.64)	31.71 (±13.60)	42.19 (±14.36)	41.12 (±13.46)

*SD = standard deviation.

Fig. 2

Cluster box plot of the DIT-2 scores of all five classes of residents. The x axis lists the five class years. The y axis lists the numerical score. There are four separate scores for each class, as represented by four adjacent boxes. The top of the box represents the 75th percentile, the bottom of the box represents the 25th percentile, and the line in the middle represents the 50th percentile (median). The whiskers (the lines that extend out from the top and bottom of the box) represent the highest and lowest values that are not outliers or extreme values. Outliers are represented as circles (values that are between 1.5 and 3.0 times the interquartile range).

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Six residents (9.5%) were assigned to Type 2, meaning that they used the PI schema most heavily. Seventeen residents (27%) were assigned to Types 3, 4, and 5, which represents heavy utilization of the MN schema. Residents assigned to Types 6 and 7 heavily utilize the P schema in their moral reasoning. Forty (63.5%) of the residents were assigned to Types 6 and 7 (Table V).

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TABLE V Types per Class

Type	First Year	Second Year	Third Year	Fourth Year	Fifth Year	Total (%)
1	0	0	0	0	0	0 (0%)
2	2	1	1	2	0	6 (9.5%)
3	1	1	1	0	1	4 (6.3%)
4	4	2	3	1	1	11 (17.5%)
5	0	0	0	0	2	2 (3.2%)
6	1	2	5	3	8	19 (30.2%)
7	4	6	4	7	0	21 (33.3%)
Total	12	12	14	13	12	63 (100%)

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TABLE V Types per Class

Type	First Year	Second Year	Third Year	Fourth Year	Fifth Year	Total (%)
1	0	0	0	0	0	0 (0%)
2	2	1	1	2	0	6 (9.5%)
3	1	1	1	0	1	4 (6.3%)
4	4	2	3	1	1	11 (17.5%)
5	0	0	0	0	2	2 (3.2%)
6	1	2	5	3	8	19 (30.2%)
7	4	6	4	7	0	21 (33.3%)
Total	12	12	14	13	12	63 (100%)

There was no significant difference between or within the five years of training for any of the four scores, although our sample size was likely insufficient to detect such differences in the subgroup analysis. The R4 class recorded the highest utilization of the P schema, with mean P and N2 scores of 49.54 (±14.43) and 47.15 (±12.18), respectively. Ten of its thirteen members were assigned to Types 6 and 7. The R5 class recorded the lowest utilization of the P schema, with mean P and N2 scores of 37.50 (±8.19) and 33.67 (±7.16), respectively. Eight of its twelve members were assigned to Type 6, and none were assigned to Type 7. The ranges of P and N2 scores narrowed each year. The R1 class recorded the widest ranges (P score range: 12 to 74; N2 score range: 14.59 to 68.14), and the R5 class recorded the narrowest ranges (P score range: 26 to 56; N2 score range: 20.84 to 42.86). Moreover, the range of all four scores was narrower in the R5 class compared with the other classes. Finally, the R1 class recorded the highest PI score (24.67 ± 12.69).

The mean N2 score of all sixty-three residents (41.12 ± 13.46) was significantly lower (p = 0.04) than the previously reported mean N2 score of 1582 people with professional degrees (44.97 ± 14.87)¹⁷. It was also significantly lower (p = 0.01) than 278 first-year medical students at the NYU School of Medicine (46.33 ± 13.41)²⁴. The mean P score of all residents (42.19) was empirically lower than the previously reported mean P scores of eighty orthopaedic surgery attendings (43.4) and 729 medical students at Texas A&M University Health Sciences Center (45.21)^20,21,25 (Table VI).

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TABLE VI Comparison of Residents with Professionals, Medical Students, and Orthopaedic Attendings*

Source	Sample Size	N2 Score (Mean [SD])	Postconventional Score (Mean [SD])	P Value
Orthopaedic residents	63	41.12 (±13.46)	42.19 (±14.36)	—
Professional degree-holders¹⁵	1582	44.97 (±14.87)	—	0.04
NYU School of Medicine²²	278	46.33 (±13.41)	—	0.01
Orthopaedic attendings^18,19	80	—	43.4	—
Texas A&M University Health Science Center²³	729	—	45.21	—

*SD = standard deviation.

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TABLE VI Comparison of Residents with Professionals, Medical Students, and Orthopaedic Attendings*

Source	Sample Size	N2 Score (Mean [SD])	Postconventional Score (Mean [SD])	P Value
Orthopaedic residents	63	41.12 (±13.46)	42.19 (±14.36)	—
Professional degree-holders¹⁵	1582	44.97 (±14.87)	—	0.04
NYU School of Medicine²²	278	46.33 (±13.41)	—	0.01
Orthopaedic attendings^18,19	80	—	43.4	—
Texas A&M University Health Science Center²³	729	—	45.21	—

*SD = standard deviation.

