Fig. 11.1
Neurosurgeons’ duties
11.4.1 Communication
The principle of beneficence dictates that the neurosurgeon should create good communication with the patient in order to appreciate and understand the patient’s needs and act in the patient’s best interests. This line of communication usually begins with the patient’s first appearance in the neurosurgical service, either in the outpatient clinic or in the emergency department. Good communication should be enhanced during the patient’s stay in the hospital. This communication is based on face-to-face communication. On discharge, the patient should always receive a follow-up appointment in the outpatient clinic to continue the care and the conversation.
It is impossible for any neurosurgeon to be available all the time to answer his/her patients’ telephone calls, especially when multiple family members request information. It is important that the treating neurosurgeon spends enough time with the patient before his discharge explaining the possible course of recovery and any possible complications or new complaints, describing clearly what the patient should do in such situations. Many patient calls may be handled by the residents, nurse practitioner, or the neurosurgeon’s secretary. The neurosurgeon should exercise his/her right to sign out to a colleague, like the neurosurgeon on call. A good neurosurgeon makes his/her patient feel all the time that he/she is available, always working for the best of the patient, and ready to help at any time. The neurosurgeon should establish, through communication, a professional relationship with the patient and his family.
Pearl
Good communication, including multiple paths of communication, forms a strong base of trust and partnership with the patient and family to help fight the patient’s disease. The neurosurgeon should show compassion and understanding to the patient and families and make himself/herself as available as possible.
11.4.2 Truth Telling
A fundamental element that bridges all the four bioethics principles is that the surgeon should always be truthful with the patient (Hebert et al 1997). Basic medical ethics obliges every medical practitioner to be honest and inform their patients honestly about the details of their problem, the expected outcomes, the different options for treatment, and the recommended method of treatment. Telling the truth is very important to build up a strong bond of trust and confidence between the patients and their treating staff. It is not rare that the course of treatment of some patients does not go as wished and planned. Unavoidable or avoidable complications or unintended errors do occur in every neurosurgeon’s practice, and they should openly discuss these adverse events with patients and should not try to hide such information.
11.4.3 Duty to Do the Very Best for the Patient
This of course goes without saying, but neurosurgeons should do their very best for their patients and not allow distractions or conflicts of interest get in the way of that. The patient’s care and well-being should be the top priority of every neurosurgeon. The neurosurgeon should think carefully about the patient’s medical condition, never take “simple” cases for granted, and build a strategy for management. In some cases, this may involve getting help from a colleague with more experience, and the surgeon’s ego should never block doing the best for the patient. In fact the neurosurgeon should search for the best method to treat the patient, and if a technology or expertise is not available in the neurosurgeon’s hospital, he/she should inform the patient about that and refer them to the right place.
11.4.4 Duty to Respect the Patient’s Rights
The patients’ rights should be respected and strictly observed all the time. Every neurosurgeon should follow an ethical code. The patient is at the center of the medical ethics and medical care. Therefore everything should be ethically and professionally done for the best of that patient. This includes “small” things like apologizing to patients if they have waited too long in the waiting room or their elective surgery has to be rescheduled due to circumstances beyond the surgeon’s control. Every patient should receive excellent care, and they should perceive that they have received excellent, dignified, and professional care.
11.4.5 Duty to Work as Part of the Team
Modern neurosurgery is not a one-person show. Proper and efficient management of any neurosurgical problem is a complex multistep procedure which needs a fully trained team. Therefore, neurosurgeons should work always within teams, including specialists, residents, nurses, physiotherapists, radiologists, pathologists, lab staff, and other related services. The neurosurgeon is clearly the head of the team for a patient scheduled for surgery under his/her care, but the head of the team must listen to and incorporate all different opinions and share with the entire team to construct and execute a suitable management plan. For example, if the physiotherapist says the patient is not ready to go home on the fourth post-op day, the neurosurgeon must not react in anger but listen and discuss and ultimately respect the opinion of a fellow professional. The treatment plan should of course be discussed with the patient (and family) as well, as the patient in reality is the head of the team.
Pearl
Working as an integral team member is still difficult for some neurosurgeons, but it is the right thing to do and will ultimately improve team morale and, more importantly, patient care.
