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Experience of moral distress among pediatric surgery trainees
Journal of Pediatric Surgery (2008) 43, 986–993
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Experience of moral distress among pediatric surgery trainees Priscilla P.L. Chiu a,⁎, Robert I. Hilliard b , Georges Azzie a , Annie Fecteau a a
Division of General Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada M5G 1X8 Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada M5G 1X8
b
Received 28 January 2008; accepted 8 February 2008
Key words: Moral distress; Ethical dilemma; Mentorship; Residency; Surgical training
Abstract Purpose: The aim of this study was to identify and qualify the ethical dilemmas faced by pediatric surgery trainees. Methods: An online survey was sent to pediatric surgery trainees graduating between 2005 and 2008. Consent was obtained, and study investigators were blinded to the identity of the respondents during data analysis. Results: Of the 40 respondents, only 59% felt they had received adequate training in bioethics to handle ethical issues pertaining to the care of critically ill children. Although 83% of respondents routinely participated in palliative care discussions, 30% of respondents desired to have more opportunities to discuss end-of-life issues with their staff. Moral conflicts were resolved through direct discussions with the medical staff, family, or friends. Despite the presence and awareness of institutional policies on ethical behavior, 58% of respondents did not believe that ethical conflicts were resolved as a result of these policies, whereas 31% of respondents felt that reporting of unethical conduct would result in personal reprisals. Conclusion: Pediatric surgery trainees face ethical and moral conflicts, but some are fearful of reprisals if these concerns are reported. A neutral forum to raise such issues may facilitate open discussions and eventual resolution of these conflicts. © 2008 Elsevier Inc. All rights reserved.
In the medical literature, there have been numerous reports about the ethical issues facing medical students during their clinical training [1-3]. However, there have been few reports on the ethical dilemmas facing surgery trainees [4] and specifically pediatric surgery residents. More specifically, pediatric surgery trainees are fully trained general surgeons who, after completion of their training in adult-based general surgery, complete an additional 2-year Presented at the 59th Annual Meeting of the Section on Surgery, American Academy of Pediatrics, San Francisco, CA, October 25-27, 2007. ⁎ Corresponding author. Tel.: +1 416 813 6405; fax: +1 416 813 7477. E-mail address: [email protected] (P.P.L. Chiu). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.02.016
training program in this subspecialty. Given their experience with adult patients through most of their training, pediatric surgery residents may be less familiar and less comfortable in dealing with ethical issues in the pediatric population, especially with critically ill infants and children. For pediatric surgery trainees, the lack of comfort or moral distress resulting from the ethical rather than medical aspects of patient care may persist into clinical practice. Reports indicate that pediatric surgeons have some difficulties when presented with clinical scenarios involving ethical dilemmas [5,6]. This suggests that there may be benefit to discussion of these dilemmas during surgical training.
Moral distress in pediatric surgery training
Fig. 1
987
Question 1 of survey—bioethics training for pediatric surgery trainees.
Pediatric surgery trainees may encounter moral distress during the course of their clinical training programs without formal support. The purpose of this study is to identify and quantify the ethical dilemmas faced by pediatric surgery residents during their training period. The objective is to determine the prevalence of this issue among the current pediatric surgery trainees and to determine the need for a forum within training programs to address this problem. This study is the first to address the prevalence of this experience in pediatric surgery training. By understanding the pervasiveness of this issue, we can better incorporate methods to resolve these issues within the training programs.
1. Method After receiving approval from our institution's ethics review board (REB #100001075), an e-mail was sent to 38
Fig. 2
pediatric surgery program directors in the United States and Canada to invite trainees in the 2005 to 2008 graduation years to participate in this survey. The e-mail provided a link to the online survey consisting of 5 sets of questions on moral dilemmas (Figs. 1-5) and 5 questions on responder demographics. The questions pertaining to experiences of moral dilemma were based on a survey used to quantify and qualify pediatric trainees' experience of moral distress in focus group discussions by one of the authors (R. I. H.) [7]. The format of the answers to survey questions consisted of categorical variables (ie, the answer is ‘yes’ or ‘no’), variables that potentially apply to the individual (ie, “check all that apply” responses), and narrative responses (ie, describe your experience). Internal validity of the survey was assessed by duplicate inquiries on the same topic within the question set using categorical and narrative responses. To determine if categorical answers differed between trainees, results were assessed using χ2 test with significance level at P b .05.
Question 2 of survey—supervision of pediatric surgery trainees.
988
P.P.L. Chiu et al.
Fig. 3
Question 3 of survey—trainee-staff conflicts.
Consent to participate in this study was obtained, and responses were based on voluntary completion of the survey. Respondents were assigned a number so that their answers
Fig. 4
would remain anonymous; only their assigned number would appear on the survey responses during analysis. Those who did not respond within 1 month of the first e-mail
Question 4 of survey—unethical and unprofessional behaviors.
Moral distress in pediatric surgery training
Fig. 5
989
Question 5 of survey—most serious experience of moral distress.
were sent a second one with the webpage link to the survey site. The completed responses from the survey Web site were compiled by a research assistant not involved in the data analysis process. This process ensured that the respondents remained anonymous.
