Proficiency of surgical faculty and residents with ethical dilemmas: Is modeling enough? Kamela K. Scott, PhD David J. Chesire, PhD J. Bracken Burns, Jr, DO Michael S. Nussbaum, MD Department of Surgery University of Florida College of Medicine - University of Florida College of Medicine -Jacksonville

Background Surgeons practice an “intense form of applied ethics.” Surgeons practice an “intense form of applied ethics.” Kodner IJ. Surgery 2008; 143:460 Most incoming residents received training in ethics during medical school Most incoming residents received training in ethics during medical school Surgery does not specify ethics training in its essential curriculum for surgical training Surgery does not specify ethics training in its essential curriculum for surgical training Downing MT, et al. Am J Surg. 1997; 174:364

Background The majority of PDs in surgery support teaching ethics, but most residencies do not currently include ethics in core curriculum The majority of PDs in surgery support teaching ethics, but most residencies do not currently include ethics in core curriculum Surgery still embraces the “see one, do one, teach one” philosophy Surgery still embraces the “see one, do one, teach one” philosophy Downing MT, et al. Am J Surg. 1997; 174:364 Lack of faculty expertise in ethics frequently cited as the major reason for its lack of inclusion Lack of faculty expertise in ethics frequently cited as the major reason for its lack of inclusion The literature questions “mentoring” as an effective teaching method for ethics The literature questions “mentoring” as an effective teaching method for ethics Helft PR, et al. J Surg Ed. 2009; 66: 35

Concern Faculty frequently self- designate or are designated as the appropriate models for ethical comportment in the clinical setting Faculty frequently self- designate or are designated as the appropriate models for ethical comportment in the clinical setting

Purpose To evaluate the need for ethics education at all levels of surgical training and practice To evaluate the need for ethics education at all levels of surgical training and practice Investigate the differences between faculty and residents in dealing with ethical scenarios Investigate the differences between faculty and residents in dealing with ethical scenarios – Levels of knowledge about the scenarios – Levels of comfort in dealing with the scenarios

Hypothesis There are no significant differences in levels of knowledge in ethics between surgical residents and surgical faculty, but faculty will be more confident in their ability to handle ethical problems There are no significant differences in levels of knowledge in ethics between surgical residents and surgical faculty, but faculty will be more confident in their ability to handle ethical problems

Questions Is there a definitive need for training in medical ethics among surgery residents and faculty? Is there a definitive need for training in medical ethics among surgery residents and faculty? Is the degree of acumen in ethics among surgical faculty such that they function effectively as models of appropriate ethical comportment? Is the degree of acumen in ethics among surgical faculty such that they function effectively as models of appropriate ethical comportment?

Experimental Design: The Pre-test Pre-curriculum questionnaire developed to assess knowledge about ethical principles and confidence in dealing with ethical issues (IRB approved) Pre-curriculum questionnaire developed to assess knowledge about ethical principles and confidence in dealing with ethical issues (IRB approved) – 13 MCQ and true/false knowledge questions – 8 questions evaluating confidence rated on a Likert scale 1-5 Knowledge and confidence scores compared between residents and faculty using Student’s t-test with p<0.05 set as significant Knowledge and confidence scores compared between residents and faculty using Student’s t-test with p<0.05 set as significant

Subjects Surgical Faculty Surgical Residents Males1329 Females37 Mean Age + SD

Results Mean # Correct (SD) Mean Total Confidence Score (SD) Total Faculty7.44 (0.33) * (6.41) * Total Residents6.69 (0.33)27.50 (5.10) Male Faculty7.23 (1.36)30.33 (6.07) Female Faculty8.33 (0.58) # (1.53) # Male Residents6.72 (2.19)27.66 (5.31) Female Residents6.57 (0.98)26.85 (4.41) * p< 0.05 compared to residents # p< compared to male faculty

Conclusions While surgical faculty are more confident in their ethical decision-making, their fundamental knowledge base in ethics is not different than that of the residents While surgical faculty are more confident in their ethical decision-making, their fundamental knowledge base in ethics is not different than that of the residents Female faculty may have greater confidence in ethical principles over male faculty Female faculty may have greater confidence in ethical principles over male faculty Supports the need for BOTH residents and faculty to engage in an integrated education program in ethics to promote on-going, effective dialogue in this complex topic within the clinical arena Supports the need for BOTH residents and faculty to engage in an integrated education program in ethics to promote on-going, effective dialogue in this complex topic within the clinical arena

Study Limitations Results are based on a subset of the surgical faculty that may have a greater investment in ethics training Results are based on a subset of the surgical faculty that may have a greater investment in ethics training Results may not accurately reflect the faculty at large (~ 50% of faculty participated in survey) Results may not accurately reflect the faculty at large (~ 50% of faculty participated in survey) Findings regarding female confidence are based upon only 3 female faculty members Findings regarding female confidence are based upon only 3 female faculty members

Future Directions Findings support the definitive need for formal ethics curricula in surgery both in residency and throughout the surgical career Findings support the definitive need for formal ethics curricula in surgery both in residency and throughout the surgical career We must promote the value of ethics curricula throughout “progressive stages of surgical life” We must promote the value of ethics curricula throughout “progressive stages of surgical life” Kodner IJ. World J Surg. 2003; 27: 1143

Future Directions Engage faculty in recognition that “see one, do one, teach one” mentality does not effectively work for complex ethical dilemmas Engage faculty in recognition that “see one, do one, teach one” mentality does not effectively work for complex ethical dilemmas Further methodological studies on teaching outcomes are needed Further methodological studies on teaching outcomes are needed

Thank You! Kamangar Surgery Residents Training Program in Medical Ethics Kamangar Surgery Residents Training Program in Medical Ethics American College of Surgeons American College of Surgeons