Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons?

BACKGROUND: The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD. MATERIALS AND METHODS: A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency. RESULTS: In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons. CONCLUSIONS: Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.

Junior doctors and moral exploitation.

In this paper I argue that junior doctors are morally exploited. Moral exploitation occurs where an individual's vulnerability is used to compel them to take on additional moral burdens. These might include additional moral responsibility, making weighty moral decisions and shouldering the consequent emotions. Key to the concept of exploitation is vulnerability and here I build on Rosalind McDougall's work on the key roles of junior doctors to show how these leave them open to moral exploitation by restricting their reasonable options. I argue that there are a number of ways junior doctors are morally exploited. First, their seniors can leverage their position to force a junior to take on some discreet decision. More common is the second type of moral exploitation where rota gaps and staffing issues means junior doctors take on more than their fair share of the moral burdens of practice. Third, I discuss structural moral exploitation where the system offloads moral burdens onto healthcare professionals. Not every instance of exploitation is wrongful and so I conclude by exploring the ways that moral exploitation wrongs junior doctors.

[Assessment of moral competence of physicians]. / Índice C en médicos de dos centros hospitalarios chilenos según el test de competencia moral de Lind.

BACKGROUND: Moral competence (MC) in physicians is fundamental, given the increasing complexity of medicine. The "Moral Competence Test" (MCT © Lind) evaluates this feature and its indicator is the C Index (CI). AIM: To explore moral competence and its associated factors among physicians working in Chile. MATERIAL AND METHODS: The MCT was answered by 236 physicians from two medical centers who voluntarily participated in the study. Besides the test, participants completed an encrypted form giving information about gender, years in practice and post-graduate studies. RESULTS: The average CI value of the participants was 20,9. Post-graduate studies had a significant positive influence on CI. There was a significant decrease in CI, between 16 and 20 years of professional exercise. Gender and the area of post-graduate studies did not have a significant influence. CONCLUSIONS: The studied physicians showed a wide range of CI which was positively affected by the postgraduate studies performed. The years of professional practice had a negative influence. Expanding training opportunities during professional practice could have a positive effect on CM as measured by CI.

Should junior doctors strike?

An impasse in negotiations between the Department of Health (DoH) and the British Medical Association in November this year led to an overwhelming vote for industrial action (IA) by junior doctors. At the time of writing, a last minute concession by DoH led to a deferment of IA to allow further negotiations mediated by the Advisory, Conciliation and Arbitration Service. However, IA by junior doctors remains a possibility if these negotiations stall again. Would the proposed action be ethically justifiable? Furthermore, is IA by doctors ever ethically defendable? Building on previous work, we explore important ethical considerations for doctors considering IA. The primary moral objection to doctors striking is often claimed to be risk of harm to patients. Other common arguments against IA by doctors include breaching their vocational responsibilities and possible damage to their relationship with patients and the public in general. These positions are in turn countered by claims of a greater long-term good and the legal and moral rights of employees to strike. Absolute restrictions appear to be hard to justify in the modern context, as does an unrestricted right to IA. We review these arguments, find that some common moral objections to doctors striking may be less relevant to the current situation, that a stronger contemporary objection to IA might be from a position of social justice and suggest criteria for ethically permissible doctor IA.

Pragmatic message to junior doctors.

Although several studies described the experience of doctors in their first postgraduate years, few shed the light on the ethical issues encountered by them. These doctors face a broad range of 'everyday' ethical challenges, from breach of confidentiality to truth-telling or improper informed consent. The daily ethical issues faced by junior doctors are not as dramatic as the major issues learned at medical school. Junior doctors have to make the best ethical decisions within the time limits available. Undergraduate medical ethics curricula should give priority to the real-life issues that doctors will face in their first years of practice.

Dangerous liaisons: doctors-in-training and the pharmaceutical industry.

