A man with moderate dementia who is living in a nursing home is diagnosed with laryngeal cancer. The man is still able to talk and interact with other people. But he doesn’t know what year it is and is unable to make decisions on his own.
The real kicker: He has no surviving family and no designated surrogate.
What does his medical team do? Should they perform a laryngectomy, when one of the man’s greatest pleasures seems to be talking to people? Should they treat him with intensive chemoradiotherapy, despite side effects that probably include increasing his dementia? Or do they give him palliative care only?
This circumstance recently occurred at Indiana University—and it’s the kind of situation for which medical residency programs should prepare future doctors, said Paul Helft, MD, associate professor of medicine at the Indiana University School of Medicine in Indianapolis and director of the Charles Warren Fairbanks Center for Medical Ethics at Indiana University Health.
“Can a medical student or a resident recognize when an issue has ethical dimensions or not?” Dr. Helft said. “Can we provide, in a learning environment, a set of tools for a person to begin to approach a complex ethical problem…. How do you begin to think about a man who can’t make his own decisions who has a terrible decision to make and nobody to help him?”
“There isn’t, at present, a standard approach to ethics training…in any specialty, whether otolaryngology or the others.”
—Mark Weissler, MD, FACS
Inconsistency
The extent to which ethics is taught in surgical residency programs, including otolaryngology programs, varies widely from institution to institution, with many programs including little or no ethics training. Faculty at ethics centers say residency is an especially crucial period for the teaching of ethics, because it is during this time that principles can be applied more easily to real-life situations. But the training is lacking in many places, they say, even as restricted residency work hours make it more difficult than ever for programs to carve out time for such training.
This December, a meeting will take place at Washington University in St. Louis, Mo., where recipients of grants for ethics training, grants administered by the university and partially sponsored by the American College of Surgeons, will discuss the results of the programs that were created.
Ira Kodner, MD, a colon and rectal surgeon who helps run the ethics training at Washington University, is hoping the results from those grants will be a springboard to further training in other residency programs. He said the goal is to arm surgeons with the tools they need.
“Our quest is really to teach the body of knowledge which previously was only dealt with by PhD philosophers who have never had the experience of dealing with patients,” Dr. Kodner said. “But it isn’t a seat-of-the-pants thing. That’s a misunderstanding. There really is a body of knowledge that needs to be learned. The goal is just to be able to recognize there’s a challenge. We see it all the time in surgery.”
Mark Weissler, MD, FACS, professor of otolaryngology-head and neck surgery at the University of North Carolina, chief of the division of head and neck oncology and a member of the ethics committee of the American College of Surgeons’ (ACS) Board of Regents, said that other than requiring the teaching of professionalism as an Accreditation Council for Graduate Medical Education core competency, which may or may not include ethics training, there is no requirement for the teaching of ethics.
“There isn’t, at present, a standardized approach to ethics training… in any specialty, whether otolaryngology or the others,” he said. Everyone would agree that ethics training is important, he said, but added that “it’s harder and harder to teach people in their four to five years of residency what they need to know technically for surgery, given the shrinking duty hours. So there’s a tension there between increasing the amount that you’re going to teach people at the time that you’re decreasing the amount of time that you have to teach them…. There’s so much else that people are worrying about right now.”
In his department, ethics is taught using a program developed by the ACS and based mainly on a set of ethical dilemmas. That program is available to any department wanting to use it, but no program is required to use it.
There have not been many studies on ethics training in surgical residency programs. A review (J Surg Educ. 66:35-42) by Dr. Helft and his team, published in 2009, found just 14 studies that were on point, covering topics such as the framework for and influence of such training, as well as a 1997 survey of the 80 general surgery residency programs.
The survey (Am J Surg. 1997;174:364-369) found that despite the fact that 85 percent of the program directors who responded supported the inclusion of ethics training in residency, 28 percent nonetheless offered no training and 48 percent held just one teaching event in ethics. While there may have been some expansion since that survey, ethics professors say the training of ethics is still scattershot.
“If you ask program directors in the abstract whether they think it’s important, they would say yes,” Dr. Helft said. “But you spend your time doing what you think is important, and there are increasing pressures that have been created by work-hour restrictions. This is a great example of the law of unintended consequences. When you begin to squeeze surgical residents and their work hours, like all residents, you force people to make choices about what they’re going to prioritize.”
New Approaches
Still, there are innovative ways that ethics is taught in some medical residency programs, from special seminars on ethical communications tools at Indiana University to “pizza grand rounds” on ethics at Washington University to leadership training and mentoring at Duke to simulated ethical dilemmas at Johns Hopkins.
