A recent study revealed 96% of plastic surgery residency program directors think ethics training in residency is important. Further, 73% said they want more resources to provide it.1

It came as no surprise to investigators that program directors believe ethics training is important and want to dedicate more time to it.

“But resources and expertise for training are more limited, so needs don’t actually match up with goals,” says Brian C. Drolet, MD, one of the study’s authors and an assistant professor in the department of plastic surgery at the Vanderbilt Center for Biomedical Ethics and Society. Other key findings:

  • Most plastic surgery programs offer some form of ethics curriculum, with a mean of three hours spent on ethics education annually;
  • 80% of the 46 program directors surveyed wanted more ethics in their curricula;
  • 70% of those surveyed concurred that their graduating chief residents were competent to handle ethical dilemmas;
  • 86% of respondents said a standardized ethics curriculum would be valuable.

The desire for more ethics training is not unique to plastic surgery. Researchers also administered the survey to program directors in anesthesiology, pediatrics, and general surgery, with similar findings.

Ethics expertise “needs to be instilled in the culture of our specialty from day one,” says Jeffrey E. Janis, MD, FACS, another of the study’s authors. The study’s findings represent an “opportunity to get out in front of this rather than respond to it,” says Janis, a professor of plastic surgery at The Ohio State University Wexner Medical Center in Columbus.

“We don’t need to wait for an egregious ethical violation to realize we need this type of education,” Janis offers. “It needs to begin early in one’s career.”

The study established that program directors truly want additional ethics resources. “Up to this point, we guessed that ethics was important. Now, we know it is,” Janis notes. “We had to diagnose the problem before we treated it.”

The findings support the need for an ethics curriculum at a national level, too. “That’s useful for faculty who don’t have expertise in ethics,” Drolet adds.

Some large institutions well-known for ethics expertise have ample resources to train residents. However, that is not generally true for smaller programs. “It can be difficult for program directors to teach ethics if they have minimal training in it themselves,” Drolet laments.

The researchers are designing a modular curriculum that can be implemented in any training program. No ethics expertise on the part of the faculty is necessary. “It will be case-based and provide the relevant literature and discussion material to teach ethics to residents,” Drolet explains.

This would meet the needs of the surveyed program directors. Many expressed interest in an established curriculum that is specialty-specific (and free). “You can buy several great clinical ethics textbooks. But my research group is of the mindset that this should be free,” Drolet says.

The reasoning is that the subject material is so fundamentally important that it should not come with a cost. “It just needs to be developed by a credible group of surgeon-ethicists and delivered through a reputable professional society,” Drolet suggests.

That ethics currently is part of every resident’s training is not a given. “That assumption is probably misguided, not only in our specialty but in every specialty,” Janis observes. “We could do better in how we provide formal resources.”

Ethics questions are included on both the written and oral exams for the American Board of Plastic Surgery. “If you are going to be tested on ethics, shouldn’t you be given the opportunity to be taught about it?” Janis asks.

Time constraints are “a major obstacle” to including ethics education in residency training programs, says Charity Scott, JD, MSCM, Catherine C. Henson Professor of Law at Georgia State University. Competing demands pull residents in many directions. “Dedicating time to ethics, especially for theoretical discussions of ethics, can become a low priority,” Scott says.

Faculty leaders of residency programs are the key to guarding against this possibility. “Without strong, consistent support from leadership, ethics education can become ad hoc at best, and nonexistent at worst,” Scott cautions.

To teach residents the day-to-day relevance of ethics, Scott recommends faculty explore the complexities of real-world ethical dilemmas, using case studies from their own clinical specialties and from their own institutions (when appropriate). Further, classroom discussions could be moderated by those who are knowledgeable about healthcare ethics, and ethics could be included in regular rounds.

“Residency is a critical time to identify ethical dilemmas in real time, while residents are learning the other dimensions of their professional practice,” Scott underscores.

Of course, time and resources are limited for all surgical specialties. If a program director adds four hours of ethics training, it could mean four fewer hours of training in the surgical specialty. “There’s so much content to deliver to your residents that you have to be very intentional in adding something else,” Drolet says.

Standardized, shared resources could help in this regard. Ideally, says Janis, “we don’t have to depend just on local resources to teach this subject. We can depend on national resources, which are in a constant state of re-evaluation and improvement.”

Janis and colleagues plan to conduct a follow-up study to reassess the state of ethics education in residency programs. “Hopefully, it will say we are doing a better job, and the trainees who are graduating will be more prepared to tackle not only their boards, but life as a plastic surgeon,” Janis says.

Ideally, faculty simply would incorporate ethics into other subject areas they are teaching already. “But while topics relevant to ethics are certainly found within ACGME residency milestones, they may not be well-articulated as such,” says Jean Cadigan, PhD, core faculty at the University of North Carolina (UNC) Center for Bioethics.

Instead, faculty try (often unsuccessfully) to find time for stand-alone ethics lectures. “There is a shortage of resources and support for teaching faculty who wish to feature practical ethics in their teaching,” Cadigan explains.

There are a few ways UNC Hospitals’ clinical ethics service offers ethics education to residents:

Ethicists hold informal discussion sessions for pediatric, pediatric critical care, and adult critical care residents. Residents choose ethically challenging cases from their own practices. Then, the group analyzes the cases.

“Sessions as short as 30 minutes can help residents successfully identify and address important ethical issues,” says Arlene M. Davis, JD, director of the clinical ethics service at UNC Hospitals.

Sometimes, senior physicians are surprised at the cases residents view as ethically problematic. “In their view, the situation presented seems a familiar or everyday occurrence,” Davis says, noting that from the residents’ perspective, it is helpful to discuss even “everyday” cases in this manner.

When evaluating the ethics education discussion sessions, ethicists learned something interesting. “We found that residents’ identification of ethical dilemmas is frequently tied, without their apparent awareness, to their performance of emotional labor,” Davis notes.2

Some cases require residents to express emotions different from what they actually feel. For example, this happens when giving bad news to a family member who is hoping for a miracle. “Identifying and discussing emotions are not common topics in resident education,” Davis says.

Further, ethics education sessions air bad feelings that can lead to burnout. “Bioethicist moderators can make visible the links between ethical dilemmas and emotional labor,” Davis adds.

Ethicists attend rounds on critical care units. “This helps residents to see how ethics methods can help address ethical dilemmas,” Davis explains.

Ethicists address residents’ concerns about legality of practice. Residents worry about the legal implications of informed consent, proxy decision-making, and withdrawal of interventions.

“We invite hospital counsel to participate in some of the sessions to further examine how both law and ethics contribute to practice,” Davis says.

The hospital ethics committee (HEC) offers a resident trainee track. “This is a fairly new track for our HEC, and we’re very excited by it,” Cadigan reports.

Residents attend HEC meetings and participate in clinical ethics consultations. Some teach ethics to medical students or newly hired nurses. Others conduct a clinical ethics research project or attend (and possibly present at) the Clinical Ethics Network of North Carolina’s annual conference.

Ethicists encourage residents to call an ethics consult when they need one. “Participating in an ethics consult as a requestor can also be an educational experience,” Davis explains.

REFERENCES

  1. Patrinely JR, Drolet BC, Perdikis G, Janis J. Ethics education in plastic surgery training programs. Plast Reconstr Surg 2019; Jun 17. doi: 10.1097/PRS.0000000000005928. [Epub ahead of print].
  2. Waltz M, Cadigan, RJ, Joiner B, et al. Perils of the hidden curriculum: Emotional labor and “bad” pediatric proxies. J Clin Ethics 2019;30:154-162.