Abstract
An attending orthopaedic surgeon, an orthopaedic resident, and a spine Fellow are scheduled to perform a multilevel spinal decompression and instrumentation from L3 to S1. The case is delayed for several hours and begins in the late afternoon. The attending orthopaedist chooses not to wait for localization radiographs and proceeds with the decompression and four-level pedicle screw instrumentation with posterior-lateral fusion. The Fellow suggests several times during the procedure that radiographs should be obtained, but the attending surgeon is late for a meeting and declines to obtain radiographs.
The attending surgeon leaves the resident and Fellow to close the wound after spinal instrumentation and fusion is complete. Radiographs are obtained prior to closure of the wound, and these indicate that the decompression has been performed at the appropriate levels but that the spinal instrumentation and fusion was from L2 to L5 rather than from L3 to S1. The Fellow notifies the attending surgeon, who has already left the hospital. The Fellow offers to remove the L2 screws, place S1 screws, and reconfigure the instrumentation prior to closing. The attending surgeon forbids the Fellow to do this and tells her, "Everything will be fine." He also states that he will discuss the surgery with the patient and family in the morning. As ordered, the Fellow and the resident close the wound.
Although some of the ethical issues regarding residency training have been discussed previously1, this actual case illustrates several additional issues and points out the moral complexity that can be involved in the practice of orthopaedics. In particular, this case involves ethical issues related to the responsibilities of faculty and trainees in medical education, concern for the safety and well-being of the patient, the importance of truth-telling, and the limits of responsibility and authority in medical training.
Disagreement between attending surgeons and trainees occurs frequently. One study published in 1996 reported a high rate of ethical disagreement between residents and attending surgeons regarding the care of patients, with 89% of residents reporting at least one event over the past year2. Nevertheless, only 34% of the residents ever discussed the issue with the attending surgeon; the remainder chose to remain quiet regarding their objections. The findings of that study indicate that although the rate of disagreement between faculty and residents can be quite high, the standard response by residents is silence and acceptance of the attending surgeon's authority3,4.
The Fellow who repeatedly suggested that radiographs be obtained demonstrated beneficence, or concern for the patient's well-being. Omitting important safety measures without a patient-centered justification unjustly exposes the patient to avoidable risks and harm. The Fellow's questioning also demonstrated concern regarding her own education; if there was a good reason why intraoperative radiographs were not necessary in this case, she needed to understand that rationale. The Fellow exhibited courage in challenging the attending surgeon. She risked damaging her future relationship with the attending surgeon as well as developing a reputation as a troublemaker within the department, even if the challenging was done with great tact. The Fellow clearly demonstrated professionalism in placing the well-being of this patient and future patients ahead of her own interests.
The attending surgeon, who did not prioritize the patient's welfare ahead of his own and did not provide a reasonable explanation for proceeding without a radiograph, thereby failed the patient—since closing the incision without revising the fusion level might well require a second operation, with the attendant additional risks of infection, bleeding, and other surgical and anesthesia-related complications. In addition, the attending surgeon failed the trainees as a mentor and as a role model.
In light of this apparent instance of negligence and the attending surgeon's instructions to leave the explanation of the surgery to him, the trainees in the above case may be left with the impression that the attending surgeon intends to withhold information regarding the error in the fusion level. Although withholding critical information is not quite telling a lie, in this case distorting the facts in this fashion could create a false impression regarding the success of the surgery as well as lay a groundwork for future accounts of why the patient's problems persist. Deception in any form demonstrates disrespect for the patient. Such deception undermines patient autonomy, and it threatens the patient's trust in medicine and medical professionals. Neither deception nor lying is consistent with the ethical practice of medicine.
In fairness, it should be noted that the Fellow is not at all certain of the exact nature of the attending surgeon's planned discussion with the patient and family. The Fellow is concerned about the possibility of a deceptive explanation because of the attending surgeon's statement that "everything will be fine." However, the attending surgeon may in fact clearly and truthfully explain the facts of the surgery and its potential outcome. The Fellow could potentially ask if she could be present for the discussion, although this would represent a somewhat risky course of action for her. Observing how the attending surgeon speaks to patients and families, especially in situations with potentially less than optimum outcomes, also represents a learning experience for the physician in training.
Even those physicians who focus on the good of their patients are sometimes reluctant to provide honest disclosure. Some doctors believe that giving patients bad news may cause harm. They may therefore be reluctant to inform patients about things that could be expected to cause sadness or worry, and they may be especially reluctant to communicate information that might elicit anger or other strong emotions.