11.4.6 Duty to Ethically Deal with Innovation and Avoid Conflict of Interest
Industry is active in providing new innovation in the form of instruments, equipment, and medications. Often these innovations have been driven by neurosurgeons by either their expressed need or their intelligence and foresight. Innovation is welcomed and needed in order to refine neurosurgical practice and improve the outcomes for neurosurgical patients (Bernstein and Bampoe 2004). It is the duty of neurosurgeons to be aware of new innovations, and choose, and properly use what is the best for the patients. The proper use of new equipment or techniques requires proper training and possibly mentoring. Medical instruments are a huge market, and it is very important that neurosurgeons deal ethically with the industrial companies and avoid any conflict of interest, as medical companies do more and more to thank neurosurgeons for using their product, most of which is well intended (Morris and Taitsman 2009; Robertson 2008; White et al. 2007).
11.4.7 Duty to Teach Students and Train Residents
Neurosurgeons in university practice (which ranges from perhaps 10–90 % of neurosurgeons in any given country) have the duty and task to teach students and residents the art and science of neurosurgery. Therefore the trainees must have the opportunity to assist and operate under supervision in a graded responsibility model. It is the duty of neurosurgeons to ensure that their trainees are safe, able, and skillful enough to treat and operate patients independently once they are certified and qualified. Teaching of residents has a myriad of its own ethical tensions and challenges which neurosurgeons deal with every day (Bernstein and Knifed 2007).
11.4.8 Duty to Do Research
Research is the backbone and the source for many developments in medicine and neurosurgery. Neurosurgeons should be involved in different types of research – basic neuroscience investigation, clinical trials, outcomes research, and qualitative research. The laboratory benches may answer the questions which are seen in the patients’ beds. Not every neurosurgeon should be involved in primary research, but it may be part of his/her job description to do so, and certainly most university-based neurosurgeons are also involved in some way. If a neurosurgeon is not primarily involved, he/she should at minimum support research such as by participating when asked by colleagues or by sharing financial resources to promote research in his/her university, hospital, or organizations. Any research involving patients should be ethically controlled.
11.4.9 Duty to Be a Good “Citizen” Including Membership in Professional Organizations
Every day in their hospitals, surgeons must be respectful to their own colleagues, to anesthetists, to nurses, and to all members of the hospital staff. They must respect and live by the rules of the Medical Advisory Committee and other in-hospital governing bodies. Good citizenship begins at home.
The main aims of all national and international neurosurgical societies and organizations all over the world are to regulate neurosurgical practice in that country, to provide a forum for continuous neurosurgical education, to promote research, to promote public outreach and education, and to promote international initiatives like global partnerships. Neurosurgeons should actively participate in such organizations so that they contribute to their local, country, subspecialty, and world communities of neurosurgeons.
Pearl
Neurosurgical practice is a noble job. Neurosurgical practice is guarded and regulated by strict ethical and professional codes. The duty of neurosurgeons should extend from treating individual patients to serving the whole of society and all of the world.
11.4.10 Duty to Undertake Continuous Medical Education (CME)
11.4.10.1 A Moral and Practical Necessity
The rapid progress and development in neurosurgery requires that neurosurgeons do their best to be current, learn the new developments, and gain new skills. The neurosurgeon has to be current in order to provide modern cutting-edge care for the patients. There is much to be done to improve the outcome of some serious and common neurosurgical problems like malignant brain tumors, severe brain and spinal cord injury, and congenital disease. Therefore, neurosurgeons must continuously educate themselves and participate in CME to stay current, update knowledge, and gain new skills in order to provide the best possible care for their patients. Not only is it essential to the continual improvement of the surgeon, but it is required by neurosurgeons’ governing bodies and if not fulfilled can lead to consequences such as loss of membership in society or even license revocation. Most neurosurgical governing bodies clearly spell out the number of hours required often in 2- or 3-year cycles and what sorts of activities qualify and have online forms to fill out at the end of every evaluation period (Royal College of Physicians and Surgeons of Canada Maintenance of Competence).
11.4.10.2 Who Should Pay for CME?
Attending workshops, conferences, and seminars is costly. Most hospitals and universities do not have the budget to support their medical staff. Many neurosurgical groups have internal redistribution of portions of their income to be used specifically for academic and CME activities. The tax system in some countries (not all) may allow a certain amount of training to be offset against taxes paid.
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