Ethics of training surgeons

Le résumé fourni par la source

In the UK there are over 6000 trainee surgeons participating in hundreds of thousands of operations annually1. How do they learn without compromising the duty of care to patients? Surgical training is complex, with stakeholders including the public, patients, surgeons, trainees, healthcare institutions, and professional bodies. Ethical challenges arise when the interests, rights, and duties of these groups conflict. Due to a lack of understanding of these issues, only a minimum ethical standard is currently being met2,3. In this Short Report, these challenges are explored and the question of how to train surgeons in an ethical way is addressed. A narrative review of the literature was conducted and details regarding the literature search are available in the Supplementary material. Four key challenges were identified: balancing duty to current and future patients; requiring informed consent for team-based care; managing conflicting roles; and balancing clinician well-being and service provision. Surgeons have a duty to provide care to all patients they treat over their career, including future patients3–6. The profession has an obligation to provide long-term, high-quality care to the public4,7,8. Surgeons fulfil these obligations by developing expertise through experience4,8–10 and passing on their skills to the next generation. Surgeons also have a duty to provide the best care possible to the patient in front of them3,5,6,10. This may conflict with their duty to build expertise, particularly when more experienced surgeons are available. Yet, patients benefit from experience built during previous operations3,4,11. Surgical skill is a resource that the public can only access in the long term by contributing to its development4,11. This social contract, grounded in distributive justice, suggests that, similarly to the way the benefits of skills are shared, the responsibility for skill development should be shared4,7,11. The above arguments do not justify putting patients at risk. Precautions must be taken to mitigate risk4,7,12. These include simulation training, supervision, adequate preparation, and graduated autonomy9,10,12. Competent care can be provided in teaching hospitals, where outcomes are equal or superior to hospitals where no surgical training is provided13. It is not ethical to treat patients as a means to an educational end6,7 by performing unnecessary procedures so trainees can practise. Intent is key, it ‘is’ ethical to learn from experience where the intent is to provide necessary care6,7,12,14. Surgical care is delivered collectively by a team7,12,13. Post-graduate trainees are not simply there to learn, as they are crucial to service provision. To give informed consent for care within a team-based structure, patients must have5 transparent information on the role of team members4,7,15, including the scope of proposed trainee involvement15. Information could be provided by institutions at the time of admission and apply to all care within the teaching hospital. Clinicians should also be prepared to answer questions about an individual’s care honestly4,15. This may be uncomfortable, as some fear that patients would refuse trainee involvement. However, this concern cannot ethically justify non-disclosure4,7,15. Trainees have been involved in surgical care for millennia. Many patients ‘are’ aware of this, and even value it7,15. Transparent and honest informed consent may engender trust between teams, patients, and the public7,15. In rare instances where a patient is adamant that their care be provided solely by a senior surgeon, a case-by-case judgement must be made based on the clinical urgency and availability of alternative options. Supervisors are both surgeons and teachers. Supervisors should promote learning opportunities for trainees as far as possible while making a judgement of trainee skill to ensure safe graduated expertise development4,9,16. Supervision may require being present (when trainees are inexperienced) or being contactable, when required (for more senior trainees)9. Surgeons have a duty to teach to maintain long-term care for the public7,9,14. The roles of surgeon and teacher can conflict. Teaching requires additional time and effort13 and is sometimes deprioritized in a time-pressured environment8. Though learning opportunities should not override patient safety, teaching should be a core responsibility, prioritized even at the expense of some service efficiency3,4,8. Trainees are both doctors and learners. Trainees have a duty to capitalize on learning opportunities17. This requires preparation and follow-up to develop clinical judgement in addition to cognitive and technical skills8,14. As doctors, trainees have a duty to put patient safety first. Trainees may push to use new skills, particularly where operating opportunities are rare. It is crucial they do not prioritize learning at the expense of patient safety4,16. Trainees must be aware of their own limitations and be candid about their level of experience, allowing supervisors to provide appropriate oversight12,14,18. Professional bodies (such as regulators and surgical colleges) have educational and regulatory duties5,18,19. They set competency standards and curricula to support safe progress through training. Workplace-based assessments are a mechanism to support trainees to achieve learning goals and ensure they meet competency standards17. Trainees should not perform procedures on patients until they have prepared to the best of their ability outside the operating theatre10,16. At present, in-theatre experience is the mainstay of surgical skill development. Technological advances in simulation and mixed reality offer additional resources10,20 and are likely to become increasingly important; adopting such technologies will require investment from institutions. Doctors may reasonably be asked to make sacrifices in the interest of providing care and forwarding their education. But these sacrifices should be proportionate and aligned with ‘their own’ well-being5,19. This respects clinicians and is also necessary for sustaining long-term care, as retention of staff and quality of care diminish when staff well-being is reduced19. Staffing within healthcare institutions should be sufficient to allow for service delivery and educational activities without exposing staff to unsustainable pressures19. The interdependent nature of stakeholder groups and their interests is represented in Fig. 1. The duties and responsibilities required of each group to promote ethical surgical training are presented in Table 1. These are proposed as a framework for promoting ethical training. Training stakeholders and their interconnected nature Framework for ethical surgical training Maintain awareness of their limitations Communicate transparently with supervisors regarding their experience Perform new skills only with adequate supervision Prioritize patient safety over learning opportunities where unavoidable conflicts arise Ensure patients are informed of trainee involvement with care and be prepared to answer questions as required Maximize learning through adequate preparation, follow-up, and acceptance of reasonable sacrifices of their own interest Treat supervisors and other staff with respect Provide supervision adequate to protect patients and trainees Exercise judgement of trainee skills and support graduate autonomy Teach and promote trainee involvement as far as it can be done so safely Maintain their own skills and development through ongoing learning Ensure patients are informed of trainee involvement with care and be prepared to answer questions as required Treat other staff with respect Expect high-quality individualized care for themselves and future patients Recognize the importance of surgical training to long-term care for the public Recognize the moral (not legal) duty to accept trainee involvement in care as part of competent team-based care Provide adequa

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.