Interaction between doctors and the pharmaceutical industry is long-standing and ingrained in modern practice. Doctors-in-training are at a vulnerable stage of their careers, both in requiring knowledge and forming lasting relationships. There is evidence that limiting contact between industry and junior doctors has a positive effect on subsequent clinical behaviour. Currently in Australia, there is no limitation on pharmaceutical representatives approaching doctors-in-training, and the majority of education sessions are sponsored by pharmaceutical companies. This purposefully creates a sense of reciprocity, which may have adverse long-term consequences on attitudes, behaviours and patient care. Several guidelines exist that may assist junior doctors in navigating these potential interactions, most notably the Royal Australasian College of Physicians' own Guidelines for Ethical Relationships between Physicians and Industry. Despite this, there is no reflection of its importance or necessity within subspecialty curricula. This should be rectified, to the benefit of both the profession and public.

A comparison of the willingness of resident and attending physicians to comply with the requests of patients at the end of life.

BACKGROUND: Little is known about the differences between physicians in training and post training in their willingness to comply with patient requests at the end of life. OBJECTIVE: To compare the attitudes of attendings and residents regarding a range of patient requests at the end of life DESIGN: Written, cross-sectional survey PARTICIPANTS: The cohort included 191 attendings randomly selected across the state of Connecticut and 240 residents from 2 university-affiliated Internal Medicine programs. MAIN MEASURES: We surveyed attendings and residents about their willingness to honor the requests of the same decisionally capable elderly patient in five scenarios involving different requests regarding end-of-life treatment. RESULTS: While a large majority of both attendings and residents were willing to comply with each of the requests to withhold intubation (100 % and 94 %, respectively), to extubate (92 % and 77 %), and to give increasingly higher doses of narcotics (94 % and 71 %), a significantly larger proportion of attendings versus residents was willing to comply with each of these requests. Small proportions of attendings and residents were willing to prescribe a lethal amount of sleeping pills (3 % and 5 %, respectively) and to give a lethal injection in its current illegal state (1 % and 4 %). A significantly larger proportion of residents (32 %) compared to attendings (19 %) was willing to give a lethal injection if legal. Adjusting for sociodemographic factors, attending status was independently associated with willingness to extubate [adjusted odds ratio (AOR) = 3.0, 95 % CI = 1.6-5.7] and to give a lethal injection if legal (AOR = 0.5, 95 % CI = 0.3-0.8). The proportion of physicians willing to extubate increased across years since graduation, with the greatest differences occurring across the residency years (69 % to 86 %). CONCLUSIONS AND RELEVANCE: Clinical experience was an important determinant of physicians' willingness to perform multiple patient requests at the end of life, with substantial changes in attitudes occurring during residency training. More research is needed to determine whether dedicated clinical exposure for physicians in training influences attitudes.

Ethical and educational considerations in coding hand surgeries.

PURPOSE: To assess treatment coding knowledge and practices among residents, fellows, and attending hand surgeons. METHODS: Through the use of 6 hypothetical cases, we developed a coding survey to assess coding knowledge and practices. We e-mailed this survey to residents, fellows, and attending hand surgeons. In additionally, we asked 2 professional coders to code these cases. RESULTS: A total of 71 participants completed the survey out of 134 people to whom the survey was sent (response rate = 53%). We observed marked disparity in codes chosen among surgeons and among professional coders. CONCLUSIONS: Results of this study indicate that coding knowledge, not just its ethical application, had a major role in coding procedures accurately. Surgical coding is an essential part of a hand surgeon's practice and is not well learned during residency or fellowship. Whereas ethical issues such as deliberate unbundling and upcoding may have a role in inaccurate coding, lack of knowledge among surgeons and coders has a major role as well. CLINICAL RELEVANCE: Coding has a critical role in every hand surgery practice. Inconstancies among those polled in this study reveal that an increase in education on coding during training and improvement in the clarity and consistency of the Current Procedural Terminology coding rules themselves are needed.

Duty hours as viewed through a professionalism lens.