Medical errors are always accompanied by decisions regarding what information to disclose to the patient and how to disclose it. We have previously reasoned that errors must always be honestly disclosed without distortion, and that patients who have been exposed to an error should be given caring and responsive attention5. While that is certainly the best ethical advice for doctors faced with an adverse outcome, the physician who commits an error of professionalism by placing personal interests ahead of the good of the patient is in a far more reprehensible situation. Any deception in this case would be contemplated as a means of protecting the surgeon from the wrath and retribution of an injured patient rather than for the sake of shielding the patient from mental anguish.
In this case, the patient requires truthful information in order to monitor his clinical outcome as well as to make informed decisions regarding subsequent treatment. The patient may have disabilities, additional expenses, and loss of income associated with the error and may legitimately seek compensation for those costs. The patient is entitled to accurate information about what was done to his body—regardless of how that information is ultimately used.
The attending surgeon is ultimately responsible, both medically and legally, for the surgery that is being performed. The attending surgeon has been authorized by the hospital to perform the designated surgery and has taken on the responsibility to do so according to professional standards. The trainees have not been so authorized. The attending surgeon has also been authorized by the academic medical institution to train and supervise the trainees and, again, has taken on the responsibility to do so according to professional standards. Again, the trainees have not. Presumably, the attending surgeon has the relevant knowledge, skills, judgment, and experience to manage the surgical procedure and to handle any unexpected events that occur before, during, and after it.
Although the Fellow has noble intentions to protect the patient from any harm associated with a repeat surgical procedure, the presumption must be that as a Fellow she is not yet adequately trained to take on the responsibilities to revise the spinal instrumentation. It is not permissible for house staff to exceed their authority except to prevent a major catastrophe6. The immediate harm to the patient in this case is not catastrophic, so obedience to the chain of command remains the rule, and the Fellow and the resident are not justified in revising the spinal instrumentation without supervision.
This case raises the obvious question of what should be done to prevent similar episodes in the future. Should the Fellow discuss the case with her chairman, another attending surgeon, or the Fellowship director? We have already outlined the potential pitfalls of further discussion with the operating surgeon, namely the risks of retribution and branding. Consequently, every training program should have a clearly defined policy regarding patient care issues, the chain of command, and actions that could be considered related to "whistle-blowing." Although this scenario is not quite analogous to whistle-blowing, it does embody the potential for consequences similar to those that may befall whistle-blowers.
Physicians in training (i.e., medical students, residents, and Fellows) need to have an available mechanism for discussing patient care concerns without fear of retribution. In many instances, the perceived lapses in appropriate patient care that they identify may represent little more than a lack of insight on their part regarding the medical complexities of a case. However, in some instances, they may have witnessed legitimate patient care issues.
The above case illustrates several complex ethical issues involving residency and Fellow training, truth-telling, adverse outcomes, and limits of responsibility. Each issue presents a moral dilemma regarding how to proceed in the best interest of the patient. When what should be done is clear and uncontroversial, physicians simply see what they do as practicing good medicine. In other cases, however, principles of ethical behavior may conflict with one another, leaving the physician with a moral dilemma regarding how to proceed. Would having the Fellow revise the fusion be less harmful to the patient than closing the wound as instructed? Would having the Fellow or the attending surgeon explain the results of the surgery be in the best interest of the patient? Would adhering to the principle of the chain of command or breaking rank and proceeding without supervision be the most appropriate course of action?
The ethical dimension of medicine is typically noticed only when a physician finds himself or herself in a dilemma in which it is not obvious which of two treasured principles of professional ethics should be upheld and which should be sacrificed. In such cases, the solution to the dilemma begins by identifying the conflicting principles and then deciding which poses the least risk to the patient.
In cases such as the one above, it is far more difficult to see one's way through the ethical landscape. Multiple distinct ethical issues are involved. The only clear path through such moral complexity is to identify each separate issue and dissect it from the others. In order to resolve such morally complex cases, each issue must be analyzed individually and must be addressed with clear analyses and reasons that are likely to be accepted by one's most esteemed colleagues. In the case above, the conflict at the heart of each separate issue is between acting for the patient's good and doing what seems to be most beneficial to the treating physician. When put in those terms, the resolution of each ethical dilemma, regardless of its complexity, becomes clear.
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