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Surgical Competence

Curricular Objectives

  1. To know the definition of surgical competence
  2. To know the standard of competence
  3. To be able to describe the appropriate management of deficiencies of competence

Summary of Case

Dr. Innovator is performing a new minimally invasive procedure. Tension rises in the operating room as he struggles with the technical aspects of the operation. The operating team becomes increasingly concerned that Dr. Innovator is unable to complete the procedure, and that he may be operating under the influence of alcohol, a problem that has troubled him in the past.


Lesson Plan

Question 1:

What should the resident do to resolve the moral quandary of participating in Dr. Innovator's operation when he is not meeting the standard of competence?

Answer:
The resident has duties to the patient, to the training institution, and to the surgical team, including Dr. Innovator.

  1. The surgeon in chief (based on the authority and responsibility of that position) should be contacted to come to the operating room to resolve the problem for the protection of the patient.
  2. The resident should not try to resolve the problem independently within the narrow and potentially dangerous context of the particular operating theatre in which the lapse of surgical competence may be occurring.
  3. If the resident is uncertain, doubts should be resolved by consultation with an authoritative representative of the institution, not by hopeful indecision.
  4. Most problems of this nature do not occur as isolated unexpected incidents. If there is a background concern about Dr. Innovator's competence, a prospective plan that includes the availability of competent staff support should be in place before the operation commences.
  5. The interests of Dr. Innovator, future patients, and the community should be protected through fair procedures established by the institution.

Question 2:

What is the standard of competence to which Dr. Innovator should be held?

Answer:
Dr. Innovator should be able to provide the conscientious preparation, reasoned judgement, technical skill, and commitment to the care of his patient that informed members of the surgical community would judge to be reasonable. This judgement should be based on competence to achieve the goal of surgery; to provide knowledge that is timely and appropriate; judgement that is balanced, attentive to the particular needs and circumstances of an individual patient, and that chooses the right operation for the right patient at the right time; and sufficient technical skill to perform the surgical intervention with a minimum of risk and a high probability of benefit.

Question 3:

Do residents bear moral and legal responsibility for the outcome of operations in which they participate? In other words, are they surgeons, or are they students?
Take a pedagogic vote: Yes, No, Don't know.

Answer:
Residents are responsible for the actions they undertake on their initiative, and which they can reasonably be expected to perform competently. They report to and are instructed by a class of surgeons who are able and willing to share progressive responsibility with them during the period of their training. Responsibility for competent performance of the duties of a surgeon is assumed in a stepwise, graded progression that is specific to the experience and abilities of individual residents as judged by their instructors.

Question 4:

How should deficiencies in competence related to alcohol, chemical dependency, illness, or age be managed?

Answer:
The use of the operating room and hospital is a privilege extended to surgeons by the community through its representatives (the hospital board) on the basis of community need for the surgeon's skills and community recognition of the surgeon's competence to meet that need. Withdrawal of privileges by the board can and should be prompt when deficiencies of competence arise that threaten the community. Privileges are reviewed at regular intervals to assure that competence is maintained as a condition of renewal.

Question 5:

Are residents competent to operate independently?

Answer:
Residents must already be "capable of practising as an independent specialist" in order to be recommended by their program director for examination by their specialty board or examination committee. The courts have held that residents are independently responsible for the surgical tasks that are appropriate to their level and that have been delegated to them, e.g. thoracotomy, wound closure. In Hopp vs. Lepp, the courts held that surgeons entering practice need not disclose to patients that they are performing operations independently for the first time if they have performed a sufficient number of procedures independently while in residency. By implication, this decision endorses independent operations by competent residents.

Question 6:

How can I justify performing an operation when there is a surgeon available who is more experienced or skilled than I am?

Answer:
Many patients and doctors, including surgeons, idealize competence in an unrealistic and confusing way. Because of the profound consequences of surgical mistakes, they may seek to find or to be the best surgeon in the universe of available surgeons to perform a given surgical procedure. This quest may lead to dislocation of patients from a supportive environment, and alienation of competent caregivers to achieve a marginal or unrealistic statistical benefit. Sound quality assurance in surgery should provide patients with surgical care that is above the morally required threshold of competence, analogous to the safety standards for aircraft pilots and bridge builders. Fine grained distinctions of proficiency and expertise above the threshold of competence identify certain surgeons, whose availability is constrained by natural limitations and is generally reserved for redo or unusually complex cases by a natural selection process. It is impractical and unwise to make expertise rather than competence the reference standard for surgical care.


Bioethics Bottom Line

Competence is a moral foundation of the doctor-patient relationship. The power imbalance inherent in the doctor-patient relationship is magnified in surgery by the invasiveness of most surgical interventions, and the heightened vulnerability of the anesthetized patient. Personal responsibility for harms and benefits of treatment is intensified for the surgeon by the unique immediacy of surgical operations and the close temporal and causal linkage of outcome to the intervention. These characteristics magnify the significance of competence as a moral foundation of the surgeon-patient relationship.

Competence is possession of the required knowledge, skill, and experience to perform a particular task reliably and produce an appropriate outcome. It is a categorical variable; one is competent, or not, to provide a particular service or perform a particular operation.

Surgical competence is specific to tasks (appendectomy vs. aneurysmectomy) and to specialties (neurosurgery vs. urology). It is gained through a progression of graded responsibility under the supervision of competent teachers. A surgeon's competence must be warranted and certified by designated representatives of the profession such as residency program directors and members of examination committees. Continuing competence is certified by the surgeon in chief of the institution that is the locus of a surgeon's practice.

Surgeons have a moral obligation to attain and maintain competence. Impairment of competence is a moral issue for surgeons individually and collectively. It may be caused by illness, fatigue, age, physical or emotional stress, alcohol, drugs, or other factors. The surgeon whose competence is impaired or in question should not perform surgical procedures. Surgeons who lack the skills to perform new or unfamiliar procedures should seek appropriate training and refer their patients to those who have the required skills. The collective responsibility of the surgical community to assure the competence of its members should be addressed through peer review. Review mechanisms include audit, quality assurance, morbidity/mortality conference, and ad hoc reviews by standards and ethics committees of the specialty societies.

Commitment to the completion of the surgical mission, including appropriate follow up care, is a fundamental component of fidelity to the trust that patients place in their surgeons.


References

Karlawish J, Paris JJ, Shewchuck TR, Siegler M. Clinical ethical concerns in the operating room. In: Malangoni MA, editor. Critical issues in operating room management. Philadelphia: Lippincott-Raven Publishers; 1997. p. 211-30.

Pellegrino E. Humanism and the physician. Knoxville: University of Tennesee Press; 1979. p.105-12.

Hopp v. Lepp (1980), 112 DLR (3rd) 67 (SCC)

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