Available resources abound for teaching ethics to residents
Eric Grossman, MD
Resident, Department of Surgery
The University of Chicago
Peter Angelos, MD, PhD, FACS
Professor of Surgery and Chief of Endocrine Surgery
Associate Director of the MacLean Center for Clinical Medical Ethics
University of Chicago Medical Center
The training of surgical residents has evolved immensely over the last decade. Today’s surgeon must master both open and laparoscopic skills, navigate an increasingly complex world of health care finance, and ultimately, learn to anticipate and handle the ethical issues encountered in practice.
In response to these evolving factors, residency programs have incorporated laparoscopic skills training into the curriculum, and residents are exposed to billing and reimbursement matters early in residency. In this ever-changing environment, ethics education has evolved into a crucial part of residency training.
Although formal ethics education is a recent addition to surgical residency, surgical residents have been taught ethics informally for years, largely by watching the faculty deal with ethical issues that arose during the care of patients. The contemporary challenge is to formally teach ethics within the time constraints of a modern surgical residency. Unfortunately, few authors have explored how best to teach ethics to surgical residents. For instance, in 1997, Downing1 detailed a scarcity of ethics education amongst surgical residents. However, in the years since, great strides have been made in teaching ethics in surgery. At the present time, 99 percent of surgical residencies include some mode of ethics education, and the majority of residency programs utilize multiple resources to augment ethics education2. In this brief review, we outline some of the resources available for enhancing ethics education in surgical residency (Summarized in Table).
Established Curricula
Incorporating ethics education into residency curriculum has been accomplished by a variety of techniques. Klingensmith has reported that a case-based approach to teaching ethics to surgical trainees is feasible, relevant, and important to the education of trainees in the current environment6. Many programs have utilized lecture-based curricula, while others have employed simulation centers with standardized professional patients2.
The American College of Surgeons (ACS) Committee on Ethics has published Ethical Issues in Clinical Surgery3, a cased-based curriculum highlighting clinically relevant and challenging situations frequently encountered by residents. Topics included in this publication range from end-of-life decisions to truth telling and confidentiality. The book is very well organized, with detailed learning objectives preceding each chapter, as well as additional readings referenced in the chapter’s conclusion. The cases presented are illustrative and the questions included in each chapter are designed to elicit resident participation. This book has already been well received, and is being utilized by residency programs across the country4. Complimenting this book, is the ACS DVD, “Professionalism in Surgery: Challenges and Choices,” which depicts 24 challenging situations faced by practicing surgeons. The vignettes portray realistic dilemmas that surgeons face in everyday practice, present possible courses of action, and highlight the principles of professionalism underlying various actions5.
In addition to the aforementioned methods, it is helpful to incorporate discussion of ethical issues into the daily life of a residency program. In an effort to have greater integration of ethics into the mainstream of the curriculum, the University of Chicago has recently devoted half of the Morbidity and Mortality (M & M) conference once a month to a discussion of an ethical issue. Although utilizing actual cases, such as from M & M, is the ideal, another option in finding cases for an ethics discussion is utilizing the cases and discussion found in The Ethics of Surgical Practice: Cases, Dilemmas, and Resolutions by Jones, McCullough, and Richman7. Although these cases may lack the detail of real cases from an M & M conference, for example, the organized format and analysis will greatly aid in the discussion.
Of the established curricula, the ones presented in this article are just a few of the specific resources available to enhance the formal presentation of ethics teaching.
Monetary Awards
Another option for incorporating formal ethics training is the use of funds specifically geared towards teaching ethics in residency. One such initiative, the Kamangar Ethics Award, stems from the generosity of Mr. Parviz Kamangar, who has been funding ethics training at the Northwest Society of Colon and Rectal Surgeons for over a decade. The recently created award provides support and materials to surgical training programs instituting ethics curricula. As of November, 2008, 16 programs were recipients of this award, and are utilizing the funds in a variety of ways, ranging from creating monthly surgical ethics conferences to evaluating how ethics education effects patient outcomes. These funds have already helped build a foundation for establishing formal ethics curricula in surgical residency, and hopefully this generosity will continue to support such endeavors.
Ethics Fellowships
Although not widely available, fellowships dedicated to medical and surgical ethics are becoming more accessible and prevalent. In addition to basic science research, residents should be encouraged to explore these dedicated fellowships during their research years. There are multiple medical ethics fellowships across the country; however, presently only the University of Chicago and Washington University, St. Louis, MO, offer programs specific to surgical ethics. These intensive fellowships are unique opportunities that not only benefit the participating resident, but also encourage the establishment of future ethics educational modalities and promote research in the field of surgical ethics. Currently, 25 surgeons have completed the ethics fellowship at the University of Chicago, leading to publications ranging from conflict of interest with industry8, to innovative solutions to organ transplantation shortages9.
| Resource | Title | Comments | ||||||
| Books |
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| DVD | Professionalism in Surgery: Challenges and Choices |
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| Award | Kamangar Ethics Award |
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| Fellowships | MacLean Center for Clinical Medical Ethics, University of Chicago Center for Ethics and Human Values, Washington University |
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In conclusion, surgeons and surgical educators have responded to the importance of ethics and are seeking novel methods to combine ethics education with residency training. Resources are abundant, and range from simply encouraging residents to utilize the ethics consultant service, to allowing residents to pursue a full-time surgical ethics fellowship. As the nature of health care evolves, we, as surgical educators, must continue to be at the forefront in training competent and compassionate surgeons who are able to handle both the complex medical and ethical aspects of patient care.
- Downing MT, Way DP, Caniano DA. Results of a national survey on ethics education in general surgery residency programs. Am J Surg. 1997; 174, 364-8.
- Grossman E, Posner MC, Angelos P. Ethics education in surgical residency: Past present, and future. 2010; Surgery. 147, 114-19
- McGrath MH. Ethical Issues in Clinical Surgery. American College of Surgeons 2007.
- Schneidman DS. ACS-developed curriculum is becoming a centerpiece of training in ethics. Bull Am Coll Surg. 2009; 94, 11-17.
- Professionalism in Surgery: Challenges and Choices, 2nd Edition. American College of Surgeons, 2008.
- Klingensmith ME. Teaching ethics in surgical training programs using a case-based format. J Surg Educ. 2008; 65, 126-28.
- Jones JW, McCullough LB, Richman BW. The Ethics of Surgical Practice: Cases, dilemmas, and resolutions. Oxford University Press, 2008.
- Schwarze ML. Conflict of interest with Industry and the challenges for surgical education. J Am Coll Surg. 2009; 766-68.
- Testa G, Angelos P, Crowley-Matoka M, Siegler M. Elective surgical patients as living organ donors: A clinical and ethical innovation. Am J Transplant. 2009; 9, 2400-05.
Online May 7, 2010