RESIDENT SUPERVISION

Transcription

1 RESIDENT SUPERVISION OBJECTIVES: Explore the ethical challenges of surgeon training in medical education Understand the obligations of the supervisor during resident education Identify the ethical implications of inadequate resident supervision Discuss the person of ultimate responsibility (PUR) and the legal implications associated with the relationship The training of residents raises many legal and ethical issues, especially in the surgical subspecialties. All physicians require some amount of graduated autonomy during their training, but the right amount is not without controversy. Allowing a resident to perform an operation that he/she is not qualified to do is to the detriment of the patient and in conflict with the principle of non-maleficence. Also, in order to respect patient autonomy, patients should be able to choose whether or not residents are involved in their care. In order to meet the needs of our aging population, resident physicians need adequate training with appropriate supervision and autonomy to develop into independently practicing physicians. Moreover, residents at teaching hospitals and county hospitals provide access to health care for many underserved or underinsured patients. Finally, there are many misconceptions about legal responsibilities in resident training environments. Despite commonly held beliefs, residents, attending physicians, and hospitals may all be liable for errors occurring at teaching hospitals when a lack of supervision is involved. Slides 3-5: Case 1 and question You are a PGY-3 resident on the second week of your total joints rotation. You have been involved in two prior total hip arthroplasty cases and are familiar with the basic steps; however, you do not feel comfortable enough with the operation to perform it alone. It is a busy day on the joint service, and your supervising attending surgeon is running two operating rooms. He calls into the room and tells you to go ahead and begin the approach. He assures you that he will be there shortly. You successfully complete the approach and are ready to make your femoral neck cut. You are unsure of where you want to make the cut and would like confirmation from your attending. The OR circulator attempts to call and page the attending multiple times but does not get an answer. What do you do? 1

2 Slides 6-7: Case continued and question You decide to pack the wound and wait for the attending. After waiting approximately twenty minutes, the anesthesiologist informs you that the patient is getting hypotensive and needs some stimulation from the surgery to help raise his blood pressure. Now what do you do? Slides 8-13: Case continued, a question, principles and AMA Opinion You decide to proceed and very slowly make your femoral neck cut. Ten minutes later, your attending enters the room and the remainder of the case is completed without complication. In the recovery room, the patient is confused and unable to move her right arm and leg. Neurology is consulted, and the patient is diagnosed with a stroke. In looking back through the OR record, you discover that in the 30-minute period when you were waiting on your attending without progressing in the case, the patient s mean arterial pressure was below 60mmHg, which was the lowest recorded value during the case. As a resident, what is your ethical obligation in this case? In this scenario, a resident surgeon is performing an operation above his level of comfort without adequate supervision. His attending is unavailable for guidance despite multiple attempts to contact him. The patient suffered a stroke that could be linked to the period of time that the resident was waiting on his attending to assist him with the case. Worse outcomes have been demonstrated after operations conducted by unsupervised junior residents when compared to senior residents or attendings. 1 In addition, longer operative times have been demonstrated in arthroplasty with cases done at teaching hospitals compared to non-teaching hospitals. 2 However, data has also been published to the contrary, concluding that resident involvement may not have an adverse effect on mortality or long-term outcomes The primary ethical obligation for the resident in this case is of nonmaleficence or to do no harm. This example is in violation of the first opinion on resident supervision from the Code of Medical Ethics of the American Medical Association, which states that residents should have appropriate faculty supervision and graduated responsibility relative to level of training and expertise. 11 2