Discussion

The P schema is the most developmentally advanced moral reasoning strategy^12,13. Correct action is determined by appealing to widely accepted, logically consistent moral ideals such as justice, autonomy, and dignity. Forty residents heavily utilized the P schema in their reasoning. Seventeen residents heavily utilized the MN schema. They believe that a morally correct decision is whatever maintains the established social order. They obey authority out of respect for the social system and the concepts of law and order^12,13. Six residents heavily utilized the PI schema. They justify the moral rightness of a decision by appealing to their personal stake in the situation^12,13, and they analyze what each party has to gain or lose in a morally relevant situation without giving any consideration to social cooperation.

While it is encouraging that a small number of residents heavily utilized the PI schema, it would have been ideal if none of the residents had used this unsophisticated approach to moral decision-making. Instead, as health care professionals, all residents should predominately use postconventional reasoning. As described by the ACGME, professional physicians are expected to demonstrate “responsiveness to patient needs that supersedes self-interest.”²² The ACGME offers an explicit endorsement of universal moral principles such as “privacy” and “autonomy”. Thus, postconventional reasoning, represented by the P schema, should be the dominant force in the moral decision-making of professional orthopaedic surgeons.

The R4 class demonstrated empirically higher utilization of the P schema. This suggests that members of the R4 class appeal to moral principles more often than members of the other classes when resolving moral dilemmas. Reasons for this finding are unclear. However, the R4 class contained five women, the most in any class. There are well-documented differences between the DIT-2 scores of men and women (Table VII). Women record significantly higher P and N2 scores when compared with men, especially women who acquire a professional education^14,15,17. Therefore, the large number of women in the R4 class may account for its higher utilization of the P schema.

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TABLE VII Sex Differences in P and N2 Scores

Scores	Sex	Sample Size	Mean (SD)*	P Value
N2 scores¹⁴	Women	4399	38.45 (15.76)
	Men	3123	34.41 (15.70)
	Difference		4.04	<0.001
P scores¹⁷	Women	6008	38.61 (15.82)
	Men	4526	34.35 (15.94)
	Difference		4.26	<0.001

*SD = standard deviation.

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TABLE VII Sex Differences in P and N2 Scores

Scores	Sex	Sample Size	Mean (SD)*	P Value
N2 scores¹⁴	Women	4399	38.45 (15.76)
	Men	3123	34.41 (15.70)
	Difference		4.04	<0.001
P scores¹⁷	Women	6008	38.61 (15.82)
	Men	4526	34.35 (15.94)
	Difference		4.26	<0.001

*SD = standard deviation.

Scholars have debated whether the DIT-2 and its theoretical foundation apply accurately to the moral reasoning of women²⁶. However, Walker’s meta-analysis demonstrated that any sex differences in moral decision-making are not caused by differences in moral reasoning, which suggests that such differences are caused by other aspects of the decision-making process^27,28. Sex differences in moral decision-making are still an area of active research. It is unclear what implications these differences may have for moral reasoning research in orthopaedic surgery, a field that historically includes more men than women. To protect the confidentiality of the eight women in our program, we have not reported our DIT-2 scores by sex.

The R5 class recorded empirically lower utilization of the P schema, which suggests that members of the R5 class utilize postconventional reasoning less than their fellow residents. This is noteworthy because chief residents are granted the most patient care responsibility and practice autonomy. One would hope that a chief resident, when faced with a moral dilemma, would utilize postconventional arguments more than approximately 38% of the time. Again, reasons for these findings are unclear. However, it is likely that the R5 class is composed of individuals with a similar moral reasoning strategy, and this cohort is less reliant on postconventional reasoning than the other classes.

The ranges of P and N2 scores narrowed each year, with the R1 class demonstrating the widest ranges and the R5 class demonstrating the narrowest. This trend suggests that the moral reasoning strategies of the residents homogenize to a class-specific approach as they progress through training. In fact, the R5 class recorded the narrowest ranges in all four scores. It is possible that each class year may experience a socialization effect in which the residents’ moral reasoning becomes more alike with time and similar educational experiences. Of note, our study was limited by its design as a cross-sectional analysis. Yearly retesting of each class is necessary to investigate how moral reasoning changes throughout a five or six-year training program. If longitudinal results are significant and reproducible, then it will be important to investigate what factors influence the scores.

