Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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394 Surgery and Healing in the Developing World
geons, as much attention should be given to developing character and to developing
ethical conduct as is given to developing clinical skills. Both are vital to a surgeon’s
eventual success.
The Hippocratic oath used to be the mainstay of ethics in medical practice in the
West. Unfortunately, accountability to a higher authority is not part of the oath.
Ethical training may begin with this famous teaching but should not be limited to
it. Physicians need to be accountable to each other, to their patients, to the appropriate
government officials, and to their Creator.
In more developed countries, the conduct of physicians is not only spelled out in
written laws but systematically enforced. Patients’ rights are upheld by courts of law.
This underlines the importance of teaching residents what the law says about a
patient’s rights and the rights and responsibilities of physicians. They should be
strongly encouraged to respect and obey these laws, even if those laws are ignored by
everyone else and are not uniformly enforced. Questions about these laws should be
included on their examinations.
Learning about laws and insisting that residents respect them during their training
is not enough, however, because laws are an external motivating force that may
not always be there. If in some countries these laws are ignored by the medical
community or rarely enforced, why should physicians persist in swimming upstream?
Unless the motivation to practice medicine ethically is internalized, the newly-trained
surgeon will eventually weary of the fight, follow the crowd, and drop to the lowest
common denominator of surgical practice.
What motivation could be stronger than uniformly enforced laws, the threat of
lawsuits, or the need to satisfy wealthy patients? In the Western world the most
powerful influences have been the Judeo-Christian teachings that physicians are
accountable to God for their actions.
Neglecting the spiritual and ethical dimensions of a surgeon’s training may in
the end produce doctors with good surgical technical and medical skills more interested
in practicing surgery for their own benefit than for the benefit of their patients.
In countries or communities where there are few safeguards, this can prove
devastating to patients, to good surgical practice, and to passing surgical knowledge
on to other qaulified individuals.
A Systematic Textbook-Based Study Program
Although residents usually read about the cases they encounter on a daily basis
and read for their case reports, there needs to be a systematic study program that
covers all important and pertinent areas of general surgery. Residents may not become
expert in plastic surgery or orthopedics, for example, but they should have
some understanding of these fields for future reference. To insure this, Program
Directors should select a well-respected and widely used general surgery textbook
and establish a systematic reading program for their residents to follow. In a four-year
residency program, the reading program should go through most if not the entire
textbook twice. It may be helpful for the Program Director to give a weekly quiz and
review for the residents the assigned material in a weekly conference.
Yearly Examinations
Residents should not only systematically study an assigned textbook but should
be tested over what they have read and heard in formal lectures, on rounds, in the
outpatient clinic, and in the operating room. Program Directors should choose a