© Springer International Publishing Switzerland 2015
Barbara G. Jericho (ed.)Ethical Issues in Anesthesiology and Surgery10.1007/978-3-319-15949-2_1111. Professionalism in the Operating Room
(1)
Department of Surgery, University of Buenos Aires, Vicente Lopez 1831 P.B. (1128), Buenos Aires, Argentina
Abstract
Acting on behalf of their patients, surgeons and anesthesiologists can be considered the moral and fiduciary agents of them. Surgeons and anesthesiologists optimize the care of their patients by exhibiting professionalism in their shared work environment. Professionalism in the operating room demands not only competence in a physician’s discipline but also a strict work ethic, adherence to the ethical principles of the profession, diligence, and effective communications skills. The prevention of potential conflicts and the resolution of existing conflicts are necessary to optimize the care and safety of patients in the operating room.
Keywords
ProfessionalismOperating RoomSurgeon-Anesthesiologist RelationshipEthicsConflict ResolutionCase Presentation
A 76-year-old female with colon cancer was admitted for an elective laparoscopic colon resection the day prior to her scheduled surgery date. The patient has diabetes mellitus, a body mass index of 36, and a vague history of coronary artery disease. The surgeon’s plan was to have the patient complete her bowel preparation as well as a preoperative evaluation/workup on the admission day. The day before her surgery, an attending anesthesiologist and a senior anesthesia resident evaluated the patient, assigned the patient’s American Society of Anesthesiologists Physical Status as III, stated there was no need at that time to arrange a postoperative admission to the intensive care unit, and advised the surgeon that the patient was “cleared and ready for surgery.” The patient then began her bowel preparation. The next morning, the patient was brought to the operating room in the preoperative ward and met the anesthesiologist assigned to care for her. The anesthesiologist evaluated the patient and determined that the patient was not medically optimized for the surgical procedure given the patient’s medical history and vague cardiac history. The anesthesiologist requested a cardiac evaluation of the patient and discussed with the surgeon the need to reschedule the surgery. After acknowledging the situation, the surgeon became particularly annoyed and enraged since the surgeon believed that he had taken all the steps necessary in order to prevent the surgery being cancelled. The surgeon then started complaining and shouting, the situation escalated, and disruptive behavior was displayed towards the anesthesiologist. The surgeon’s behavior was witnessed not only by the patient but also by the operating room staff.
The people’s good is the highest law (Cicero, 106–43 BC, De Legibus)
Introduction
In 2001, the Institute of Medicine published a landmark report that redefined patient care as the “provision of care that is safe, effective, efficient, timely and patient centered for all those who are in need” [1]. This concept of healthcare delivery placed the patient’s safety and welfare at center stage. For surgeons and anesthesiologists this concept of care expands care from one that simply consists of a “flawless technique during the performance of an operation” to care that also includes all of the needs of the patient and his or her family. The application of this concept of patient-centered care requires the further consideration of enhanced communication skills and the practice of ethical principles in the care of patients [2]. Patient-centered healthcare delivery emphasizes both the surgeon and the anesthesiologist as fiduciary agents who act on behalf of their patients. Thus, in addition to strong clinical and technical skills, an anesthesiologist and surgeon should have a thorough knowledge of bioethics and the practice of humanism to provide the best care for their patients. Ethics, therefore, lies at the center of professionalism.
Surgeons and anesthesiologists work together in the same environment, the operating room. The operating room is the hospital unit where surgical procedures are performed and each operating room is designed and equipped to provide surgical care to patients with specific conditions. In an efficient, optimal operating room, there should be the guarantee of the highest quality of surgical care and patient safety; the ease of scheduling patients for procedures; an atmosphere of trust and a respectful working environment; the maximization of operating room efficiency and efficacy with a decrease in delays and cancellations of surgical procedures; and satisfaction among patients, personnel and physicians. If these issues of the operating room are considered ahead of time, on the day of surgery, the teams delivering care can focus on the patient without distractions that could lead to conflicts and compromise patient safety. Therefore, the operating room environment requires teamwork to delivery high quality care.
In order to provide this high quality care, there is a team consisting of physicians of different specialties, nurses, technicians, and support personnel. This team approach is essential for patient care. Unusual to other areas of the hospital, though, the operating room involves two physicians (the surgeon and the anesthesiologist) sharing concurrently the management and responsibility of a single patient. This responsibility underscores important decisions, usually involving life and death. Other factors that can impact this provision of care include fatigue, sleep deprivation, and pressure on production and on outcomes [3].