2. Results Of the 38 accredited pediatric surgery training programs in the United States and Canada contacted, 25 program directors responded by referring their trainees to the online survey. A total of 45 pediatric surgery trainees enrolled into the survey, with 40 trainees completing at least 1 section from all questions in the survey. Only 12 (30%) of the 40 respondents had completed their pediatric surgery training, graduating in 2005 and 2006, with the remainder of the respondents currently in pediatric surgery training programs (Fig. 6). Of the 40 respondents, 27 (68%) were in US training programs. Of the respondents, 27 (68%) were male and 32 (80%) were married, with 65% of respondents indicating they were parents. Previous reports suggested that pediatric surgeons have had medical ethics education before entering their pediatric surgery residency [6,8]. Question 1 inquired whether the trainees' prior training provided sufficient bioethics exposure to deal with the care of the critically ill infant or child (Fig. 1). Twenty-four (59%) respondents indicated that they have had sufficient bioethics training to confront these ethical issues. There was no difference between male and female respondents (χ2 test, P = .9; Table 1), but more respondents currently in training (graduation years of 2007 and 2008; 68%) felt they had sufficient bioethics training as compared with those who had recently graduated from their program (graduation years 2005-2006, 42%; Table 1). This difference, however, did not reach statistical significance (χ2 test, P = .12).
Moral distress may also arise from the lack of opportunity for trainees to discuss palliative care decisions with a senior colleague. Although 80% of respondents indicated that they routinely participated in the palliative care plans of their critically ill patients and only 5% of respondents would defer end-of-life discussions to staff or colleagues, 30% of respondents to part 2 of question 1 indicated that they would have liked to discuss their questions or moral objections with their staff. Issues pertaining to end-of-life care also accounted for 40% of the narrative responses to question 5, the most serious episode of moral distress encountered during their pediatric surgery training (Table 2). Trainees stated that they found it “difficult and troubling” to engage in discussions on topics ranging from withdrawal of care in neonates to futility of care. Failure to address such concerns with their staff, especially when there was lack of agreement in the patient care plans, was particularly problematic. Trainees expressed deep ethical concern toward the pursuit of surgical treatments in “hopeless” situations, particularly when such treatments resulted in additional complications and suffering for the patients and their families. Lack of adequate expertise in the clinical setting may be a source of moral distress to trainees, especially in surgery where technical experience is accumulated over time [9]. Although most respondents felt that they were sufficiently skilled or adequately supervised to perform procedures or render care during their residency, 20% of respondents felt that they had been put into a situation for which they were not fully competent and had expressed such concerns to their attending staff. In some cases, the distress was because of the intensity of the training program and because of the “overall amount of patient care and the high demands/expectations to provide care” while in a training environment, as indicated in the responses to question 5 (Table 2). Trainees also expressed frustrations over the “lack of staff involvement in patient care,” leaving them “alone” to communicate with patient Table 1 Adequacy of previous bioethics training to confront ethical issues pertaining to the care of the critically ill infant or child by sex of respondents (χ2 test, P = .9) and by year of training of respondents (χ2 test, P = .12) Sufficient bioethics training?
Yes No Fig. 6
Year of graduation of respondents (n = 40).
Response by sex
Response by year of training
Male (%)
Female (%)
2005-2006 (%)
2007-2008 (%)
56 44
54 46
42 58
68 32
990 Table 2 Responses to question 5, “Describe the most serious moral distress you have had in your pediatric surgery experience” End-of-life issues and the care of critically ill patients: “End-of-life discussion between family and staff… a difference of opinion on whether supportive care or aggressive intervention is warranted…” “Suboptimal care provided by ICU staff and turf battles impeding provision of standard care” “Continued futile care in a young patient with terminal disease—at request of family” “…operating on a patient with near total NEC and trying to decide whether surgical intervention was the ethical thing to do or not” “Disagreement with medical services…instituting care I disagree with that subsequently causes a complication” “Dealing with parents of abused children” “Withdrawal of support in neonate with terminal lesions/problems” “Not knowing enough to properly counsel families…” “Fetoscopic cord transection of suspected acardiac and anencephalic twin” “…a NICU infant with only 10 cm of total intestine (due to NEC)… the family was very inappropriate… They did not visit this child when he was very sick.” “Decisions to withdraw care on seriously ill, potentially salvageable patients when there is conflict between staff about plan of care” Unprofessional and unethical conduct: “Being involved in a clinical case where I felt surgery was not warranted and was not the standard of care…” “Seeing a faculty surgeon verbally castigate a resident for a fairly minor treatment decision” “… other medical professionals… practice and teach in our institution in a standard that is not on par with my own” “Dealing with clinical corner-cutting by some attendings and/or late-night unresponsiveness (especially by private staff)” “During the operation…I distanced myself during the case by taking a purely assisting role…” Lack of adequate supervision or communication, inter-personal conflicts: “I have the most difficulty when implementing staff plans which I disagree with.” “…I find it difficult when staff fight with other staff through the fellow.” “Staff are sometimes unwilling or unhappy participating in patient care at times that are not convenient, that is, nights/weekends.” “Lack of staff surgeon involvement and communication with patient and family members” “Disagreeing with an attending physicians plan, carrying out the plan then observing a bad outcome” “I was asked to obtain central emergency IV access and place bilateral chest tubes in a critically ill 12-year-old… without an in-house surgeon to help me at the hour of 12:00 am.” “Staff often fail to communicate patient care plans to their oncall colleagues which results in changes in plan at night/on the weekend, which may not be necessary or beneficial to the patient.”
