March 2017

Ethics Corner

B. Stevens Richards, III, MD
Ethics Committee Member

The committee publishes in each issue of the newsletter a case of possible ethical or professionalism dilemma and invites members to send their comments. Please send your comments to The committee will collect all responses, summarize and publish them in the subsequent newsletter.

Here is a rare scenario, fortunately.

Dr. Smith works in an academic environment and had a 16 year old female patient with spinal deformity needing surgical correction. He met with the family preoperatively explaining the surgery, including the potential complications. The operative consent signed by the parent listed him as the primary surgeon along with “associates, technical assistants, and other health care providers”. The family met Dr. Smith’s trainee assistant the day before surgery.

During the operation, the intraoperative neuromonitoring tracings went flat when the trainee inadvertently violated the spinal canal with a pedicle-finding trocar. All of the appropriate resuscitative measures were undertaken and, although the waves began returning after 45 minutes, Dr. Smith elected to forego the final instrumentation until a later setting. The incision was closed, and the patient was transferred to the recovery room where she was spontaneously moving her lower extremities. A future surgical procedure will be needed.

Postoperatively, Dr. Smith meets with the family explaining the problem that occurred, and then goes on to tell them that the trainee was responsible for the mistake despite Dr. Smith’s instructions to be careful, and that he (Dr. Smith) saved the day...

Questions for SRS members:

  1. What is the appropriate manner in which Dr. Smith should have discussed this issue with the family?
  2. The operative consent stated that others would assist in the surgery. The family was aware of that. Does that make it reasonable for the trainee to be blamed for the complication?
  3. Along the same line, does allowing the trainee to perform some of the procedure in Dr. Smith’s name (as listed on the operative consent) make Dr. Smith the responsible individual if something goes wrong?

Please send in comments, which will be archived and published in this “Ethics corner” June 2017 issue

Early responses:

1. This is excellent. Ultimately, the attending surgeon is responsible for a trainee's actions. I don't know if it's different now and/or the same everywhere, but in Ohio, a patient traditionally could not take legal action against a resident without naming the supervising attending physician as a defendant as well. Two points:

A. As mentioned, the attending surgeon determines an appropriate level of responsibility for a trainee. If the trainee is largely responsible for a mistake, it still falls on the surgeon to realize this was either very bad luck, insufficient guidance, or inappropriate delegation of responsibility. No matter which, the attending surgeon ultimately is responsible for the mistake having occurred. The buck stops with the attending surgeon.

B. In this scenario, making yourself look better at the expense of a trainee will likely irreparably affect the care the trainee can provide the family on behalf of the attending surgeon. This is unprofessional behavior. When discussing complications, the tone should be as neutral and non-inflammatory as possible. It should focus on dealing with the complication, not assigning blame.

2. A common scenario of who is responsible for each action. While I typically use “we”, when questioned by patient or family as to actual occurrence, we must be honest. However, the scenario presented should lead to our thoughtfulness of how we discuss and present to our patient’s information. Being the “hero”, does not help. Also, being present in the room and scrubbed, can be highlighted.

Chair: Kamal N. Ibrahim Committee: John P. Lubicky, Hilali Noordeen, Brent D. Adams (C), Jason Bernard (C), Ryan D. Muchow (C), Timothy S. Oswald, James M. Eule, Timothy A. Garvey, H. Robert Tuten, B. Stephens Richards III, Jochen P. Son-Hing, MD, FRCSC