How to assess the need for and implement a case-based ethics curriculum
Mary E. Klingensmith, MD, FACS
Washington University in Saint Louis
Background
Residents are not mentored in surgical ethics today as they were in days past. Increasingly, the 80-hour workweek, combined with the shift in care from the hospital to the outpatient setting, has left a void for residents to be mentored by faculty. In the past, residents had greater oppor-tunity to become familiar with patients and their families in ways that do not exist today as hospitalizations are briefer. With essentially unlimited work hours, residents were able to be present for more aspects of a patient's care, and thus were more likely to be present when the attending physician had end-of-life or other weighty discussions with patients and their families. Given these shifts and sensing this void, we developed a case-based ethics curriculum in the surgical residency training program at Washington University in Saint Louis. This article will describe our efforts, attempt to convince you to start a similar curriculum in your own program, and provide tips for doing so.
Defining the need
The case-based approach to our surgical ethics curriculum fell together after a series of conversations with residents defined the need. A chief resident expressed doubt to me regarding his ability to navigate an end-of-life discussion with a patient's family, saying he'd never been part of such a conversation, nor had he thought much about how to even approach the subject with a family. A senior resident on the trauma service recounted the details of a case which had clearly made an impression: A Jehovah's witness trauma victim died of anemia while the family mem-bers squabbled over whether the patient truly held the tenets of that faith with regard to blood transfusion. The residents needed to get together to talk about these cases and they needed practical advice for how to proceed in similar instances in the future. I was fortunate that this need was also perceived by Ira Kodner, MD, FACS, a colon and rectal surgeon at my hospital with many years of clinical experience and a keen interest in surgical ethics. Dr. Kodner proved to be the perfect resource: He was completing training in ethics at the University of Chicago and was delighted to share an audience with the residents on a monthly basis to discuss cases the residents would bring for discussion.
This need and my ability to meet it occurred just as the ACGME's competency initiative was being rolled out. As a program director, I was not enthusiastic when I initially learned of the competency initiative. It looked like "busy work." But on further reflection, I've come to more fully appreciate the need to carefully define and address the six competency areas and the overall concept. My timing of the beginning of the ethics sessions was perfect: I could cover two of the six competencies - "professionalism" and "systems-based practice" - with this single new initiative.
Nuts and bolts (and pizza)
Our one-hour sessions are held on a monthly basis. Throughout the month, residents and stu-dents are encouraged to collect cases that they encounter in their every day work. An outline of the case, with emphasis on the ethical dilemma, is presented to a surgeon-ethicist and a non-MD ethicist who moderate the discussion. We also invite trainees and faculty from other specialties (surgical and nonsurgical), as well as others in the community who might be interested, to parti-cipate in the discussion. To date, this has included chaplains, nurses, patient advocates, and even business school professors with an interest in health economics and policy. To add to the appeal (especially for students and residents), we also provide pizza and soda. The moderators review the case in the context of existing medical ethics literature and lead thought-provoking discus-sions. The moderators encourage audience participation; interestingly, a greater number of students and residents seem more comfortable contributing to these discussions, where mastery of surgical knowledge has no direct bearing on the discussion, than to our typical case-based clinical discussions. Occasionally, residents and students do not have sufficient cases to carry us through the hour, so we discuss topics from news headlines that might have a bearing on our lives as clinicians (see examples below). If we touch upon a topic where we feel we need more information, we'll arrange to have guests knowledgeable in that area participate in the following session; these guests have ranged from Jehovah's witness faith educators, who helped us to understand their concerns with blood transfusions, to organ procurement coordinators, who spoke about cultural issues surrounding tissue donation.
Examples of past topics
| Truth telling to patients-Referred to tertiary center after surgical misadventure |
Jehovah"s witnesses and blood products -Life-threatening anemia |
| Cultural/religious attitudes toward organ donation-How to approach various families |
Truth telling/profit in medicine-The selling of placentas |
| When is care futile?-Demented nursing home patient with ruptured AAA |
Informed consent/autonomy-Intubation for end-stage COPD |
| Advanced directives-The Terry Schiavo case |
How do we as surgeons police ourselves?-Questionable surgical practices |
| Informed consent-Use of marginal organs for transplantation |
Refusal of care-Young female refused C-section to save unborn child |
How to do this at home
We are fortunate at my institution to have a surgeon-ethicist as a resource, as well as the university-sponsored "Center for the Study of Ethics and Human Values," which has been a tremendous resource. Yet, you need not have such an established network of support as this to be successful. First, you can look to your hospital's ethics consult service or ethics committee for individuals who may wish to participate. Pastoral care is another potential resource. We have also relied heavily on the other professional schools related to our discipline (law, business, and nursing) to help us identify individuals who may have expertise in a certain area under discussion. It has proven valuable to have residents from other specialties, as well as other professional students, participate in some of our discussions, thus increasing the variety of view-points to consider. Finally, simply providing the residents and students with a forum in which to discuss these cases has proven to be very rewarding. Keeping the sessions focused on cases that the residents bring forward for discussion keeps it relevant and timely to their needs. This seems to have been one of the keys to our success.
Finally, it has been important for the residents to see that some dilemmas remain unsolved even after a thoughtful and thorough discussion. Much of surgery can be distilled into "right and wrong" or "yes and no;" it helps the residents to see the gray areas that these dilemmas illustrate, which serves as a good preparation for their professional lives ahead where moral instincts should provide direction.
Summary
Our case-based approach to an ethics curriculum has provided our residents and students with fundamental knowledge of ethical principles and has given them practical advice to apply to situations they may encounter in the future. We are also able to use this offering to address two of the six ACGME competency areas. By including individuals from a number of backgrounds, we have been able to address a wide variety of ethical dilemmas, while keeping discussions relevant and current to resident concerns.
Resources
- The American College of Surgeons is developing a case-based ethics curriculum which will be available to residency programs in the near future.
- Bosk, C L: Forgive and Remember: Managing Medical Failure. U Chicago Press, 1981.
- McCullough, L B, Jones, J W, and Brody, B A: Surgical Ethics. Oxford University Press, 1998.
