Conflicting Curriculums: Ethics education for residents inconsistent across programs

A man with moderate dementia who is living in a nursing home is diagnosed with laryngeal cancer. The man is still able to talk and interact with other people. But he doesn’t know what year it is and is unable to make decisions on his own.

The real kicker: He has no surviving family and no designated surrogate.

What does his medical team do? Should they perform a laryngectomy, when one of the man’s greatest pleasures seems to be talking to people? Should they treat him with intensive chemoradiotherapy, despite side effects that probably include increasing his dementia? Or do they give him palliative care only?

This circumstance recently occurred at Indiana University—and it’s the kind of situation for which medical residency programs should prepare future doctors, said Paul Helft, MD, associate professor of medicine at the Indiana University School of Medicine in Indianapolis and director of the Charles Warren Fairbanks Center for Medical Ethics at Indiana University Health.

“Can a medical student or a resident recognize when an issue has ethical dimensions or not?” Dr. Helft said. “Can we provide, in a learning environment, a set of tools for a person to begin to approach a complex ethical problem…. How do you begin to think about a man who can’t make his own decisions who has a terrible decision to make and nobody to help him?”

“There isn’t, at present, a standard approach to ethics training…in any specialty, whether otolaryngology or the others.”

—Mark Weissler, MD, FACS

Inconsistency

The extent to which ethics is taught in surgical residency programs, including otolaryngology programs, varies widely from institution to institution, with many programs including little or no ethics training. Faculty at ethics centers say residency is an especially crucial period for the teaching of ethics, because it is during this time that principles can be applied more easily to real-life situations. But the training is lacking in many places, they say, even as restricted residency work hours make it more difficult than ever for programs to carve out time for such training.

This December, a meeting will take place at Washington University in St. Louis, Mo., where recipients of grants for ethics training, grants administered by the university and partially sponsored by the American College of Surgeons, will discuss the results of the programs that were created.

Ira Kodner, MD, a colon and rectal surgeon who helps run the ethics training at Washington University, is hoping the results from those grants will be a springboard to further training in other residency programs. He said the goal is to arm surgeons with the tools they need.