P.P.L. Chiu et al. Table 2 (continued) Stress of the workplace: “My staff feel I do a great job except for the program director who did not want me to match into this program.” “…moral distress to me is related to the overall amount of patient care and the high demands/expectations to provide care while learning. I have always felt 'backed up' but there is a baseline level of stress—some of it moral—in the intense training we receive.” ICU indicates intensive care unit; NICU, neonatal intensive care unit; NEC, necrotizing enterocolitis.
families about treatment plans. Distress may have arisen from a lack of knowledge or expertise “to properly counsel families as to the appropriate or best course of action” in an acute situation. Notably, 15% of trainees continued to experience guilt or restless feelings over such unresolved moral conflicts. Conflict between the trainee and staff surgeon in the context of patient care may result from the trainee's inexperience. Such conflicts may also result from poor communication between the staff and the trainee as pertains to the rationale for the treatment plan (Table 2). Few moral conflicts were attributed to differences in ethical values (33%) or religious beliefs (7%) between the staff and trainee (Table 3). Among the respondents, 63% experienced moral objection to a patient's treatment plan but declined to express their opposition to the attending staff. Importantly, 32% of respondents felt compelled to participate in their staff's treatment plans despite their own objections, and 93% continued to participate in the patient's care. Only 55% of trainees achieved eventual resolution of such disagreements with their senior colleagues. Responses to question 5 provided further insights into the trainees' frustrations with conflicting opinions for patient treatment plans. Some trainees recounted feelings of guilt associated with these experiences, where the trainee disagreed with an attending physician's plans but proceeded to carry them out, only to observe “a bad outcome” for the patient (Table 2). In some
Table 3 surgeon
Basis of moral conflict between trainee and staff
Basis of moral conflict between trainee and staff
% of respondents Yes
No
Difference in ethical values Difference in religious beliefs Felt compelled to participate in management plan despite personal experience of moral conflict Avoided conflict by avoiding direct involvement in patient's care Expressed moral opposition to staff concerning management plan
33 7 32
67 93 68
7
93
37
63
Moral distress in pediatric surgery training instances, the conflict arose between specialty services, where “disagreement with the medical services” toward continued aggressive treatment perceived as futile care gave rise to the moral distress for the surgical trainee. The traditional model of medical training is an apprenticeship such that residents are mentored by senior colleagues who not only provide clinical training but also serve as role models. Trainees who witness unprofessional or unethical conduct in their mentors or other staff may experience guilt and moral distress, especially if that conduct compromises patient care. In response to question 4, few trainees reported witnessing unprofessional or unethical behavior. Sexual or financial misconduct were infrequent. The survey found that 27% of respondents witnessed “an excessive use or abuse of power by faculty” members, with 1 respondent recounting a particular incident where “a faculty surgeon verbally castigated a resident for a fairly minor treatment decision” (Table 2). In providing patients with the appropriate standard of care, 29% of respondents had experienced situations where they felt that their colleagues had failed to provide safe medical practice or the appropriate standard of care, expressing concern that “other professionals were not practicing their craft to an acceptable standard.” Some trainees found it particularly troubling when dealing with perceived “clinical cornercutting” by senior colleagues or “late-night unresponsiveness” when trying to reach the staff surgeon on call. One respondent felt particularly uncomfortable with the “lack of meticulousness” with which the staff surgeon had handled a patient's operation, with the trainee regressing from the operator's role to that of an assistant to “distance” himself/ herself from the case. Few trainees reported unprofessional or unethical conduct to their program director (25%), division chief (14%), or surgeon-in-chief (11%). Trainees sought counsel from friends (46%), family (36%), or other mentors (29%) to address and resolve such conflicts. Although 91% of respondents were aware of institutionbased policies for the reporting of such unprofessional or unethical conduct and made use of these mechanisms, 58% of these residents felt that these policies did not help to resolve their conflicts. More importantly, 31% of respondents felt that reprisals could result from such reporting, particularly when a senior colleague was involved. For most questions in the survey, there was no statistically significant difference in the responses based on sex of the trainees, suggesting that most encounters of moral distress relate to the general environment and experience of surgical training. However, there were significant differences between male and female trainees in their willingness to express their moral conflict or comply with staff's management plans (Table 4). More female trainees expressed concern for the lack of supervision in providing patient care or performing procedures than male trainees (χ2 test, P = .004). Although the difference did not reach statistical significance, there was also a trend toward more female trainees experiencing
991 Table 4 Experiences of moral distress based on sex of respondent Question
Sex of respondent
χ2
Male (%)
P
Female (%)
2. Moral distress due to lack of supervision or expertise 46 Yes, I expressed my concerns about 7 the lack of supervision to my attending staff surgeon. Yes, I felt guilty from these 7 31 experiences. 3. Moral distress from conflict with staff Yes, I felt compelled to participate 26 46 in my staff's plans despite my personal moral conflict. 4. Witness unprofessional or unethical conduct I reported such unprofessional 11 31 conduct to the program director. I discussed with the individuals 33 8 directly about their unethical behavior.
.004
.053
.037
.125 .079
feelings of guilt resulting from the lack of supervision or expertise compared with their male counterparts (χ2 test, P = .053). Furthermore, more female trainees felt compelled to “go along” with their staff's management plans despite their own moral objections as compared with male trainees (χ2 test, P = .037). There was also a trend toward sex differences in the handling of witnessed unprofessional or unethical behavior by colleagues, with more female trainees reporting this conduct to the program director and more male trainees addressing the individual involved directly (Table 4).