Understanding medical professionalism and its evaluation is essential to ensuring that physicians graduate with the requisite knowledge and skills in this domain. It is important to consider the context in which behaviours occur, along with tensions between competing values and the individual's approach to resolving such conflicts. However, too much emphasis on behaviours can be misleading, as they may not reflect underlying attitudes or professionalism in general. The same behaviour can be viewed and evaluated quite differently, depending on the situation. These concepts are explored and illustrated in this paper in the context of duty hour regulations. The regulation of duty hours creates many conflicts that must be resolved, and yet their resolution is often hidden, especially when compliance with or violation of regulations carries significant consequences. This article challenges attending physicians and the medical education community to reflect on what we value in our trainees and the attributions we make regarding their behaviours. To fully support our trainees' development as professionals, we must create opportunities to teach them the valuable skills they will need to achieve balance in their lives. [P]rofessionalism has no meaningful existence independent of the interactions that give it form and meaning. There is great folly in thinking otherwise. Hafferty and Levinson (2008)[1] Understanding and evaluating professionalism is essential to excellence in medical education and is mandated by organizations that oversee medical training [2]. Historically, attention has been focused largely on the professionalism of individual students or residents, at least for the purposes of evaluation. Yet there is now a growing appreciation that professionalism can be defined, understood, and evaluated from multiple perspectives [3]. Importantly, context has been recognized as critical to shaping trainees' behaviours, and hence as important to our understanding of them [4]. A restriction in duty hours for trainees is clearly an important environmental and contextual factor to consider in evaluating professional behaviour. In this paper I will review some key issues with respect to understanding and evaluating professionalism, and then discuss these in the context of duty hour reform. Readers should note that this is not intended to be a comprehensive review of the literature of either professionalism or duty hour reform, but rather a critical narrative review that uses selected articles.

End-of-life decision making in Taiwan: healthcare practice is rooted in local culture and laws that should be adjusted to patients' best interests.

The observed Taiwanese neonatal professionals' more conservative attitudes than their worldwide colleagues towards end-of-life (EOL) decision making may stem from cultural attitudes toward death in children and concerns about medicolegal liability. Healthcare practice is rooted in local culture and laws; however that should be adjusted to patients' best interests. Improving Taiwanese neonatal professionals' knowledge and competence in EOL care may minimize ethical dilemmas, allow appropriate EOL care decision making, avoid infants' suffering, and ease parents' bereavement grief.

The attitudes of neonatal professionals towards end-of-life decision-making for dying infants in Taiwan.

The purposes of research were to describe the neonatal clinicians' personal views and attitudes on neonatal ethical decision-making, to identify factors that might affect these attitudes and to compare the attitudes between neonatal physicians and neonatal nurses in Taiwan. Research was a cross-sectional design and a questionnaire was used to reach different research purposes. A convenient sample was used to recruit 24 physicians and 80 neonatal nurses from four neonatal intensive care units in Taiwan. Most participants agreed with suggesting a do not resuscitate (DNR) order to parents for dying neonates (86.5%). However, the majority agreed with talking to patients about DNR orders is difficult (76.9%). Most participants agree that review by the clinical ethics committee is needed before the recommendation of 'DNR' to parents (94.23%) and nurses were significantly more likely than physicians to agree to this (p=0.043). During the end-of-life care, most clinicians accepted to continue current treatment without adding others (70%) and withholding of emergency treatments (75%); however, active euthanasia, the administration of drug to end-of-life, was not considered acceptable by both physicians and nurses in this research (96%). Based on our research results, providing continuing educational training and a formal consulting service in moral courage for neonatal clinicians are needed. In Taiwan, neonatal physicians and nurses hold similar values and attitudes towards end-of-life decisions for neonates. In order to improve the clinicians' communication skills with parents about DNR options and to change clinicians' attitudes for providing enough pain-relief medicine to dying neonates, providing continuing educational training and a formal consulting service in moral courage are needed.

Understanding doctors' ethical challenges as role virtue conflicts.

This paper argues that doctors' ethical challenges can be usefully conceptualised as role virtue conflicts. The hospital environment requires doctors to be simultaneously good doctors, good team members, good learners and good employees. I articulate a possible set of role virtues for each of these four roles, as a basis for a virtue ethics approach to analysing doctors' ethical challenges. Using one junior doctor's story, I argue that understanding doctors' ethical challenges as role virtue conflicts enables recognition of important moral considerations that are overlooked by other approaches to ethical analysis.

The intensity and frequency of moral distress among different healthcare disciplines.

