AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. October 2004, Volume 6, Number 10.

Clinical Cases

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The Reluctant Resident

Surgery residents should always answered truthfully when asked by patients about their experience with surgical procedures.

Commentary by Jeffrey L. Ponsky, MD

Kelly is still upset over yesterday's events as she gets ready for her shift. A simple laparoscopic appendectomy, and the attending had to take over. "I was having trouble," she reminds herself. And that wasn't the first time. "I mean, a second-year surgery resident is supposed to be able to do a laparoscopic appendectomy." She starts to review what happened just before the attending took over when her pager beeps at her. She heads down to the ER.

The surgeon meets her outside the exam room. "Patient's name is Emily Blanchard. She's 14, and started feeling pain in her periumbilical area last night. This morning the pain localized to her lower right quadrant, and on exam, she has rebound tenderness. She has a temperature of 100 degrees and her white blood count is 12. I'm guessing it's appendicitis, but that's what you're here for."

"Have you ruled out the possibility of an ectopic pregnancy?" Kelly can't believe that 2 cases of appendicitis would present in 2 days.

"She says she hasn't been sexually active."

Kelly enters the exam room. "Hi, Emily. I'm Dr. Washington, but you can call me Kelly. How long have you been in pain?"

"Since last night."

"Can you show me where it hurts?" Emily points to her right side, slightly above her hips.

As Kelly lightly presses on the area she asks, "Does this hurt?"

Emily nods.

Kelly orders an ultrasound to confirm an inflamed appendix and rule out gynecological complications. After she completes the ultrasound and confirms the inflamed appendix, she and Emily make eye contact. "Well, Emily, it looks to me like you've got appendicitis, which means we'll need to remove your appendix. I'd like to talk to one of your parents about it, is one of them here?"

"My dad's in the waiting room," Emily mumbles.

"Is it alright if I bring him back here?" Kelly asks.

"Sure."

A nurse brings Mr. Blanchard into the room and Kelly calls for the attending surgeon. When both of them have arrived she informs them of her diagnosis and the need for surgery. Mr. Blanchard catches the attending's eye and asks, "Are you going to be the surgeon?" The attending shakes his head, "Dr. Washington will be the operating surgeon under my direct supervision." Kelly feels the blood rush to her face. Mr. Blanchard looks her in the eye and asks, "Have you done this before?"

What should Kelly do?

Commentary

A resident must deal with myriad frustrations and conflicts as he or she progresses through training. This case demonstrates 2 such situations. Kelly is struggling to gain technical competence in the performance of laparoscopic appendectomy; clearly she has not yet attained this and is frustrated by her lack of progress. This frustration is typical among residents as they strive to learn new technical procedures and must be "rescued" to complete them. What is crucial is that they recognize this frustration as the norm, and know that to attempt these techniques without assistance until they have gained competence and confidence is dangerous for the patient and unethical. If a procedure is completed, but poorly and without assistance, it jeopardizes patient safety and does little to advance the skills of the resident.

Kelly is fortunate that her attending surgeon has so properly included her in the operating team, so that, later, when asked if she has performed this surgery before, she can truthfully reply, "Yes, but always with the assistance of an attending surgeon." She is thus being honest and ethical. Kelly will soon attain competence in this and other procedures. However, a career in surgery is a continuous learning process and Kelly should seek and enjoy the assistance and advice of an attending or more experienced surgeon often throughout her residency and the rest of her career.

An excellent surgeon is not threatened by the advice or assistance of others.

Jeffrey L. Ponsky, MD, is director of Graduate Medical Education and vice chairman of the Education Division at the Cleveland Clinic. He also heads the Surgical Endoscopy section of General Surgery.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.