3. Discussion Pediatric surgery trainees experience ethical distress in the rendering of care for critically ill patients, especially with regard to end-of-life issues. Results of this survey confirm that issues surrounding end-of-life care are the most frequent source of moral distress for pediatric surgery trainees. This has also been demonstrated for pediatric residents [7,10]. Interestingly, the perspective of pediatric surgical trainees concerning their preparedness in dealing with such issues varies depending on their level of training. Although the results did not reach statistical significance, recent graduates felt less prepared to confront the ethical issues involved with critically ill pediatric patients than new trainees. These results suggest a slight difference in perspective on adequacy of bioethics training based on the trainees' clinical experience in or exposure to pediatric surgery. This discrepancy could also potentially reflect the recent institution of a formal ethics curriculum in some
992 North American pediatric surgery programs. Interestingly, these results were in sharp contrast to those recently reported for pediatric residents, where senior pediatric residents voiced greater ease dealing with bioethics issues than their junior colleagues [7]. Sex-based differences in moral and ethical development have been widely debated in the psychology and philosophy literature since Carol Gilligan first proposed a “2-voice” model that suggested the basis for the differences in male (ie, justice) and female (ie, care) moral reasoning [11]. Although controversial, this “ethic of care” theory was proposed as a “different voice” of moral reasoning for women with less emphasis on the rules, rights, and obligations that dominate male ethics and more on relationships and contexts, especially when applied to a “caring profession” such as medicine [12]. Our results may support such a theory, insofar as female trainees were significantly more willing to express their concerns but were more inclined to persist with patient care rather than halt for the sake of personal moral objections. However, it was not the intention and it is beyond the scope of this study to address the issues relating to gendered moral ethics. Currently, no pediatric surgery training program provides specific mechanisms to address the moral distress encountered by their trainees. Furthermore, the brevity of pediatric surgery training (2 years) compared with pediatric medical training (minimum training period is 4 years) affords pediatric surgery residents less opportunity to voice and resolve their ethical conflicts. As a result, pediatric surgery trainees may fail to express and resolve the moral distress encountered during their training. Although most trainees were able to resolve such conflicts through the counsel of friends and family members, the survey revealed that many pediatric surgery trainees failed to communicate or resolve these conflicts with their staff. The survey results imply that despite personal objections to the line of management, residents continued to provide patient care. These results indicate that surgical trainees lack the opportunity and forum to discuss their moral distress and could not withdraw from patient care as would be expected from an attending surgeon experiencing the same moral distress. Resolving conflicts may prevent the trainee from adopting an “avoidance” behavior toward patient care or, worse, the dishonest conduct by the trainee to avoid staff reprisals or “wrath” [13]. Ultimately, the resolution of such conflicts for the trainee may contribute to their success in handling and resolving similar conflicts in the future. The intense nature of pediatric surgery training has also contributed to moral distress of residents who are novices to the management of critically ill infants and children. Pediatric surgery trainees are fully trained general surgeons who pursue additional pediatric surgical training to qualify for specialty board certification. At the start of their pediatric surgical training, trainees may be experts in the surgical care of the adult patient, but they lack experience with the pediatric patient. In “starting over again” as a new
P.P.L. Chiu et al. resident, the trainees expressed “concern” and distress over the brevity and intensity of their specialty training, their initial lack of specific technical skills and clinical knowledge in pediatric surgical care, especially when coupled with lack of supervision or assistance from senior colleagues. The mentoring of trainees has become an increasingly important focus in surgical practice, not only to provide the necessary clinical and moral support during residency but also to ensure successful transition to independent practice [14,15]. Few surgical training programs have formal mentorship arrangements for trainees, yet this may provide trainees with an effective means to voice personal concerns, to seek clinical advice, and to address unresolved moral conflicts. The survey results also indicate that pediatric surgery residents are skeptical about the ability of institution-based policies to regulate and enforce ethical and professional conduct. This skepticism may be fueled by the residents' past experience in surgical training rather than the pediatric surgery residency-specific issues. However, the trainees' reluctance to communicate such behaviors for fear of reprisal strongly supports the need for training programs to provide a neutral environment to express such concerns. Since 2006, an ethics curriculum has been devised by The Hospital for Sick Children, Toronto, and sponsored by the Program Director's Committee of the American Pediatric Surgical Association to provide residency programs with a forum for the discussion of ethical issues pertaining to the care of the pediatric patient. These informal discussions may provide the forum for current trainees to discuss and resolve moral conflicts compared with previous trainees. Further studies would be required to determine whether the implementation of the ethics curriculum has impacted on the prevalence of moral distress among pediatric surgery trainees.
References [1] Patenaude J, Niyonsenga T, Fafard D. Changes in students' moral development during medical school: a cohort study. CMAJ 2003;168: 840-4. [2] Caldicott C, Faber-Langendoen K. Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students. Acad Med 2005;80:866-73. [3] Hicks LK, Lin Y, Robertson DW, et al. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study. BMJ 2001;322: 709-10. [4] Escobar M, McCullough L. Responsibility managing ethical challenges of residency training: a guide for surgery residents, educators and residency program leaders. J Am Coll Surg 2006;202:531-5. [5] Bagwell C, Goodwin S. Spinning the wheels: a CAPS survey of ethical issues in pediatric surgery. J Pediatr Surg 1992;27:1385-90. [6] Robin ML, Caniano DA. Analysis of clinical bioethics teaching in pediatric surgery residency. J Pediatr Surg 1998;33:373-7. [7] Hilliard R, Harrison C, Madden S. Ethical conflicts and moral distress experienced by paediatric residents during their training. Pediatr Child Health 2007;12:29-35.
