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• Explore the ethical challenges of surgical training
• Understand the obligations of the supervisor during resident education
• Identify the ethical and legal implications of inadequate resident supervision
• Discuss the person of ultimate responsibility (PUR) and the legal implications associated with the relationship
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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
Samuel Crosby, MD attending is running two operating rooms.
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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 make your femoral neck cut. You are unsure of
Wavebreak Media/Thinkstock Photos 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.
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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
Sam Crosby, MD raise his blood pressure.
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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
Wavebreak Media/Thinkstock Photos without complication.
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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. iStock/Thinkstock Photos
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In looking back through the OR record, you discover that in the
30-minute period where you were waiting on your attending without
Wavebreak Media/Thinkstock Photos progressing in the case, the patient’s mean arterial pressure was below 60 mmHg, which was the lowest recorded value during the case.
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• 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
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• 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
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• 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%).
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• Senior residents supervising junior residents on call may be sued and found liable even if they do not have direct contact with the patient.
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• Supervsing physicians that are not present during the patient care may 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 can be liable for resident errors as well.
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• 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)
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You are a PGY-5 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
Jochen Sand/Digital Vision/Thinkstock Photos started and that she will be there in a minute.
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You begin the case and start to release the transverse carpal ligament. Shortly into
Donald H. Lee, MD 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.
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What is your obligation of disclosure to the patient 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?
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You are the PGY-5 chief resident on the foot and ankle service. You assign yourself to work with a specific surgeon on
David Thordarson, MD a given day because you are particularly interested in doing a calcaneus ORIF that is on the schedule.
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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,
Wavebreak Media/Thinkstock Photos
“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.
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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
Wavebreak Media/Thinkstock resident involved in my case.”
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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 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
Photodisc/Thinkstock Photos 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.
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• 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?
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 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.
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• 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.
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• If a resident is to perform the operation and provide care under the supervision of the surgeon, the patient should be informed of this.
• The surgeon should be an active participant throughout the key components of the operation.
• It’s unethical to mislead the patient as to the identity of the surgeon who performs the operation.
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• 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.
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• Medical organization ethical guidelines and legal implications should also be considered.
• Innovation in resident education may offload some of the ethical burden.
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