Ethics in cardiothoracic surgery
Must Surgeons in Training Programs Allow Residents to Operate on Their Patients to Satisfy Board Requirements?

Presented at the Fifty-first Annual Meeting of the Society of Thoracic Surgeons, San Diego, CA, January 24-28, 2015.
https://doi.org/10.1016/j.athoracsur.2015.08.049Get rights and content

Introduction

Surgical trainees and their attending surgical instructors face a perennial question that is integral to our model of graduated participation in caring for patients: How can one accurately determine when a resident is ready to advance to the next level of responsibility? Those judgments depend on accurate evaluation of the trainee’s developing judgment and increasing technical skills that become more refined with time and experience. Surgical educators have traditionally based their evaluations of residents on subjective observations, integrating those observations into practical judgments that they use to permit increasing levels of responsibility. The Thoracic Surgery Directors Association (TSDA) recently adopted the Accreditation Council on Graduate Medical Education (ACGME) milestone concept [1], which provides objective standards to use for determination of readiness to advance in training.

Surgeons have differing judgments of residents’ capabilities, however, based on their variable personal experiences with trainees, different personal yardsticks of performance, and diverse philosophies of patient care and medical education. An implicit tension exists between the requirements of caring for patients and those of educating trainees, a tension that produces quandaries for academic surgeons: What tradeoffs between doing one’s absolute best for one’s patients and fulfilling one’s obligations as a teacher are acceptable? That question was addressed in a recent debate sponsored by the Cardiothoracic Ethics Forum at the Annual Meeting of The Society of Thoracic Surgeons. The discussion was based on a hypothetical scenario that illustrates a common problem of surgical education.

A highly respected residency program has a problem. The chief of cardiothoracic surgery believes that residents should complete the American Board of Thoracic Surgery (ABTS) operative requirements in the home institution if the service has a sufficient number of cases. He finds that several residents are at risk of failing to meet the ABTS requirement for congenital heart cases by the time they finish their residency, despite having a moderately busy pediatric cardiac surgery program. The program’s two pediatric cardiac surgeons, Dr Smith and Dr Jones, have a reputation for not allowing residents to do more than assist in their operations, out of concern for the safety of their patients and for the increasing scrutiny of surgical results—the simple, straightforward cases that were once used for training residents are progressively less available because interventional cardiologists do those cases. Do Drs Smith and Jones have an obligation to allow thoracic surgery residents to operate on their patients so the residents can achieve their ABTS requirements?

Section snippets

Richard G. Ohye, MD

Surgeons have an obligation to allow thoracic surgery residents to operate on their patients so the residents can achieve their ABTS requirements. Medical education is obviously a crucial part of maintaining a sustainable health care delivery system. Few physicians would argue against the idea that it is one of the responsibilities of our job, but should this be considered an obligation that we must carry out as a part of our covenant as a physician? This question is the root of the debate.

James J. Jaggers, MD

Attending cardiac surgeons are not only ethically justified not to allow residents to operate on their patients, but they are morally obligated to do what they think is in the best interest of their patients.

Richard Ohye and I are both surgical educators. We both are members of departments of thoracic surgery and participate in the training of thoracic surgery residents. And we both lead congenital cardiac surgery divisions with congenital cardiac surgery training programs. We have both

Robert M. Sade, MD

Ohye and Jaggers both make the case for their respective positions using data from the published literature and personal outcomes, as well as analysis of moral commitments. According to Ohye, Drs Smith and Jones are obligated to allow thoracic surgery residents to operate on their patients because taking residents through operations can be done safely, as proved by his results and those of others. According to Jaggers, the hypothetical surgeons have no such obligation because surgeons’ primary

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