Moral distress in pediatric surgery training [8] Fallat M, Caniano DA, Fecteau AH. Ethics and the pediatric surgeon. J Pediatr Surg 2007;42:129-36. [9] Newton M. Moral dilemma in surgical training: intent and the case for ethical ambiguity. J Med Ethic 1986;12:207-9. [10] White B, Hickson G, Theriot R, et al. A medical ethics issues survey of residents in five pediatric training programs. Am J Dis Child 1991;145: 161-4. [11] Gilligan C. In a different voice: psychological theory and women's development. Cambridge, MA: Harvard University Press; 1982.
993 [12] Conradi E, Biller-Andorno N, Boos M, et al. Gender in medical ethics: re-examining the conceptual basis of empirical research. Med Health Care Philos 2003;6:51-8. [13] Green M, Mitchell G, Stocking C, et al. Do actions reported by physicians in training conflict with consensus guidelines on ethics? Arch Intern Med 1996;156:298-304. [14] McDonald P. Reflections on the mentoring of a young surgeon. Can J Surg 2006;49:168-9. [15] Warnock G. Developing a culture of mentoring. Can J Surg 2006;49: 164-5.
www.elsevier.com/locate/jpedsurg
Experience of moral distress among pediatric surgery trainees Priscilla P.L. Chiu a,⁎, Robert I. Hilliard b , Georges Azzie a , Annie Fecteau a a
Division of General Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada M5G 1X8 Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada M5G 1X8
b
Received 28 January 2008; accepted 8 February 2008
Key words: Moral distress; Ethical dilemma; Mentorship; Residency; Surgical training
Abstract Purpose: The aim of this study was to identify and qualify the ethical dilemmas faced by pediatric surgery trainees. Methods: An online survey was sent to pediatric surgery trainees graduating between 2005 and 2008. Consent was obtained, and study investigators were blinded to the identity of the respondents during data analysis. Results: Of the 40 respondents, only 59% felt they had received adequate training in bioethics to handle ethical issues pertaining to the care of critically ill children. Although 83% of respondents routinely participated in palliative care discussions, 30% of respondents desired to have more opportunities to discuss end-of-life issues with their staff. Moral conflicts were resolved through direct discussions with the medical staff, family, or friends. Despite the presence and awareness of institutional policies on ethical behavior, 58% of respondents did not believe that ethical conflicts were resolved as a result of these policies, whereas 31% of respondents felt that reporting of unethical conduct would result in personal reprisals. Conclusion: Pediatric surgery trainees face ethical and moral conflicts, but some are fearful of reprisals if these concerns are reported. A neutral forum to raise such issues may facilitate open discussions and eventual resolution of these conflicts. © 2008 Elsevier Inc. All rights reserved.
In the medical literature, there have been numerous reports about the ethical issues facing medical students during their clinical training [1-3]. However, there have been few reports on the ethical dilemmas facing surgery trainees [4] and specifically pediatric surgery residents. More specifically, pediatric surgery trainees are fully trained general surgeons who, after completion of their training in adult-based general surgery, complete an additional 2-year Presented at the 59th Annual Meeting of the Section on Surgery, American Academy of Pediatrics, San Francisco, CA, October 25-27, 2007. ⁎ Corresponding author. Tel.: +1 416 813 6405; fax: +1 416 813 7477. E-mail address: [email protected] (P.P.L. Chiu). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.02.016
training program in this subspecialty. Given their experience with adult patients through most of their training, pediatric surgery residents may be less familiar and less comfortable in dealing with ethical issues in the pediatric population, especially with critically ill infants and children. For pediatric surgery trainees, the lack of comfort or moral distress resulting from the ethical rather than medical aspects of patient care may persist into clinical practice. Reports indicate that pediatric surgeons have some difficulties when presented with clinical scenarios involving ethical dilemmas [5,6]. This suggests that there may be benefit to discussion of these dilemmas during surgical training.
Moral distress in pediatric surgery training
Fig. 1
987
Question 1 of survey—bioethics training for pediatric surgery trainees.
Pediatric surgery trainees may encounter moral distress during the course of their clinical training programs without formal support. The purpose of this study is to identify and quantify the ethical dilemmas faced by pediatric surgery residents during their training period. The objective is to determine the prevalence of this issue among the current pediatric surgery trainees and to determine the need for a forum within training programs to address this problem. This study is the first to address the prevalence of this experience in pediatric surgery training. By understanding the pervasiveness of this issue, we can better incorporate methods to resolve these issues within the training programs.
1. Method After receiving approval from our institution's ethics review board (REB #100001075), an e-mail was sent to 38
Fig. 2
pediatric surgery program directors in the United States and Canada to invite trainees in the 2005 to 2008 graduation years to participate in this survey. The e-mail provided a link to the online survey consisting of 5 sets of questions on moral dilemmas (Figs. 1-5) and 5 questions on responder demographics. The questions pertaining to experiences of moral dilemma were based on a survey used to quantify and qualify pediatric trainees' experience of moral distress in focus group discussions by one of the authors (R. I. H.) [7]. The format of the answers to survey questions consisted of categorical variables (ie, the answer is ‘yes’ or ‘no’), variables that potentially apply to the individual (ie, “check all that apply” responses), and narrative responses (ie, describe your experience). Internal validity of the survey was assessed by duplicate inquiries on the same topic within the question set using categorical and narrative responses. To determine if categorical answers differed between trainees, results were assessed using χ2 test with significance level at P b .05.
Question 2 of survey—supervision of pediatric surgery trainees.
