The Right Choice?

Duty Hours Pose Ethical Dilemmas


 

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

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