Medical trainees face unique challenges as they transition from medical outsiders to primary operators.[1] This tends to be a rapid socialization process where they are continually evolving both consciously and unconsciously to meet the demands of changing roles and expectations from service to service and team to team.[2] Likewise, the senior trainees and faculty responsible for training them face unique challenges poised between a need to educate and support the next generation of clinicians and not jeopardize patient care through the involvement of less experienced operators. The authors believe these collective set of unique dilemmas surrounding medical education can collectively be termed “medical trainee ethics”—what are the distinct set of values and virtues that govern acceptable behavior related to trainees' education and involvement in healthcare?

The culture and ethics of medical education are the product of all its members, faculty, residents, students, patients, nurses, technologists, and others, weighted toward those in positions of power or authority. As such, all members bear a degree of ethical responsibility. For example, one issue related to medical education is that patients may not always benefit from trainee participation in their care, and may even be directly harmed by it.[3] Nevertheless, training the next generation of clinicians is necessary to maintain healthcare services and trainee involvement does not necessarily equate with worse care. IR teams at training programs should be committed to supporting trainees' education and grant them graduated autonomy as they progress toward graduation. Yet, all members must strive not to have this jeopardize the concurrent commitment to patient care. For trainees, this requires being as prepared for a case as possible and having the intellectual honesty to ask questions and help when faced with a situation beyond their current skill or comfort level. Trainees who know their limitations and effectively communicate them build trust and allow faculty to safely grant more autonomy.[4] Faculty should thoughtfully gage trainees' comfort and experience and tailor the degree of autonomy accordingly.[5] Nurses and technologists should respect the autonomy granted to the trainees while advocating for the safety of the patient, that is, feeling open to respectfully raise a concern if they feel that patient care is being jeopardized. Patients should also respect that training institutions have a commitment to medical training that comes with the involvement of trainees in their care. However, patients also have a right, to a degree, to choose who they feel comfortable participating in their care.[6] For example, a patient may request that no students or residents be involved in the IR case. The faculty involved should speak with the patient and advocate for trainee involvement while respecting their preferences. In other words, the faculty may explain their commitment to medical education and that they will be involved and ultimately responsible for the patient's care. If the patient is adamant, that preference should be respected.[6]

An additional common issue faced by trainees is moral injury, where the trainee feels compelled to participate in or fail to prevent something that violates their beliefs and values.[7] For example, an IR resident may feel that a request for a third biliary drain is futile, but their faculty agrees to the case, and they feel compelled to participate in a procedure that they believe causes harm without benefit. A related issue is the second victim effect, describing the trauma experienced by clinicians when an adverse event occurs.[8] Of course, these issues are not unique to IR or trainees, but they do tend to be more prevalent and visceral for those in procedural specialties, lower in the pollical hierarchy. These are important issues for programs to consider, as burnout is prevalent in IR and moral injury is likely a major contributor.[9] IR trainees can experience intense feelings of self-doubt when these issues arise but be reluctant to share these concerns as they may adversely affect their faculty and peers' opinions of them. Ideally programs would cultivate a supportive culture where trainees feel encouraged to share their hesitations, concerns, and doubts without fear of being belittled or written off.[10] The burden of doing so falls primarily on faculty and program directors to create such a culture both through individual interactions as well as implementing thoughtful initiatives and policies that support IR trainee's wellness. For example, that third biliary drain may not be futile, and the more experienced faculty can thoughtfully explain their reasoning or share past experiences shaping their decision. They can even offer to do the case without the trainee's involvement without penalizing them.

Fostering a productive and safe learning environment for IR trainees can also be complicated by hidden curricula, microaggressions, and discrimination. Hidden curricula refer to the underlying socialization processes in medical education that transmit specialties' values and behavioral norms outside of formal curricula.[11] Microaggressions are less overt comments or actions that express a biased attitude toward a person.[12] Surveys have shown that these less overt assaults are experienced by the majority of students and surgical residents and are associated with a positive depression screen and higher likelihood of withdrawing or transferring from the institution.[13] [14] They tend to be underreported out of fear of retaliation, which can occur in up to a third of cases.[14] These issues also rest heavily on the cultures of the program, institution, and specialty. How faculty, mentors, and other authority figures behave has an important impact on the socialization process of trainees[2]; for example, if a well-respected IR regularly makes belittling comments, it normalizes this behavior and can make their trainees and staff consciously and/or subconsciously adopt similar discriminatory approaches toward other staff, trainees, and colleagues. Examples include female trainees having to repeatedly confirm they are a physician, comments about the professionalism of hairstyles often associated with a certain race, or even the scrub tech repeatedly interrogating trainees about every action during a case. It is those side comments made by faculty and staff about new junior trainees being “babies” or needing to “earn the right” to be called by their name. Navigating these issues as a trainee is challenging. It can be hard to stand up for oneself or report such behavior due to fear of retaliation and being viewed as overly sensitive since these “microbehaviors” seem small individually. As such, the burden of fostering a more inclusive and supportive culture falls more on faculty, staff, and program directors to advocate for trainees and call out such behavior among their colleagues. Often those involved do not have malicious intent and can be confronted privately and sometimes without disclosing the identity of the trainee involved, for example, “I've noticed that you tend to…” or “Some of your evaluations mention that you say things that make people uncomfortable like….” Program leadership can also emphasize a culture of respect and open communication among faculty, staff, and trainees[15] and establish anonymous means of reporting such behavior with a transparent workflow of addressing such concerns that protect reporters from retaliation.[16]

The issues discussed earlier are only some of the more salient ethical dilemmas surrounding IR training. Other potential issues include conflicts of interest from industry programs targeting trainees, posting loosely deidentified cases and images on social media, and regularly being asked to obtain consent for procedures in which they have never participated. Such issues are rarely formally and openly discussed during training, and there is limited research on the unique ethical dilemmas faced by IR trainees. Nevertheless, these issues are important and deserve greater attention and formal discussion during IR training if our specialty is to cultivate a supportive and effective educational culture for IR trainees.

Article published online:
02 November 2023

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