3 Ethical Principles Non-maleficence: the health and well-being of the patient should never be harmed in the interest of training physicians Beneficence: intervening to benefit the well-being of the patient AMA Opinion on Resident Physicians Involvement in Patient Care Appropriate supervision with graduated responsibility appropriate to level Clearly identify residents as part of team supervised by the attending Patient should be able to refuse care from resident and transfer care if desired Slides 14-15: Question and legal responsibilities Who is legally responsible for this adverse outcome? Legal Responsibilities Residents are not free from legal responsibility, and the idea of being on somebody else s credit card is incorrect. Resident physicians are named in almost one in four lawsuits (22%). 12 Senior residents supervising junior residents on call may be sued and found liable even if they do not have direct contact with the patient. Supervising physicians that are not present during the patient care can be vicariously liable for the residents under their supervision or may be liable if it is determined that inadequate supervision was present. Hospitals and institutions that sponsor residents may be liable for resident errors as well. In legal terms, the operating resident, the attending surgeon, and the institution may all be held legally responsible for this adverse outcome that was a result of inadequate supervision. Slides 17-18: Questions and reporting and prevention information What is your reporting obligation in this case? What should be done to prevent this from happening in the future? Reporting and prevention of future incidents Discuss with attending surgeon Discuss with Orthopaedic Program Director or Chair Discuss with Hospital Risk Manager Discuss at Departmental Morbidity and Mortality Conference (per AMA Opinion on Resident Physicians Involvement in Patient Care) 3

4 In this case, the resident is obligated to discuss this case with the attending surgeon, and to try to formulate a plan to prevent this from occurring in the future. If a change is not made or a pattern of similar incidents occurs, then the resident is obligated to inform the Orthopaedic Program Director or Chair of the problem and go through the appropriate channels to ensure adequate supervision. Some institutions also require that all incidents be reported to the Hospital Risk Manager. Another option that would be in accordance with the AMA Opinions on Resident Physicians Involvement in Patient Care is to discuss this case at a departmental Morbidity and Mortality conference in order to raise awareness and prevent reoccurrence. Slides 19-21: Case 2 and questions You are a PGY-5 orthopedic surgery resident on the hand service. You are doing a routine carpal tunnel release surgery. Your attending is consenting the next patient for surgery and tells you to get started and that she will be there in a minute. You begin the case and start to release the transverse carpal ligament. Shortly into the case you realize that the recurrent motor branch of the median nerve has been cut. Your attending enters the room. You inform her that you believe the nerve has been cut. A primary repair of the lacerated nerve is performed, and the case is completed. The patient awakes and is unable to actively demonstrate thumb opposition. What is your obligation of disclosure in this case? Is the attending surgeon obligated to disclose the involvement of a resident to the patient? Who is the person of ultimate responsibility (PUR)? What are the legal implications of this case? Who is liable in this situation? In this case, an operative complication occurred by a resident when the supervising surgeon was not in the room. It is important to disclose to the patient that the weakness is likely due to the injury to the nerve. A discussion about the repair and likely outcomes for the patient is appropriate as well. Disclosure that the resident was the one performing the procedure without supervision is not imperative; however, it is important not to mislead the patient about resident involvement. In this case the Person of Ultimate Responsibility (PUR) is the attending surgeon. However, in a scenario with a bad outcome occurring as a direct result of negligence, the resident, the attending surgeon, and the institution may all be determined to be liable. 13 4

5 Slides 22-24: Case 3 and question You are the PGY-5 chief resident rotating on the foot and ankle service. You assign yourself to work with a specific surgeon on a given day because you are particularly interested in doing a calcaneus ORIF that is on the schedule. In the preoperative area, you go to introduce yourself and to obtain surgical consent from the patient. When you start to explain the surgery and its associated risks to the patient, she interrupts you and asks, Who will be doing my surgery? You know that it is typical for this particular surgeon to be present for the entirety of any case but to allow the chief resident to be the primary operator while providing guidance as necessary. How do you respond to the patient s question? Slides 25-31: Case 3 continued, questions, and principles You explain to the patient that your attending will be present for the entire operation and will be in charge but that you will be assisting him, and you both will be performing the operation together. You finish your discussion with the patient and obtain consent. As you are preparing to exit the room, the patient states, You know, I would actually prefer not to have a resident involved in my case. What do you do now? You explain the situation to your attending. He tells the patient that choosing to have surgery at a teaching hospital includes the understanding that residents and students may be involved in her care. He states that the resident will only be observing and that he will be performing the operation. Once you get to the OR and the patient is put to sleep, positioned, prepped and draped, the attending marks out the incision and then passes you the scalpel. He has you complete the approach and obtain a reduction. Then he tells you to insert the implants. Should you continue to perform the operation or refuse to take such an active role? Should you question your attending s representation of your role in the case? Does the patient have a right to have care without trainee involvement? 5

