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Operative simulcasts: Patient’s donations to surgeon’s educations

2008; Elsevier BV; Volume: 47; Issue: 2 Linguagem: Inglês

10.1016/j.jvs.2007.12.001

1097-6809

James W. Jones, Laurence B. McCullough,

Dental Education, Practice, Research

I love acting. It is so much more real than life.Oscar Wilde, The Picture of Dorian Gray As the chair of the program committee for a national surgical association, you are presiding over a discussion about the arrangements for a “How I Do It” section. The meeting is being held in a city with a large progressive medical center boasting several technically renowned surgeon originators of popular procedures. Some members of the committee desire to have the session broadcast the performance of procedures real-time to the audience. Such a program was well accepted several years ago. What should be considered ethically?AThe educational value to the attending surgeons.BThe educational value to future patients.CThe educational value to residents and medical students.DThe possibility of increased risk to the patients.EThe engagement value that would attract more attendees. Most surgeons are professional extroverts. They are proud of what they do in the operating room. They talk about their feats and even their defeats in the OR lounge, in the hospital hallways, in classrooms, and from the dais at meetings. Engaging in such discourse is part of the surgical persona and is a vital direct way of spreading technical knowledge and professional bonding. A sure sign of excellence recognized by peers is to have other surgeons visit your OR to watch you operate. A few years back, some enterprising surgeons commanded sizable fees for visitors learning new techniques in their ORs. We are well into the digital information age, and it is fitting that the latest technology be used by surgeons to disseminate surgical techniques. Intraoperative procedural photographs and video have been used educationally to good advantage for over a century. Isn’t live real-time broadcast simply a technologic extension of the educational OR visit to a larger audience and thus ethically unproblematic? Broadcasting live operations for educational purposes, narrated by the attending surgeon en passant, seems to be a reasonable teaching technique, but under closer scrutiny it smacks of antiprofessionalism. Such a practice replaces the ethical primacy of the patient with the ego needs of the surgeon–performer and the profession. In doing so, this practice impinges on the first four of the nine professional responsibilities in the Code of Professional Ethics of the College of Surgeons, which states: During the continuum of pre-, intra-, and postoperative care we accept responsibilities to:•Serve as effective advocates for our patients’ needs;•Disclose therapeutic options including their risks and benefits;•Disclose and resolve any conflict of interest that might influence the decisions of care;•Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period.1Code of professional conduct.J Am Coll Surg. 2003; 197: 603-604PubMed Google Scholar In response, one might argue that the patient’s care is not compromised and the practice’s justification lies in its educational value. The educational benefit of real-time procedures, compared with narration of an edited video, is, however, questionable.2Cotton P. Live video demonstrations.Endoscopy. 2005; 37: 695-699Crossref PubMed Google Scholar, 3Guillonneau B. Live surgical demonstration: is it worthwhile?.Nat Clin Pract Urol. 2007; 4: 59Crossref PubMed Scopus (13) Google Scholar Guillonneau proposes, Video recording of surgery that is then presented to the audience by the surgeon is another way of surgical teaching. The immediacy of the live operation is lost, but this has the advantage of being more interactive, since the video can be replayed at any time to review a technique, an anatomic detail, or a surgical situation. What we lose in spectacle, we gain in education.3Guillonneau B. Live surgical demonstration: is it worthwhile?.Nat Clin Pract Urol. 2007; 4: 59Crossref PubMed Scopus (13) Google Scholar In other words, for real-time operative broadcasts, rather than the surgeon’s presentation being the educational event, the actual patient care becomes the event, with the surgeon’s narrative secondary—spectacle supersedes schooling. It seems beyond tasteless to state that a major factor in the spectator popularity of NASCAR is the possibility of spectacular smash ups and the associated injuries. We have grown more technologically sophisticated since the Roman games, but human nature still loves to witness danger, especially danger to others. Imagine how interesting a bullfight would be if the matador fought from an armored car. Witnessing a live operation is more exciting than watching a video precisely because of the uncertainty. Will there be hemorrhage or will the defibrillation work? Because live-broadcast surgery puts patient care at unavoidable risk of becoming a spectacle, it subordinates fiduciary responsibility to protect one’s patient to the surgeon’s and the profession’s mere