From 1998 to 2003, the CSED collected data from 1582 people who had obtained professional degrees beyond bachelor’s degrees (e.g., medical, dental, law, and nursing). The residents’ mean N2 score was significantly lower than the mean N2 score of these professionals¹⁷. Similarly, the residents’ mean N2 score was significantly lower than the mean N2 score of two consecutive classes of first-year medical students at the NYU School of Medicine²⁴. The residents also recorded a mean P score that was lower than the mean P score reported by Baldwin et al. and Baldwin and Bunch in their combined sample of eighty practicing orthopaedic surgeons^20,21. Likewise, the residents’ mean P score was lower than the mean P score of 729 medical students at Texas A&M University Health Science Center, who were tested between 1991 and 1998²⁵. Furthermore, the mean P score of the attending cohort of Baldwin et al. was lower than the mean P score of 44.87 (±15.86) recorded by the 1582 professional degree-holders¹⁷. Statistical analysis of these P scores was not possible because of unreported standard deviations.

These results suggest that the moral reasoning of orthopaedic surgery residents differs from that of orthopaedic surgery attendings, medical students, and people with professional degrees, but that resident reasoning is most similar to the reasoning of attending orthopaedic surgeons. One explanation for the discrepancy between medical student and orthopaedic resident scores could be that medical students who apply for orthopaedic surgery residencies utilize different moral reasoning strategies compared with their classmates. Alternatively, orthopaedic surgery applicants might display similar moral reasoning compared with their classmates, but applicants who are ranked to match may be unique in their moral reasoning. Quintero et al. found support for selective matching by demonstrating that faculty interviewers give higher rankings to applicants who share their own personality type²⁹.

Additional data are needed to confirm or reject these medical student-selection or residency program-selection hypotheses as they relate to moral reasoning. Moreover, these empirical comparisons among medical students, residents, and attendings highlight the need for longitudinal studies. For example, residents utilized principled reasoning less frequently than medical students and attendings. It is important to determine whether the training environment has a substantial impact on postconventional reasoning or whether these empirical differences are insignificant over time. Similarly, our R1 class recorded the highest PI scores of all five classes, while medical student cohorts record high P scores. This suggests that the transition from medical school to residency negatively impacts moral reasoning.

Of note, the sex, ethnic, and racial composition of orthopaedic surgeons has changed substantially since the study by Baldwin et al. in the late 1990s²⁰. Today’s residents are heavily influenced by restrictions on work hours, standardized testing, and a dynamic health care system. Similar changes have also occurred in undergraduate medical education since the 1998 study by Self et al.²⁵. These changes may have influenced the moral reasoning of the applicants, residents, and surgeons within the field, and the impact of such changes should be studied in conjunction with other variables such as resident burnout. Similarly, the professional idealism of medical students, especially in the preclinical stage of training, may impact their moral reasoning.

GME programs should encourage the development of sophisticated moral reasoning strategies when training orthopaedic surgeons. If it can be confirmed that the P and N2 scores of orthopaedic residents are significantly lower than those of medical students and practicing physicians at large, then it may be necessary to intervene during residency training to influence moral reasoning. An analysis by Baldwin and Bunch suggests that heavy emphasis on technical skill acquisition may present a challenge²¹. An intense focus on the established rules of practice may discourage residents from embracing patterns of mental behavior that are necessary for postconventional reasoning. Similarly, residents may not be challenged to identify and reflect on moral issues in daily practice.

Bebeau reviewed moral reasoning research in medical, legal, nursing, and dental education¹⁵. Seven studies demonstrated that a curriculum of ethics instruction significantly increases medical students’ utilization of postconventional moral reasoning. Notably, Bebeau found that Hartwell’s³⁰ ethics curriculum of student-centered small group discussions is most effective at increasing a learner’s utilization of postconventional reasoning. Furthermore, studies have shown that a minimum of twenty to twenty-nine hours of instruction in the first year of medical school are needed to have a significant effect, and that gains made through this curriculum are sustainable over all four years^25,31.

Any intervention in orthopaedic surgery GME will likely impact residents’ moral reasoning strategies if it consists of at least twenty hours of small group discussion sessions over the course of one year early in the program. These sessions should include self-reflective exercises in which residents are asked to study a moral dilemma and construct justifications for their decisions based on the foundational principles of morality. Any positive effect may be sustainable through the remaining years of training and even extend beyond graduation.

Positively influencing the moral reasoning of orthopaedic surgery residents may have far-reaching effects. As Baldwin et al. reported, orthopaedic surgeons with greater utilization of postconventional reasoning demonstrated significantly fewer malpractice claims per year²⁰. We are unaware of any research that correlates moral reasoning and measures of clinical and academic performance in orthopaedic residents. If such causal correlations are found, then moral reasoning may represent a modifiable predictor of future performance. Residency programs will then have great reason to influence moral reasoning through curricular interventions.

