Ethics Corner

Robert F. Murphy, MD
Ethics & Professionalism Committee Member

"I'm Ready"

Scenario:

Dr. Jones is an established surgeon at an academic medical center. She has recently hired a new partner, Dr. Smith, who has just finished his fellowship in pediatric orthopaedics at a reputable program known for adequate volume training in spinal deformity. Prior to Dr. Smith’s arrival, Dr. Jones spoke with the fellowship director who assured her that this individual performed quite well and was capable of treating spinal deformity patients.

A few weeks later, Dr. Smith approaches Dr. Jones about co-scrubbing spinal deformity cases together. Dr. Smith espouses the benefit of two attending co-surgeons from a patient safety perspective and is also interested in “getting off on the right foot” with nursing staff, anesthesia, intra-operative neuromonitoring and vendors. Dr. Jones agrees to support her junior partner and scrub their spinal deformity cases together.

About six months into this relationship, Dr. Jones notes that her junior partner’s skills are improving regarding soft tissue dissection and screw placement. However, she’s also noted that Dr. Smith continues to struggle with critical portions of the procedure, including rod loading and deformity correction. He appears indecisive and deferential during critical portions of the procedure, leading to increased operative times and blood loss.

Dr. Jones currently is concerned that Dr. Smith is still not able to safely perform pediatric spinal deformity surgery independently with a trainee, but she has not yet directly addressed her concerns with him. One day, while in the administrative offices, Dr. Jones sees a posting slip for a spinal deformity case for Dr. Smith on a day when Dr. Jones will be out of town at a meeting.

What should Dr. Jones do?

Discussion:

Assessing competency is a process that occurs throughout medical education and training. Further, determining the competency of a young surgeon who has completed training can be challenging. For residency training programs, the American Council on Graduate Medical Education has provided six core competencies, although none of them specifically enumerate surgical technical proficiency.¹ The American Board of Orthopaedic Surgery has created a resident surgical skills assessment program which allows faculty members to assess resident performance of common orthopaedic procedures.²

However, complex cases such as pediatric spinal deformity correction are not listed. To date, no specific standardized spine competencies exist for fellowship programs. Thus, it is usually the responsibility of the fellowship faculty and fellowship director to assess trainee competency and readiness for independent practice. In an educator and trainee role, remediation and more time in training are the usual solutions when technical expertise or competencies are not yet considered adequate. A factor that complicates the current scenario is that the individual in question, Dr. Smith, has full operative privileges at the facility and is an attending surgeon.

As a final measure prior to unrestricted practice, specialties such as the American Board of Orthopaedic Surgery and the American Board of Neurological Surgery provide a rigorous peer review of an individual’s practice. Although these are critical and rigorous metrics, they only indirectly assess technical capabilities.

Opportunities for improvement or resolution

1. The priority is always patient safety. If you have concerns that a patient is at risk with the young surgeon in question, then it is your medical responsibility to communicate with him with regards to postponing his case until you can help.
   1. From the SRS Standards of Professionalism: Standard 1 A spinal surgeon shall, while caring for and treating a patient, regard his or her responsibility to the patient as paramount.
2. Your younger inexperienced partner could be offended that you are questioning his competency, thus soliciting the help of a mediator may be necessary. As the assessment of surgical competency may be based on two contrasting viewpoints, a non-vested third party surgeon (preferably with spinal deformity experience) will be helpful in decision making. Asking this individual to co-scrub with your new partner for a set number of cases is reasonable and further assesses the younger surgeon’s competency.
   1. From the SRS Standards of Professionalism: Standard 10 A spinal surgeon shall provide only those services and use only those techniques for which he or she is qualified by personal education, training, or experience.
3. Soliciting feedback from other care providers can be helpful (e.g. anesthesia, scrub techs, radiology techs, circulating nurses).

References

1. The ACGME Milestones Guidebook. https://www.acgme.org/Portals/0/MilestonesGuidebook.pdf. Accessed November 12, 2019.
2. ABOS/CORD Surgical Skills Assessment Program. https://www.abos.org/wp-content/uploads/2019/02/abos_cord_surgical_skills_assessment_program.pdf. Accessed November 12, 2019.

 

Chair: B. Stephens Richards III Committee: Anthony M. Petrizzo; Jochen P. Son-Hing; Gary Fleischer (C); Stuart H. Hershman (C); Christopher J. Kleck (C); Robert F. Murphy (C); Mark Oppenlander (C); Paulo Jose Silva Ramos (C); Anuj Singla (C); William F. Young Jr. (C); Jacob M. Buchowski; David A. Hanscom; Steven D. Glassman, Chair Elect; Sherif M. El Ghamry; Hee-Kit Wong; S. Samuel Bederman; John P. Lubicky