Washington University’s grant program, to be showcased in December, is paid for in part by a man who’d been told by a doctor that his rectal cancer would kill him and that he should go home and write his will. Later, under the care of other doctors, he recovered. He was so astounded by the first doctor’s actions that he funded lectureships and grants on medical ethics.
In Washington University’s general surgery residency program, residents take real-life cases and mull them over during monthly “pizza grand rounds,” which involve free-wheeling discussions on some gut-wrenching situations. The medical school has an elective for fourth-year medical students in which they can take one of these dilemmas and write a manuscript in the journal Surgery, which has an arrangement with the school to provide such a forum.
“These are very interesting sessions,” Dr. Kodner said.
An online training program for residents is also being developed, Dr. Kodner said.
One otolaryngology residency program that deeply incorporates ethics training is at Duke University. There, ethics is a key part of training “tomorrow’s leaders,” said Walter Lee, MD, assistant professor in Duke’s division of otolaryngology-head and neck surgery (OHNS). The program began incorporating new ethics training recently as part of a vision developed over the last year and half, he said.
“It’s not so much what you do,” Dr. Lee said. “It’s more important who you are, because if you’re the right person, then you will make the right decision for the right reason, and you will do the right thing. Teaching them how to do the right thing, if you haven’t addressed the core person, isn’t adequate. That’s going to be lacking.”
So the program has a six-session course that aims to help cultivate the kind of leader the program’s professors hope comes out of Duke’s residency. The sessions focus on integrity, initiative, self-discipline, responsibility and accountability, and there’s an introductory session.
At Duke, producing the right kind of doctor out of residency starts with the admission process, said Liana Puscas, MD, Duke’s OHNS residency program director.
“What we’re looking for are applicants and faculty who already have these qualities, and we’re looking to develop them,” she said. “Our program is really switching over to a behavioral-based interview for our residency applicants because it’s based on the principle that the best predictor of future behavior is past behavior.”
But once in the program, residents are in a give and take with attending physicians and others about the ethical implications of situations that come up in the clinic, Dr. Lee said. Those “in the hallway” conversations are extremely important, he said.
“The resident says, ‘Why did you do this versus that, what were issues you were thinking about?’” he said. “Those kind of discussions are actually the most effective in teaching ethics.”
Missed Moments
But there is no “formal plan” for incorporating those discussions into the ethics training, they said.
One study, led by Joseph Carrese, MD, at Johns Hopkins University’s Berman Institute of Bioethics, found that opportunities for teaching “everyday ethics” were often missed. Situations included a resident performing a minor procedure without much previous experience, for example, or a patient needing to be screened for depression but not wanting to be (Med Educ. 2011;45(7):712-721).
In the study, investigators observed interactions at two clinics between residents and their preceptors, finding that ethical situations arose in 109 out of 135 cases over a two-week period. The preceptor explicitly pointed out the ethical content and taught about it in just 13 of those cases (12 percent). The investigators determined that although the content was implicitly identified in 44 cases (40 percent), the message may have been lost or misinterpreted in those cases.
“One of the best places to teach ethics is in real time with real patients as faculty preceptors and residents are standing shoulder to shoulder working with patients,” Dr. Carrese said. “There were clearly times when faculty did not explicitly identify an issue or teach about it when they were capable of doing it.” He said that in some cases the ethical issues may have been pointed out and discussed prior to the study period, but that he didn’t think that accounted for all of the missed opportunities.
Ethics professors say it’s this kind of explicit training that is needed to truly teach ethics. They say that more is required than just the so-called “hidden curriculum,” the absorption of ethical sensibilities and values through observation of faculty in the clinic.
“I think there is clearly a need and a role for something more explicit, and there’s literature out there that supports that,” Dr. Lee said.
Dr. Carrese said that the age-old question of whether a resident can be made to be “more ethical,” or whether you’re either ethical or not when you leave home, is a little off base. It’s the knowledge and skills that really matter, he said. And those can be taught.
“Let’s take the issue of empathy,” he said. “It’s very hard for me to say whether literally I can make somebody more empathic in the sense of, are they in their soul emphatic, do they really care about their patients. But whether or not that’s true, I’m pretty sure I can teach them to have the skill set of being more empathic. So I can teach them to be more aware of patients who are in need of empathy, to have a proper attitude about it, to be more knowledgeable and ultimately to be more skilled in saying things that are empathic.”