Acting on behalf of their patients, surgeons and anesthesiologists can be considered the moral and fiduciary agents of their patients. Surgeons and anesthesiologists optimize the care of their patients by exhibiting professionalism in their shared work environment. Professionalism in the operating room demands not only competence in a physician’s discipline but also a strict work ethic, adherence to the ethical principles of the profession, diligence, effective communications skills, and working as a member of a team. In the operating room, the prevention of potential conflicts and the resolution of existing conflicts are necessary to optimize the care and safety of patients.
In this chapter, we will review principles that promote professionalism in the operating room, provide elements that can identify the roots of potential conflicts, and introduce strategies for the prevention and resolution of such conflicts.
Professionalism and Ethical Principles
Teamwork is paramount for patient care in the operating room. Surgical and anesthesia teams work hand in hand in many procedures, be it elective or emergent, low complexity or high complexity. Mutual respect among all healthcare providers in the operating room should be the rule and excellent communication among all team members improves patient safety and promotes good patient outcomes.
Competence, diligence, legal issues and concerns, ethics, and concern for patient safety in the operating room are important considerations for all members of the perioperative team. These are concepts embodied in professionalism. In fact, professionalism comprises a “set of values reflected in the philosophy and behavior of individuals whose calling is first and foremost to serve individuals and populations whose care is entrusted to them, prioritizing the interests of those they serve above their own” [4].
John Gregory (1724–1774), a Scottish physician and moralist, must be credited as the one who allowed the transformation of medicine from a trade to a profession. A profession is a group of individuals who are bound by a common ethic or code of conduct. Gregory, in fact, introduced the foundation of medical ethics and defined medicine as “the art of preserving health, of prolonging life, of curing diseases and of making death easy” [5]. He also introduced the concept of the physician as a fiduciary agent to the patient by being “the person having duty, created by his or her understanding to act primarily for another’s benefit in matters connected with such undertaking” [5].
The concept of the surgeon and anesthesiologist as the patient’s moral fiduciary agent can be captured in several reflections. For instance, the surgeon/anesthesiologist should have the patient’s interest as the primary consideration in the physician–patient relationship, as well as in surgical research and education. Similarly, this commitment divests self-interest and makes it a secondary consideration. Self-interest is thus blunted and makes the fiduciary’s role morally demanding.
Ethics Remains at the Center of Professionalism in Both Surgery and Anesthesiology
Presidents of the American College of Surgeons have addressed widely the issue of professionalism in surgery. Dr. Copeland mentioned the importance of a surgical way of life and defined it as “the art and practice of surgery staying in your conscious thought continually” [6]. McGinnis quoted H. Debas stating that “Professional status is not an inherent right, but one granted by society and this obligates surgeons to put their patients’ interests above their own. It must not be forgotten that ethical codes are the major characteristic that differentiate professions from occupations” [7].
Ralph M Waters (1883–1979) is considered a great contributor to the development of professionalism in anesthesiology. He considered it critical to establish a systematic body of scientific knowledge, scientific organizations, and a continuous improvement in clinical practice, represented by high quality anesthesia training programs [8]. In addition, Henry Beecher (1904–1976) was also a significant contributor to professionalism and medical ethics. His role was pivotal in medical research and innovation [9].
Professionalism is the basis of the contract between medicine and society and is guided by three fundamental principles [10]: (1) The supremacy of patient welfare, which is the dedication of physicians to serving patients’ interests. Physicians are considered the moral and fiduciary agents of their patients; (2) Patient autonomy: surgeons and anesthesiologist should empower patients to make informed decisions about their treatment. Nonetheless, there are clinical situations which leave room for paternalism, such as trauma patients presenting for emergency surgery who do not have decision-making capacity and do not have a known surrogate decision maker; (3) Social justice: Aristotle first conceptualized justice as “the rendering to each individual of what is due to him or her” -justice is interpreted as the fair, equitable, and appropriate distribution of what is due or owed to persons. More recent works on social justice originate from John Rawls’ “A Theory of Justice”, in which he argues that a social arrangement forming a political state is a communal effort to advance the good of all individuals [11].
Related posts:
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Perioperative Considerations of Do Not Resuscitate and Do Not Intubate Orders in Adult Patients
Informed Consent and the Disclosure of Surgeon Experience
Ethical Challenges in High-Risk Innovative Surgery
Futility and the Care of the Perioperative Patient
Honesty in the Perioperative Setting: Error and Communication
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