Previous research has described psychomotor, cognitive, and affective factors that are associated with clinical and academic success in orthopaedic training³². Lippert et al. described the personal and professional values (e.g., selflessness, commitment, cooperativity, and integrity) of residents as their affective domain³³. Although affective domain is an important predictor of resident success, there are few objective tools that evaluate this area³⁴. The DIT-2 may represent a reliable and valid tool that can measure aspects of affective domain in orthopaedic residents, especially if sophisticated moral reasoning strategies are independently associated with greater success in residency, or if such strategies correlate strongly with pre-established factors for later success.

Self and Baldwin theoretically support the use of moral reasoning as an admissions criterion for both medical school and residency programs; however, they acknowledge the need for more research³⁵. A comprehensive understanding of an individual’s moral decision-making cannot be obtained with use of a single metric like the DIT-2. Several metrics, such as reasoned response exercises, behavioral interviewing, and variations on the multiple mini-interview, should be administered and evaluated simultaneously to improve the validity and reliability of moral reasoning assessments^1,36,37. Similarly, Objective Structured Clinical Examinations (OSCEs) and Standardized Patients (SPs) activities may have a role. Gaining a comprehensive understanding of a candidate’s affective domain may justify the large investment in a multimetric evaluation. For example, applicants for orthopaedic surgery residencies have focused intensely on their personal academic advancement. It is highly valuable for residency programs to distinguish motivated applicants who heavily utilize postconventional reasoning from those whose self-interest negatively impacts their moral decision-making.

Some have argued that the theory of moral reasoning is misguided. Haidt proposed that individuals rarely utilize principled, rational deliberation when faced with a moral dilemma, but rather rely on a type of moral intuition when making moral decisions³⁸. Haidt is correct that one does not always reason through moral judgments. Orthopaedic surgeons make many moral decisions quickly and intuitively without much deliberation. However, there are also instances where principled reasoning is utilized by surgeons. Analyzing the moral reasoning strategies of residents does provide insight into how a resident may reason through certain moral dilemmas, but it does not adequately describe the entirety of a resident’s moral behavior.

To gain the fullest understanding of a person’s moral decision-making, moral intuition must be evaluated along with moral reasoning. One should also evaluate moral decision-making under different contexts. Moreover, many other variables (e.g., time constraints, familiarity with topic, predecision priming, order effect, etc.) are likely to influence one’s moral decisions. Ideally, surgical educators may be able to design OSCEs and unannounced SP activities to evaluate these variables and eliminate the Hawthorne effect, or eliminate the modification of subject behavior in response to being observed³⁹.

Our department hosts one of the country’s largest orthopaedic surgery residency programs, thereby maximizing our sample size. We did not randomly sample our residents, however, and we lack data from residents outside of our institution. Therefore, our results may not be representative of, or applicable to, all orthopaedic residents. Although we have reported on several trends in resident moral reasoning, many results were not significant. We nevertheless believe that sharing our results and discussion introduces the concept of moral reasoning as a learned, modifiable, and measurable characteristic. Finally, there may be concern over the retesting of the five residents whose data was initially purged. However, no curricular interventions were made between the administration of the retest, the DIT-2 has a test-retest reliability of approximately 0.80, the DIT-2 is available for public viewing on the CSED web site, and research has demonstrated that respondents cannot easily fake moral reasoning beyond their actual stage of moral development^16,23,40.

Conclusion

Orthopaedic surgery residents at our institution utilized postconventional reasoning less frequently than expected for professional physicians. The R4 class recorded the highest utilization of postconventional reasoning, which may be a result of the higher percentage of women in the class. For unclear reasons, the R5 class demonstrated the lowest utilization of postconventional reasoning. Our cross-sectional data suggest that each class homogenizes toward a class-specific utilization of postconventional reasoning as they progress through training. It remains unclear if training impacts moral reasoning strategies. Residents utilized postconventional reasoning less than orthopaedic attendings, medical students, and individuals with professional degrees, which suggests that our residents differ from these groups for unclear reasons. If moral reasoning is a predictor of residency performance, it should be influenced through curricular interventions. Additional research is needed before making moral reasoning an admissions criterion for medical school or orthopaedic residency. Lastly, moral intuition must be evaluated to understand moral decision-making more fully.

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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.

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medical residencies ; reasoning

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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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John J. Mercuri, Raj J. Karia, Kenneth A. Egol, Joseph D. Zuckerman; Moral Reasoning Strategies of Orthopaedic Surgery Residents. The Journal of Bone & Joint Surgery. 2013 Mar;95(6):e36 1-9.

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