Non-Violence in Surgical Training

Nedim C. Buyukmihci, V.M.D.a

The following is to stimulate thought about the dilemma of developing the psychomotor skills necessary to do surgery without resorting to 'practice' nonhuman animals in veterinary medicine. It is not intended to be a precise method of how to develop these skills, rather it is intended to argue that it is possible to achieve these skills without killing healthy nonhuman animals and to urge those facing this dilemma to voice their opposition and demand they be allowed to work towards a solution (alternative).

It must be understood at the outset that the surgical training veterinary medical students currently receive prior to obtaining their degree does not make them surgeons. At best, for the average student, it may increase their confidence as it initiates them to the complexities of surgery. It has the potential, however, of reducing the student's confidence because of the confusion and frustration the students may experience during the very limited exposure they receive during school. Contrariwise, it may inspire overconfidence making the student a serious liability to patients and clients upon graduation, until experience improves the new graduate's skills.

Although these problems will not be overcome simply by instituting alternatives, certain alternatives such as inanimate objects may allow for increased exposure to basic skills which are fundamental to more complex procedures.^2,3,5,8,10 Because these materials are not associated with the logistical problems live nonhuman animal use entails, they can be used repeatedly and at the student's convenience. Increased experience with knot tying boards and suturing of foam rubber models cannot help but improve proficiency thereby making any subsequent live nonhuman animal experience that much more rewarding.

As an example, at the Ohio State University College of Veterinary Medicine, Dr. Dan Smeak taught students how to ligate blood vessels by using foam pads and red string to simulate incisions. He and his coworkers found that students who practiced on these inanimate models did better when faced with a real surgery than students who had learned on the animals themselves.^12,13

Whereas one must at some point use live nonhuman animals to improve the skills necessary to do surgery, it does not follow that one must purposefully kill these animals in the process. In this respect the typical manner in which surgical skills are taught to veterinary medical students in this country is ethically indefensible. Nonhuman animals taken from pounds or purchased from dealers or breeders are used and killed like so many disposable commodities. This is in stark contrast to the situation in human medicine in which people aspiring to become physicians do not kill humans (nor, as is increasingly becoming the case, nonhumans) in the name of education.

The killing of nonhuman animals in veterinary medical education continues, unfortunately, out of convenience and habit, not because it is pedagogically necessary. There are several alternatives to the killing of healthy nonhuman animals in surgical training. Bear in mind that the British veterinary medical schools use cadavers and an apprentice system. The fact that many of their graduates compete successfully for residency and faculty positions in this country attests to our respect for their abilities. Furthermore, the school of veterinary medicine at the University of Utrecht in the Netherlands does not harm or kill any nonhuman animals in its surgical or other training. What is particularly pertinent here is that this school is fully accredited by the American Veterinary Medical Association (AVMA).

In this country, however, when students have requested alternatives to the killing of healthy nonhuman animals, they usually have been met with ridicule and sarcasm. Their personal life-styles have been attacked as if absolute consistency is required in order to give credibility to a moral premise. Some faculty, apparently having only 'heard' the word alternative, have made sarcastic statements to the effect that one cannot learn surgery using vegetables. Some students have also been told that they should reconsider their career choice. This type of demeaning behavior towards these students not only is unprofessional, it also discourages a search for more humane methods of teaching.

Anything which involves a nonhuman animal or simulates certain anatomical features should be acceptable for the acquisition of basic skills such as suturing, some aspects of tissue handling, and the like. This can include knot tying boards or similar mechanical devices, especially when combined with visual aids such as photographs or videotapes for use during times when personal supervision is inconvenient. Models simulating various organs also have been shown to be feasible in preparing students for the real patient.3,5,6,7,8 A cadaver can provide the added dimension of learning surgical anatomy at the same time. There now is evidence that students training on cadavers develop proficiency equal to those using live animals.1,11,14

It should be obvious that the source of the cadaver is important if one is proposing an alternative for moral or ethical reasons. It would not do to use cadavers from the pound, for example, if one is opposed to using these animals in the living state even though the procedures may be terminal (non-survival surgery) and, therefore, would result in the same outcome for the animal (death).