self-interest. In doing so, simulcast crosses an unacceptable ethical line. Worse, it does so unnecessarily, because more effective education can be achieved without subordinating fiduciary responsibility to one’s patient. An additional, serious ethical challenge to simulcasting originates in the ethics of informed consent. A properly executed informed consent process for simulcast would require the surgeon to tell the patient that the surgeon will be giving two simultaneous performances, the operation and the presentation. The informed consent process requires that the patient also be informed of risks that are clinically significant,4McCullough L. Jones J. Brody B. Informed consent: autonomous decision making of the surgical patient.in: McCullough L. Jones J. Brody B. Surgical ethics. Oxford University Press, New York, NY1998: 15-39Google Scholar, 5Jones J.W. McCullough L.B. Richman B.W. Informed consent: it’s not just signing a form.Thorac Surg Clin. 2005; 15 (v): 451-460Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar in this case, that the associated distraction is not likely to be detrimental but could possibly be. Ethics deals with possibilities as seriously as probabilities. This unavoidable requirement that the surgeon should inform the patient that simulcasting the procedure might possibly be harmful indicts the practice. Why in the name of common-sense professionalism would an ethical surgeon offer a patient an option that may be clinically harmful, without any offsetting benefit of providing an effective learning experience for others? I have been a witness to some of our most talented technical experts “on stage”; those were exciting performances, indeed; contests of life and death, but the surgical matador took no physical risk whatsoever. Most ended well. In some, the surgeon left the wound closure to subordinates and joined the audience in scrubs and well-deserved glory. But even if one live telecast procedure was injurious to the unconscious patient participant, the improvement in spectator’s future care fails to provide ethical justification, because incurring such risk for one’s patient is inconsistent with fiduciary responsibility to the patient. The utilitarian reasoning of greatest good for the greatest number should be reserved for government committees and other bureaucratic big-picture organizations; the surgeons’ ethic during a procedure is to devote themselves to one patient at a time. Consideration must also be given to whether the surgical care is adversely affected by live presentations. Data are scarce on the subject and randomized data nonexistent. Schmidt and associates6Schmidt A. Lazaraki G. Hittelet A. Cremer M. LeMoine O. Deviere J. Complications of endoscopic retrograde cholangio-pancreatography during live EndoscopyWorkshop demonstrations.Endoscopy. 2005; 37: 695-699Crossref PubMed Scopus (41) Google Scholar compared 168 patients having live workshop demonstrations of endoscopic retrograde cholangiopancreatography with an equal number matched by diagnosis having routine procedures. Endoscopic procedures are hardly technically comparable to major cardiovascular procedures, but the study found no differences in complication rates. They go on to report that there were some notable differences in the manner preoperative and operative care was conducted. Ten percent of patients in the demonstration group were delayed an average of 9 days to serve as subjects, some requiring antibiotics and analgesia to tide them over. General anesthesia was used significantly more often (87.5%) in the demonstration group vs the controls (44%). And cholangiopancreatoscopy used in the demonstration patients was unnecessary in the routine cases. They then make the patently implausible claim that “there were no ethical problems”, a rather blinkered view since “workshop” patients were subjected to avoidable clinical risks that were of no clinical benefit to them. When simulcast is compared with post hoc video presentations, it is plain that the latter is consistent with fiduciary responsibility for one’s patient, while the former is not. The surgeon being relieved of the intraoperative on-stage pressure assures that the patient receives 100% of the surgeon’s attention, and the audience receives a reflective, unstressed educational presentation. Society is beginning to recognize the danger of distractions when performing simple tasks such as using a cell phone while driving. There should be little hesitation in believing that avoiding distractions in performing a complex operation is much more important. What surgeon would permit OR personnel to chatter about unrelated topics during the serious times of a procedure? Some might miss the macho surgeon persona we all basked in a few years ago. Ah, the color, the strength, the excitement, the sheer invincibility of the iron men and their wooden ships, but like the steam locomotive or the gunfighters of the Old West, those times have come and gone. A professional resolution advising against live educational operations seems to us to be a pretty good idea. Sometimes, newer is not better in surgical ethical practice and education.