988
P.P.L. Chiu et al.
Fig. 3
Question 3 of survey—trainee-staff conflicts.
Consent to participate in this study was obtained, and responses were based on voluntary completion of the survey. Respondents were assigned a number so that their answers
Fig. 4
would remain anonymous; only their assigned number would appear on the survey responses during analysis. Those who did not respond within 1 month of the first e-mail
Question 4 of survey—unethical and unprofessional behaviors.
Moral distress in pediatric surgery training
Fig. 5
989
Question 5 of survey—most serious experience of moral distress.
were sent a second one with the webpage link to the survey site. The completed responses from the survey Web site were compiled by a research assistant not involved in the data analysis process. This process ensured that the respondents remained anonymous.
2. Results Of the 38 accredited pediatric surgery training programs in the United States and Canada contacted, 25 program directors responded by referring their trainees to the online survey. A total of 45 pediatric surgery trainees enrolled into the survey, with 40 trainees completing at least 1 section from all questions in the survey. Only 12 (30%) of the 40 respondents had completed their pediatric surgery training, graduating in 2005 and 2006, with the remainder of the respondents currently in pediatric surgery training programs (Fig. 6). Of the 40 respondents, 27 (68%) were in US training programs. Of the respondents, 27 (68%) were male and 32 (80%) were married, with 65% of respondents indicating they were parents. Previous reports suggested that pediatric surgeons have had medical ethics education before entering their pediatric surgery residency [6,8]. Question 1 inquired whether the trainees' prior training provided sufficient bioethics exposure to deal with the care of the critically ill infant or child (Fig. 1). Twenty-four (59%) respondents indicated that they have had sufficient bioethics training to confront these ethical issues. There was no difference between male and female respondents (χ2 test, P = .9; Table 1), but more respondents currently in training (graduation years of 2007 and 2008; 68%) felt they had sufficient bioethics training as compared with those who had recently graduated from their program (graduation years 2005-2006, 42%; Table 1). This difference, however, did not reach statistical significance (χ2 test, P = .12).
Moral distress may also arise from the lack of opportunity for trainees to discuss palliative care decisions with a senior colleague. Although 80% of respondents indicated that they routinely participated in the palliative care plans of their critically ill patients and only 5% of respondents would defer end-of-life discussions to staff or colleagues, 30% of respondents to part 2 of question 1 indicated that they would have liked to discuss their questions or moral objections with their staff. Issues pertaining to end-of-life care also accounted for 40% of the narrative responses to question 5, the most serious episode of moral distress encountered during their pediatric surgery training (Table 2). Trainees stated that they found it “difficult and troubling” to engage in discussions on topics ranging from withdrawal of care in neonates to futility of care. Failure to address such concerns with their staff, especially when there was lack of agreement in the patient care plans, was particularly problematic. Trainees expressed deep ethical concern toward the pursuit of surgical treatments in “hopeless” situations, particularly when such treatments resulted in additional complications and suffering for the patients and their families. Lack of adequate expertise in the clinical setting may be a source of moral distress to trainees, especially in surgery where technical experience is accumulated over time [9]. Although most respondents felt that they were sufficiently skilled or adequately supervised to perform procedures or render care during their residency, 20% of respondents felt that they had been put into a situation for which they were not fully competent and had expressed such concerns to their attending staff. In some cases, the distress was because of the intensity of the training program and because of the “overall amount of patient care and the high demands/expectations to provide care” while in a training environment, as indicated in the responses to question 5 (Table 2). Trainees also expressed frustrations over the “lack of staff involvement in patient care,” leaving them “alone” to communicate with patient Table 1 Adequacy of previous bioethics training to confront ethical issues pertaining to the care of the critically ill infant or child by sex of respondents (χ2 test, P = .9) and by year of training of respondents (χ2 test, P = .12) Sufficient bioethics training?
Yes No Fig. 6
Year of graduation of respondents (n = 40).
Response by sex
Response by year of training
Male (%)
Female (%)
2005-2006 (%)
2007-2008 (%)
56 44
54 46
42 58
68 32
990 Table 2 Responses to question 5, “Describe the most serious moral distress you have had in your pediatric surgery experience” End-of-life issues and the care of critically ill patients: “End-of-life discussion between family and staff… a difference of opinion on whether supportive care or aggressive intervention is warranted…” “Suboptimal care provided by ICU staff and turf battles impeding provision of standard care” “Continued futile care in a young patient with terminal disease—at request of family” “…operating on a patient with near total NEC and trying to decide whether surgical intervention was the ethical thing to do or not” “Disagreement with medical services…instituting care I disagree with that subsequently causes a complication” “Dealing with parents of abused children” “Withdrawal of support in neonate with terminal lesions/problems” “Not knowing enough to properly counsel families…” “Fetoscopic cord transection of suspected acardiac and anencephalic twin” “…a NICU infant with only 10 cm of total intestine (due to NEC)… the family was very inappropriate… They did not visit this child when he was very sick.” “Decisions to withdraw care on seriously ill, potentially salvageable patients when there is conflict between staff about plan of care” Unprofessional and unethical conduct: “Being involved in a clinical case where I felt surgery was not warranted and was not the standard of care…” “Seeing a faculty surgeon verbally castigate a resident for a fairly minor treatment decision” “… other medical professionals… practice and teach in our institution in a standard that is not on par with my own” “Dealing with clinical corner-cutting by some attendings and/or late-night unresponsiveness (especially by private staff)” “During the operation…I distanced myself during the case by taking a purely assisting role…” Lack of adequate supervision or communication, inter-personal conflicts: “I have the most difficulty when implementing staff plans which I disagree with.” “…I find it difficult when staff fight with other staff through the fellow.” “Staff are sometimes unwilling or unhappy participating in patient care at times that are not convenient, that is, nights/weekends.” “Lack of staff surgeon involvement and communication with patient and family members” “Disagreeing with an attending physicians plan, carrying out the plan then observing a bad outcome” “I was asked to obtain central emergency IV access and place bilateral chest tubes in a critically ill 12-year-old… without an in-house surgeon to help me at the hour of 12:00 am.” “Staff often fail to communicate patient care plans to their oncall colleagues which results in changes in plan at night/on the weekend, which may not be necessary or beneficial to the patient.”