Sharpening of one's skills in hemostasis and critical tissue handling seems unlikely to be accomplished except on living animals. One way this can be done is by using a patient who needs the surgery, under strict supervision by a surgical instructor.9 Initial involvement by the student may be limited to fairly simple steps such as skin incision or suturing. As her or his skills improve, the student gradually could increase the level of involvement until he or she was able to do some of the more common procedures in their entirety. This would mean more work on the part of those involved in the training of the students. In addition, it would be desirable, although not necessary, to increase the clinical part of the curriculum from the current average of less than a year to something longer in most situations in order to increase the students' exposure to clinical surgery. Any perceived 'disadvantages' to such a program should be viewed in the context that the program would help nonhuman animals who needed the surgery and would be ethically defensible and less desensitizing to the students.

An alternative could be the use of a patient dying of cancer or other hopeless situation. This is, in principle, no different from willing one's organs for use after death. After getting permission from the client, the patient would be deeply anesthetized. The various procedures would be done and then the patient would be euthanatized without allowing recovery from the anesthetic. It should be obvious that this is no different in any meaningful respect from the manner in which it is done on healthy animals who are killed afterwards. Postoperative care skills can be developed on any patient, including those who actually needed the surgery. It largely is immaterial from a pedagogical aspect that someone else did the surgery.

Another alternative which would provide not only surgical experience for students, but also would give the students experience in caring for animals after surgery involves cooperating with local animal shelters. Under a system called benevolent transfer by the Michigan Humane Society, potentially adoptable animals would be transferred from a local shelter to a school of veterinary medicine. The animals would be attended to by veterinary medical students. Physical examinations, diagnostic procedures and treatments would be rendered by the students, with supervision by experienced faculty. Those animals not already neutered would be spayed or castrated by the students. After the animals have recovered and when it is safe to have them leave the hospital, they would be transferred back to the shelter. In the limited situations in which this has been done, these animals have been shown to have a higher adoption rate. As with programs using patients already having human companions, this program would be beneficial to all. The spay and castration aspects of such a program now are a standard part of the curriculum at Washington State University and the University of California.

The AVMA, which is responsible for accreditation of veterinary medical schools in this country, does not dictate the manner in which surgery is taught. Its concern lies primarily in ensuring that students are exposed to sufficient numbers of patients in order to have an experience base that will provide for continued learning after graduation. As mentioned, they have accredited at least one school which does not harm or kill nonhuman animals in its programs. Although sometimes used as a reason for disallowing alternatives, one can see that any such plea to AVMA accreditation problems is vacuous.

Because the majority of veterinary medical schools in this country utilize dogs or cats from pounds, it is appropriate to address this issue with respect to surgical training. The mind-set is that these dogs and cats are going to be killed anyway, so why not utilize them to some meaningful end? If it was that simple, it would be illogical to argue against this. There are, however, many factors that make the continued use of animals from pounds for surgical training a problem regardless whether the animals were actually going to be killed on the day of the proposed surgery laboratory.

One of the most compelling reasons for not using animals from the pound is that it institutionalizes our dependency upon a source of animals which all should be decrying and attempting to prevent. All would agree that the 'overpopulation' of dogs and cats, with its attendant mass destruction of 'surplus' individuals, is a societal ill due to human irresponsibility. If, however, it is maintained that animals from the pound are necessary for teaching, it may be unlikely that a concerted effort will be made to eliminate this tragic situation. The conflict of interest could be too great.b

Another compelling reason for discontinuing the use of pound derived animals is that it fosters confusion and insensitivity in students and faculty. There are no morally relevant differences between dogs from the pound and dogs who might have a human guardian. Dogs from either group have the same capacity to suffer or to enjoy life. The statement by many who support using pound derived animals that the latter animals are 'going to die anyway' ignores the principle of the matter. Veterinarians should have the highest sensitivity for nonhuman life and should be fostering a reverence for life in those aspiring to be veterinarians. Viewing and using other animals as simple teaching tools with no meaningful regard for their lives is the antithesis of this principle.

Another consideration is the stress placed upon the dogs or cats during transportation from the pound to the school. Whereas it may not seem like much to a human observer, one needs to be empathetic to the other animals' situation. Having already been caught and transported to a strange place by strangers, any further handling and transportation by other strangers undoubtedly will cause further stress. The animals in question do not know, like a human observer would, that the trip is finite. If this was being done for the sake of these animals, as in the case of benevolent transfer, one could effectively argue that any additional stress would be outweighed by the prospect of a long life in a good home. Although killing these individuals rather than subjecting them to further handling and transportation may seem 'wasteful,' it is in the animals' best interests, if it is decided that death is the final disposition.

