As “simple procedures” diminish, should thoracic surgeons in training programs be mandated to allow residents to operate on patients in order to satisfy board requirements? This was the question posed during an ethics debate at the annual meeting of the Society of Thoracic Surgeons.
It is ethical, and it is necessary.
BY RICHARD G. OHYE, M.D.
The linchpin of this discussion is the “obligation,” which is defined as “a course of action that someone is required to take, whether legal or moral” to have residents perform surgery. My position is that, yes, we do have such a mandate.
I doubt that Dr. Jaggers and I would disagree that teaching residents is something we do as academic surgeons. The devil is in the details. Among our concerns are patient safety and closer scrutiny on surgical practices due to public reporting, which makes everything we do readily available. Further, simple, straightforward cases are going away; interventional cardiologists are doing lots of stents, mitral valves, and atrial septal defect closures, so those kinds of procedures are going away.
Looking at case logs from congenital cardiac and CT residents at our institution, however, there are still incomplete canals, tricuspid valve repairs, mitral valve repairs and replacements, aortic valve repairs, patent ductus arteriosus repairs, vascular rings, pulmonary valve replacements, and conduits. Residents are capable of doing these procedures; they are incredibly talented individuals and you just have to let them operate.
In addition, our results – and more importantly, our patients – have not suffered. We let our residents do between one-third and one-half of our cases, and the cases only count if they’re skin-to-skin. Our results, compared by STAT category, compare favorably with STS benchmarks and are either at or below expected values. By the end of this year, our expected mortality should be about 23%, but our observed mortality is less than half that value with the residents doing lots of cases.
So what about the ethics – who would you want operating on you? There is an ethical dilemma that goes along with medical education because no matter how good my residents may be, I am more experienced. I can do every procedure faster and “better” than they can. But the teaching of students is not a new concept, it’s even in the Hippocratic Oath, so this is an old and well-accepted practice.
There is a strong parallel between medical education and medical research. We still have to follow all of those important guidelines we have for medical research – do what’s right for the patient and exercise good judgment. We must not just “do no harm.” We must actively do good.
Academic surgeons have an obligation to teach. We take care of patients, do research to push the whole field forward, and educate to bring up the next generation of doctors. The cases for residents to perform are all there – yes, we’re a big program, but even smaller programs should see plenty of cases – and I think I’ve shown that these can be performed safely and yield excellent results. As long as the results are good, you don’t need to worry about public scrutiny. The case for medical education is similar to that of medical research: It is ethical, and it is necessary.
Dr. Ohye is head of the pediatric cardiovascular surgery division and surgical director of the pediatric heart transplant program of the University of Michigan, in Ann Arbor; he argued in support of a mandate.
Patients may not benefit, and may actually be harmed
BY JAMES JAGGERS, M.D.
The central issue in this debate is whether or not the surgeon’s responsibility as an educator and member of the training program overrides the surgeon’s responsibility to provide the patient with the best possible outcome. Put another way, should the responsibility to treat the patient to the best of the surgeon’s ability be subordinated to the success and survival of the training program for the sole purpose of giving the resident sufficient operative experience to be board eligible?
Both versions of the Hippocratic Oath and the more recent Declaration of Geneva, the AMA’s Code of Ethics, and the ACGME Mission Statement clearly enforce that the primary responsibility of the physician is to the patient, while also endorsing physician responsibility to community via service and education. Using patients as a means to an end – in this case, to satisfy board requirements – and to do so without patients’ explicit consent, violates the fundamental principle of respect for individuals.