INTRODUCTION: The objectives of this study are to assess and compare differences in the intensity, frequency, and overall severity of moral distress among a diverse group of healthcare professionals. METHODS: Participants from within Baylor Health Care System completed an online seven-point Likert scale (range, 0 to 6) moral distress survey containing nine core clinical scenarios and additional scenarios specific to each participant's discipline. Higher scores reflected greater intensity and/or frequency of moral distress. RESULTS: More than 2,700 healthcare professionals responded to the survey (response rate 18.14 percent); survey respondents represented multiple healthcare disciplines across a variety of settings in a single healthcare system. Intensity of moral distress was high in all disciplines, although the causes of highest intensity varied by discipline. Mean moral distress intensity for the nine core scenarios was higher among physicians than nurses, but the mean moral distress frequency was higher among nurses. Taking into account both intensity and frequency, the difference in mean moral distress score was statistically significant among the various disciplines. Using post hoc analysis, differences were greatest between nurses and therapists. CONCLUSIONS: Moral distress has previously been described as a phenomenon predominantly among nursing professionals.This first-of-its-kind multidisciplinary study of moral distress suggests the phenomenon is significant across multiple professional healthcare disciplines. Healthcare professionals should be sensitive to situations that create moral distress for colleagues from other disciplines. Policy makers and administrators should explore options to lessen moral distress and professional burnout that frequently accompanies it.

Physicians' and nurses' expectations and objections toward a clinical ethics committee.

The study aimed to explore the subjective need of healthcare professionals for ethics consultation, their experience with ethical conflicts, and expectations and objections toward a Clinical Ethics Committee. Staff at a university hospital took part in a survey (January to June 2010) using a questionnaire with open and closed questions. Descriptive data for physicians and nurses (response rate = 13.5%, n = 101) are presented. Physicians and nurses reported similar high frequencies of ethical conflicts but rated the relevance of ethical issues differently. Nurses stated ethical issues as less important to physicians than to themselves. Ethical conflicts were mostly discussed with staff from one's own profession. Respondents predominantly expected the Clinical Ethics Committee to provide competent support. Mostly, nurses feared it might have no influence on clinical practice. Findings suggest that experiences of ethical conflicts might reflect interprofessional communication patterns. Expectations and objections against Clinical Ethics Committees were multifaceted, and should be overcome by providing sufficient information. The Clinical Ethics Committee needs to take different perspectives of professions into account.

Family violence assessment practices of pediatric ED nurses and physicians.

BACKGROUND: Recommendations by the ENA and other professional organizations have not resulted in widespread adoption of routine assessment for family violence such as child abuse and intimate partner violence. The aim of this qualitative study was to use a theory-driven approach to explore the salient beliefs and attitudes of nurses and physicians related to routine assessment of child abuse and intimate partner violence in the pediatric emergency department. METHODS: Nurse and physician participants from a large Midwestern pediatric trauma center responded to a series of open-ended questions designed to identify positive or negative attitudes toward family violence assessment, approving or disapproving beliefs about family violence assessment, and the perception of ease or difficulty in performing family violence assessment. RESULTS: Respondents valued early identification and the associated health benefits of keeping pediatric patients safe, as well as linking at-risk families to community resources. They believe that victims, health care organizations, and some providers approve of routine family violence assessment but also believe that some providers and families who value privacy disapprove. Previously identified barriers and facilitators to family violence assessment were confirmed by participants. A finding unique to this study was that participants expressed the belief that routine family violence assessment offers more complete health care to children. DISCUSSION: Participants viewed child abuse and intimate partner violence as an event in a child's life that affects the child's health. Participants valued the benefits of routine family violence assessment; however, translating these value beliefs into practice remains elusive. A theoretical framework may provide insight into yet unidentified aspects of known barriers and facilitators.

Futile treatment, junior doctors and role virtues.

Futile treatment is one ethically challenging situation commonly encountered by junior doctors. By analysing an intern's story using a role virtues framework, I propose a set of three steps for junior doctors facing this problem. I claim that junior doctors ought always to investigate the rationale underlying decisions to proceed with apparently futile treatment and discuss their concerns with their seniors, even if such discussion will be difficult. I also suggest that junior doctors facing this ethical challenge ought always to be willing to initiate and engage in ethical dialogue, and that in some situations further action (such as taking concerns outside the team or refusing to participate in treatment) may be morally appropriate.