Ann Thorac Surg 2002;74:1049
© 2002 The Society of Thoracic Surgeons
Invited commentary
Martin F. McKneally, MDa
a Department of Surgery and Joint Centre for Bioethics, University of Toronto, Toronto, ON M5G 1L4, Canada
e-mail: martin.mckneally{at}utoronto.ca
Surgical competence is a fundamental and distinctive element of the ethic of surgery. Competence includes knowledge that is timely and appropriate, judgment that is balanced and attentive to the particular circumstances of the individual patient, and technical skill to perform the surgical intervention with a minimum of risk and a high probability of benefit [1]. Residents develop their competence by assuming progressively increased levels of responsibility. Their progress is supervised by surgeons trusted by society to guide and safeguard patients, residents, and institutions through a training experience that intuitively seems hazardous for all three stakeholders.
The safe conduct of this experience, reported in this issue of The Annals by Baskett and colleagues [2], is an important public statement about cardiac surgery. The Maritime Heart Institute’s report of competent care provided by cardiac surgical residents is unusually explicit in its discussion of the issue of the safety of care provided by residents during training. Much of the training experience is excluded from the surgical literature, cloaked in tacit understandings that characterize the hidden curriculum of our surgical culture. In his perceptive essay "Education of a Knife" [3], Atul Gawande, a surgical resident with outstanding writing skills, movingly describes the resident’s experience of this process.
Neither residents nor skilled teachers of residents will be surprised by the findings of the Halifax surgeons. It will be useful for patients and the public to recognize more widely that residents are surgeons, residing in the hospital at intervals to assure timely availability of surgical care. Residents’ advancement through the process of graded responsibility toward independent surgical practice is based on their demonstration to their teachers that they have achieved the required level of knowledge, judgment, and skill. Many young surgeons reach their peak in psychomotor skills before the more experience-dependent maturation of their judgment. Mentoring by more seasoned senior surgeons optimizes their performance. The role of surgeon/teachers is an important, subtle feature of the Halifax paper, possibly explaining why the preoperative risk level was higher in the resident cases. The authors remind us that residents were able to choose their cases. Residents know that teaching is not an autonomic function; they tended to seek difficult cases that they could treat surgically with the supervision of gifted surgeon/teachers. These teachers, trusted by their community to nurture the growth of resident surgeons safely, provide society with a steady supply of competent specialists.
References
- McKneally M.F. Surgical competence. Bioethics for Clinicians: Surgery. Ann RCPSC 1999;32(suppl):77.
- Baskett R.J.F., Buth K.J., Legare J.-.F, Hassan A., et al. Is it safe to train residents to perform cardiac surgery?. Ann Thorac Surg 2002.
- Gawande A. Education of a knife. Complications: A Surgeon’s Notes on an Imperfect Science. New York: Metropolitan Books, 2002:11-34.