6 In this instance, the attending is misrepresenting the role of a resident in an operation. The role of the resident in the operation should be clearly stated, and honesty about his/her participation is the most appropriate course. According to the AMA s Opinion on Resident Physicians Involvement in Patient Care, the patient has a right to have care without trainee involvement, and transfer of care should occur if the supervising surgeon is unable or unwilling to acquiesce. 8 Ethical Principles Respect for autonomy: patients should be able to choose not to have residents participate in their care Distributive justice/resource allocation: there are not unlimited resources in our healthcare system ACS Statement on Principles The surgeon should be in the operating suite or the immediate vicinity for the entire surgical procedure. There may be instances consistent with good patient care that are valid exceptions. The surgeon may delegate part of the operation to associates or residents under his or her personal direction. If a resident is to perform the operation and provide continuing care under the supervision of surgeon, the patient should be informed of this. The surgeon should be an active participant throughout the key components of the operation. It is unethical to mislead the patient as to the identity of the surgeon who performs the operation Slides 32-33: Summary Important ethical problems are inherent in resident education. The goal is to provide high quality care to the greatest number of patients without sacrificing patient safety or misleading patients. Ethical principles of non-maleficence, beneficence, patient autonomy, and distributive justice/resource allocation are central to this discussion. Medical organization ethical guidelines and legal implications should also be considered. Innovation in resident education may offload some of the ethical burden. 6

7 The effective training of orthopaedic surgery residents may produce ethical dilemmas where the principles of non-maleficence and patient autonomy are in opposition to the principles of beneficence, distributive justice and resource allocation. The goals of orthopaedic surgery are to provide high quality care to the greatest number of patients without sacrificing patient safety or misleading patients and compromising their autonomy in medical decision making. This requires a delicate balance and a comprehensive understanding of ethical principles to help physicians and educators deliver optimal patient care while educating residents. The implementation of the following two steps could address some of the problems described in this module: 1. Attending surgeons should be forthcoming and transparent regarding who will be performing their patients surgeries. This means that at the preoperative evaluation or conference, they should explain that they work at a teaching hospital and that a resident will be observing, assisting or performing the operation (based on their typical practice). This allows a patient to pursue alternative arrangements for surgery if he or she does not accept residents participation, and in this way preserves patient autonomy. 2. It is important to develop methods to improve resident and junior surgeon proficiency prior to hands on experience with real patients. There is no perfect replacement for real time experience; however, cadaver labs and simulators can help trainees learn the steps and get crucial motor repetitions in advance of or in conjunction with their clinical experience. Moreover, it is important that unethical behavior in resident training, specifically that which puts patients at risk, be addressed professionally. There has long been a culture of hierarchy and unquestioning subservience in resident training in the United States. Physicians in training should have a person through whom they can report such events: a chief resident, program director or chairman. In an acute situation, such as the first case where the resident is stuck in the operating room, the resident should feel comfortable going to any more senior residents or faculty to help the patient and then addressing the situation with the program director at a later time. In patient care situations, all team members should be working toward the ultimate goal of helping the patient. Patients have the right to know who will be involved in their care, and they should have the ability to choose who participates in it. Physicians in training should remember that their 7

8 attending surgeon is the person of ultimate responsibility and should not put the patient at risk at the expense of learning. Residents and fellows should also acknowledge that they may be legally held responsible for poor outcomes, and thus the notion that they are operating on someone else s credit card is unethical and irresponsible. In addition to the ethical principles discussed above, guidelines put forth by medical associations such as the American Medical Association and American College of Surgeons can help to inform and influence physician practice. Consideration of the legal implications of improper resident supervision should also be weighed, and all health care team members should understand their legal, professional, and ethical obligations. References 1. Cosgrove CM, Thornberry DJ, Wilkins DC, Ashley S: Surgical experience and supervision may influence the quality of lower limb amputation. Ann R Coll Surg Engl 2002;84: Woolson ST, Kang MN: A comparison of the results of total hip and knee arthroplasty performed on a teaching service or a private practice service. J Bone Joint Surg Am 2007;89: Renwick AA, Bokey EL, Chapuis PH, et al: Effect of supervised surgical training on outcomes after resection of colorectal cancer. Br J Surg 2005;92: Lee SL, Yaghoubian A: Comparison of pediatric laproscopyic appendectomy outcomes between teaching and non-teaching hospitals: a multi-institutional study. J Laparoendosc Adv Surg Tech 20(10): Offner PJ et al: General surgery residents improve efficiency but not outcome of trauma care. J Trauma-Injury Infection & Critical Care 55(1) Dimick JB, Cowan JA, Colletti LM, Upchurch GR: Hospital teaching status and outcomes of complex surgical procedures in the United States. Arch Surg 139(2): Jordan SW et al: Resident involvement and plastic surgery outcomes: an analysis of 10,356 patients from the American College of Surgeons National Surgical Quality Improvement Program database. Plast Reconstr Surg 131(4) Moran M, Yap SL, Walmsley P, Brenkel IJ: Clinical and radiologic outcome of total hip arthroplasty performed by trainee compared with consultant orthopedic surgeons. J Arthroplasty 2004;19:

9 9. Hutter MM, Glasgow RE, Mulvihill SJ: Does the participation of a surgical trainee adversely impact patient outcomes? A study of major pancreatic resections in California. Surgery 128(2): Raval MV, Wang X, Cohen ME: The influence of resident involvement on surgical outcomes. J Am Coll Surg 213 (1): Council on Ethical and Judicial Affairs: Code of Medical Ethics, Opinion Chicago, IL, American Medical Association, ed (See addendum or use link below for complete text) page 12. Sohn DS: Medical liabilitiy and orthopedic residents: Case law could hold residents, attending physicians, and hospitals liable. AAOS Now, December Wegman B, Stannard JP, Bal BS. Medical Liability of the Physician in Training. Clin Orthop (2012). 470 (5): Holt G, Nunn T, Gregori A: Ethical dilemmas in orthopaedic surgical training. J Bone Joint Surg Am 2008;90:

10 Addendum Guidance from the Code of Medical Ethics of the American Medical Association Opinion Resident Physicians' Involvement in Patient Care Residents and fellows have dual roles as trainees and caregivers. First and foremost, they are physicians and therefore should always regard the interests of patients as paramount. To facilitate both patient care and educational goals, physicians involved in the training of residents and fellows should ensure that the health care delivery environment is respectful of the learning process as well as the patient s welfare and dignity. 1. In accordance with graduate medical education standards such as those promulgated by the Accreditation Council for Graduate Medical Education (ACGME), training must be structured to provide residents and fellows with appropriate faculty supervision and availability of faculty consultants, and with graduated responsibility relative to level of training and expertise. 2. Residents and fellows interactions with patients must be based on honesty. Accordingly, residents and fellows should clearly identify themselves as members of a team that is supervised by the attending physician. 3. If a patient refuses care from a resident or fellow, the attending physician should be notified. If after discussion, a patient does not want to participate in training, the physician may exclude residents or fellows from that patient s care or, if appropriate, transfer the patient s care to another physician or nonteaching service, or to another health care facility. 4. Residents and fellows should participate fully in established mechanisms for error reporting and analysis in their training programs and hospital systems. They should cooperate with attending physicians in the communication of errors to patients. (See Opinion E-8.121, "Ethical Responsibility to Study and Prevent Error and Harm.") 5. Residents and fellows are obligated, as are all physicians, to monitor their own health and level of alertness so that these factors do not compromise their ability to care for patients safely. (See Opinion E-9.035, "Physician Health and Wellness.") Residents and fellows should recognize that providing patient care beyond time permitted by their programs (for example, "moonlighting") might be potentially harmful to themselves and patients. Other activities that interfere with adequate rest during off-hours might be similarly harmful. 6. Residency and fellowship programs must offer means to resolve educational or patient care conflicts that can arise in the course of training. All parties involved in such conflicts must continue to regard patient welfare as the first priority. Conflict resolution should not be punitive, but should aim at assisting residents and fellows to complete their training successfully. When necessary, higher administrative authorities or the relevant Residency Review Committee (RRC) should be involved, as articulated in ACGME guidelines. (I, II, V, VIII) Issued November 2005 based on the report "Resident Physicians' Involvement in Patient Care," adopted June