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Ethics in Practice   |    
Moral Complexity
James D. Capozzi, MD1; Wesley Bronson, BA2; Rosamond Rhodes, PhD2
1 Department of Orthopaedic Surgery, Winthrop University Hospital, 222 North Station Plaza, Mineola, NY 11501. E-mail address: jcapozzi@winthrop.org
2 Department of Bioethics Education (R.R.), Mount Sinai School of Medicine (W.B.), One Gustave Levy Place, New York, NY 10029
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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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Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Aug 03;93(15):e88 1-3. doi: 10.2106/JBJS.K.00084
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

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.

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    Accreditation Statement
    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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    Dorothea Z. Lack, Ph.D.
    Posted on October 02, 2011
    Response to Moral Complexity
    None given

    I read the 'Ethics in Practice' essay in the current issue of JBJS, and I very much agree with the one respondent that it is not acceptable for Doctors in Training to be left with no available Attending Surgeon, as was the case in the aforementioned article. Furthermore, I believe that hospitals in general should pass rules barring the common practice of leaving the Doctors in Training to 'close' after surgery. If they are not qualified to operate, they are not qualified to 'close'. The fact that these Doctors in Training are being warned about the consequences of being 'whistle blowers' is a comment on hospital cultures in general. I could say a lot more, but I know how busy you must be, so I will leave it at that.

    James D. Capozzi, MD
    Posted on August 15, 2011
    Responding to Dr. Jan Koenig's comment
    Winthrop University Hospital

    I agree with the readers comments regarding the primary surgeon leaving the hospital. Although in some hospitals fellows may have full admitting and operative privileges, we must all remember they are still physicians in-training. In addition to the specific technical training they are acquiring, fellows and residents are always observing all aspects of instructors' behavior. Leaving the operating suite and hospital prior to the end of a case may not be the behavior we would want them to emulate.

    Jan Koenig MD
    Posted on August 03, 2011
    The Absent Professor
    Director of Orthopedic Surgery Mercy Medical Center Rockville Centre, NY

    I enjoyed Dr Capozzi's article entitled 'Moral Complexity'. Wasn't the fact that the only Attending Orthopedic Surgeon on the case left the hospital before the surgery was completed also a breach of ethical medicine? One would think that the patient's expectations was that his surgeon would at least be in the OR suite or hospital until the surgery was completed. Maybe then he or she could have returned to fix the problem. I would like to know the Authors' feelings about this. I think this is not what we should be teaching our residents and fellows.

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