P.P.L. Chiu et al. Table 2 (continued) Stress of the workplace: “My staff feel I do a great job except for the program director who did not want me to match into this program.” “…moral distress to me is related to the overall amount of patient care and the high demands/expectations to provide care while learning. I have always felt 'backed up' but there is a baseline level of stress—some of it moral—in the intense training we receive.” ICU indicates intensive care unit; NICU, neonatal intensive care unit; NEC, necrotizing enterocolitis.
families about treatment plans. Distress may have arisen from a lack of knowledge or expertise “to properly counsel families as to the appropriate or best course of action” in an acute situation. Notably, 15% of trainees continued to experience guilt or restless feelings over such unresolved moral conflicts. Conflict between the trainee and staff surgeon in the context of patient care may result from the trainee's inexperience. Such conflicts may also result from poor communication between the staff and the trainee as pertains to the rationale for the treatment plan (Table 2). Few moral conflicts were attributed to differences in ethical values (33%) or religious beliefs (7%) between the staff and trainee (Table 3). Among the respondents, 63% experienced moral objection to a patient's treatment plan but declined to express their opposition to the attending staff. Importantly, 32% of respondents felt compelled to participate in their staff's treatment plans despite their own objections, and 93% continued to participate in the patient's care. Only 55% of trainees achieved eventual resolution of such disagreements with their senior colleagues. Responses to question 5 provided further insights into the trainees' frustrations with conflicting opinions for patient treatment plans. Some trainees recounted feelings of guilt associated with these experiences, where the trainee disagreed with an attending physician's plans but proceeded to carry them out, only to observe “a bad outcome” for the patient (Table 2). In some
Table 3 surgeon
Basis of moral conflict between trainee and staff
Basis of moral conflict between trainee and staff
% of respondents Yes
No
Difference in ethical values Difference in religious beliefs Felt compelled to participate in management plan despite personal experience of moral conflict Avoided conflict by avoiding direct involvement in patient's care Expressed moral opposition to staff concerning management plan
33 7 32
67 93 68
7
93
37
63
Moral distress in pediatric surgery training instances, the conflict arose between specialty services, where “disagreement with the medical services” toward continued aggressive treatment perceived as futile care gave rise to the moral distress for the surgical trainee. The traditional model of medical training is an apprenticeship such that residents are mentored by senior colleagues who not only provide clinical training but also serve as role models. Trainees who witness unprofessional or unethical conduct in their mentors or other staff may experience guilt and moral distress, especially if that conduct compromises patient care. In response to question 4, few trainees reported witnessing unprofessional or unethical behavior. Sexual or financial misconduct were infrequent. The survey found that 27% of respondents witnessed “an excessive use or abuse of power by faculty” members, with 1 respondent recounting a particular incident where “a faculty surgeon verbally castigated a resident for a fairly minor treatment decision” (Table 2). In providing patients with the appropriate standard of care, 29% of respondents had experienced situations where they felt that their colleagues had failed to provide safe medical practice or the appropriate standard of care, expressing concern that “other professionals were not practicing their craft to an acceptable standard.” Some trainees found it particularly troubling when dealing with perceived “clinical cornercutting” by senior colleagues or “late-night unresponsiveness” when trying to reach the staff surgeon on call. One respondent felt particularly uncomfortable with the “lack of meticulousness” with which the staff surgeon had handled a patient's operation, with the trainee regressing from the operator's role to that of an assistant to “distance” himself/ herself from the case. Few trainees reported unprofessional or unethical conduct to their program director (25%), division chief (14%), or surgeon-in-chief (11%). Trainees sought counsel from friends (46%), family (36%), or other mentors (29%) to address and resolve such conflicts. Although 91% of respondents were aware of institutionbased policies for the reporting of such unprofessional or unethical conduct and made use of these mechanisms, 58% of these residents felt that these policies did not help to resolve their conflicts. More importantly, 31% of respondents felt that reprisals could result from such reporting, particularly when a senior colleague was involved. For most questions in the survey, there was no statistically significant difference in the responses based on sex of the trainees, suggesting that most encounters of moral distress relate to the general environment and experience of surgical training. However, there were significant differences between male and female trainees in their willingness to express their moral conflict or comply with staff's management plans (Table 4). More female trainees expressed concern for the lack of supervision in providing patient care or performing procedures than male trainees (χ2 test, P = .004). Although the difference did not reach statistical significance, there was also a trend toward more female trainees experiencing
991 Table 4 Experiences of moral distress based on sex of respondent Question
Sex of respondent
χ2
Male (%)
P
Female (%)
2. Moral distress due to lack of supervision or expertise 46 Yes, I expressed my concerns about 7 the lack of supervision to my attending staff surgeon. Yes, I felt guilty from these 7 31 experiences. 3. Moral distress from conflict with staff Yes, I felt compelled to participate 26 46 in my staff's plans despite my personal moral conflict. 4. Witness unprofessional or unethical conduct I reported such unprofessional 11 31 conduct to the program director. I discussed with the individuals 33 8 directly about their unethical behavior.
.004
.053
.037
.125 .079
feelings of guilt resulting from the lack of supervision or expertise compared with their male counterparts (χ2 test, P = .053). Furthermore, more female trainees felt compelled to “go along” with their staff's management plans despite their own moral objections as compared with male trainees (χ2 test, P = .037). There was also a trend toward sex differences in the handling of witnessed unprofessional or unethical behavior by colleagues, with more female trainees reporting this conduct to the program director and more male trainees addressing the individual involved directly (Table 4).
3. Discussion Pediatric surgery trainees experience ethical distress in the rendering of care for critically ill patients, especially with regard to end-of-life issues. Results of this survey confirm that issues surrounding end-of-life care are the most frequent source of moral distress for pediatric surgery trainees. This has also been demonstrated for pediatric residents [7,10]. Interestingly, the perspective of pediatric surgical trainees concerning their preparedness in dealing with such issues varies depending on their level of training. Although the results did not reach statistical significance, recent graduates felt less prepared to confront the ethical issues involved with critically ill pediatric patients than new trainees. These results suggest a slight difference in perspective on adequacy of bioethics training based on the trainees' clinical experience in or exposure to pediatric surgery. This discrepancy could also potentially reflect the recent institution of a formal ethics curriculum in some
992 North American pediatric surgery programs. Interestingly, these results were in sharp contrast to those recently reported for pediatric residents, where senior pediatric residents voiced greater ease dealing with bioethics issues than their junior colleagues [7]. Sex-based differences in moral and ethical development have been widely debated in the psychology and philosophy literature since Carol Gilligan first proposed a “2-voice” model that suggested the basis for the differences in male (ie, justice) and female (ie, care) moral reasoning [11]. Although controversial, this “ethic of care” theory was proposed as a “different voice” of moral reasoning for women with less emphasis on the rules, rights, and obligations that dominate male ethics and more on relationships and contexts, especially when applied to a “caring profession” such as medicine [12]. Our results may support such a theory, insofar as female trainees were significantly more willing to express their concerns but were more inclined to persist with patient care rather than halt for the sake of personal moral objections. However, it was not the intention and it is beyond the scope of this study to address the issues relating to gendered moral ethics. Currently, no pediatric surgery training program provides specific mechanisms to address the moral distress encountered by their trainees. Furthermore, the brevity of pediatric surgery training (2 years) compared with pediatric medical training (minimum training period is 4 years) affords pediatric surgery residents less opportunity to voice and resolve their ethical conflicts. As a result, pediatric surgery trainees may fail to express and resolve the moral distress encountered during their training. Although most trainees were able to resolve such conflicts through the counsel of friends and family members, the survey revealed that many pediatric surgery trainees failed to communicate or resolve these conflicts with their staff. The survey results imply that despite personal objections to the line of management, residents continued to provide patient care. These results indicate that surgical trainees lack the opportunity and forum to discuss their moral distress and could not withdraw from patient care as would be expected from an attending surgeon experiencing the same moral distress. Resolving conflicts may prevent the trainee from adopting an “avoidance” behavior toward patient care or, worse, the dishonest conduct by the trainee to avoid staff reprisals or “wrath” [13]. Ultimately, the resolution of such conflicts for the trainee may contribute to their success in handling and resolving similar conflicts in the future. The intense nature of pediatric surgery training has also contributed to moral distress of residents who are novices to the management of critically ill infants and children. Pediatric surgery trainees are fully trained general surgeons who pursue additional pediatric surgical training to qualify for specialty board certification. At the start of their pediatric surgical training, trainees may be experts in the surgical care of the adult patient, but they lack experience with the pediatric patient. In “starting over again” as a new
P.P.L. Chiu et al. resident, the trainees expressed “concern” and distress over the brevity and intensity of their specialty training, their initial lack of specific technical skills and clinical knowledge in pediatric surgical care, especially when coupled with lack of supervision or assistance from senior colleagues. The mentoring of trainees has become an increasingly important focus in surgical practice, not only to provide the necessary clinical and moral support during residency but also to ensure successful transition to independent practice [14,15]. Few surgical training programs have formal mentorship arrangements for trainees, yet this may provide trainees with an effective means to voice personal concerns, to seek clinical advice, and to address unresolved moral conflicts. The survey results also indicate that pediatric surgery residents are skeptical about the ability of institution-based policies to regulate and enforce ethical and professional conduct. This skepticism may be fueled by the residents' past experience in surgical training rather than the pediatric surgery residency-specific issues. However, the trainees' reluctance to communicate such behaviors for fear of reprisal strongly supports the need for training programs to provide a neutral environment to express such concerns. Since 2006, an ethics curriculum has been devised by The Hospital for Sick Children, Toronto, and sponsored by the Program Director's Committee of the American Pediatric Surgical Association to provide residency programs with a forum for the discussion of ethical issues pertaining to the care of the pediatric patient. These informal discussions may provide the forum for current trainees to discuss and resolve moral conflicts compared with previous trainees. Further studies would be required to determine whether the implementation of the ethics curriculum has impacted on the prevalence of moral distress among pediatric surgery trainees.
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