Finally, it is specious to argue that the pound derived animals were 'slated for death.' Only the most socialized and docile dogs are chosen for use in surgery laboratories. These individuals also would have the highest chance of being adopted if there were resources available to keep them at the pound for a longer period of time. To say, therefore, that these dogs were 'going to die anyway' ignores the fact that their fate is heavily dictated by financial considerations and logistics. The situation is compounded when there is an agency ready and willing to purchase these animals.

In conclusion, there are no pedagogical reasons why nonhuman animals must undergo unnecessary surgery followed by death in order to teach the principles of surgery to veterinary medical students or others. Humane alternatives are available and require only a change in mind-set to facilitate their use.4 Students cannot legally be forced to harm or kill nonhuman animals as part of their education. There is ample precedent for this. It will take, however, continued effort by students to prevail upon various professors to provide an alternative program at all the schools. It can be very intimidating to do so. Take heart, however, in the fact that there is nothing the professors can do to you that is as bad as what they expect you to do to the other animals.

References

1. Carpenter, L.G., Piermattei, D.L., Salman, M.D., Orton, E.C., Nelson, A.W., Smeak, D.D., Jennings, P.B. and Taylor, R.A.: A comparison of surgical training with live anesthetized dogs and cadavers. Vet. Surg. 20: 373-378, 1991.

"No statistically significant differences could be detected between the two groups [of students, with respect to skill, outcome]."

2. Dunayer, E.: Alternatives to the harmful use of nonhuman animals. The Association of Veterinarians for Animal Rights, 1990.

3. Greenfield, Cathy L.; Johnson, Ann L.; Arends, Mark W. and Wroblewski, Andrzej J.: Development of parenchymal abdominal organ models for use in teaching veterinary soft tissue surgery. Vet. Surg. 22 (5): 357-362, 1993 (September-October).

"Models of the canine spleen, kidney, and liver were made from soft plastic to simulate the organs of the live animal as closely as possible in appearance and tissue handling properties. Each organ model was independently evaluated by five small animal surgeons who performed several common surgical procedures on each model. All models had a realistic appearance and, with the exception of one tissue handling problem with the kidney model, and one with the liver model, tissue handling properties of the models were comparable to those of the organs in the live animal. All models were useful for teaching each of the procedures evaluated."

The authors posit, "We believe that veterinary students will develop better surgical skills using realistic soft tissue models as an adjunct to live animal training than they can using traditional methods alone."

4. Greenfield, C.L.; Johnson, A.L.; Smith, C.W.; Marretta, S.M.; Farmer, J.A. and Klippert, L.: Integrating alternative models into the existing surgical curriculum. J. Vet. Med. Ed. 21 (1): 23-27, 1994 (Spring).

Discusses the modification of their surgical training curriculum to meet animal welfare and student conscience concerns. Have met with approval by faculty and students and still evolving.

"At The University of Illinois, we have made humane issues a priority in our surgical teaching program and we have taken a pro-active attitude."

"Over the next few years, our surgical laboratory curriculum will continue to evolve to the point of having no nonsurvival surgical laboratories. The elective neutering procedures on humane shelter animals will be used for all instruction of live-animal surgery and postoperative patient care during the 3rd-year surgical laboratories."

5. Greenfield, Cathy L.; Johnson, Ann L.; Schaeffer, David J. and Hungerford, Laura L.: Comparison of surgical skills of veterinary students trained using models or live animals. J. Am. Vet. Med. Assoc. 206 (12): 1840-1845, 1995 (15 June).

Found that there was no significant difference between traditionally trained students for the most part.

6. Holmberg, D.L.; Cockshutt, J.R. and Basher, A.W.P.: Use of a dog abdominal surrogate for teaching surgery. J. Vet. Med. Ed. 20 (2): 61-62, 1993 (Fall).

The authors found DASIE to be an effective alternative for preparing students for live surgery. It was well received by the students.

7. Holmberg, David L. and Cockshutt, Joanne R.: A non-animal alternative for teaching introductory surgery. Humane Innovations and Alternatives 8: 635-637, 1994.

8. Johnson, Ann L. and Farmer, James A.: Evaluation of traditional and alternative models in psychomotor laboratories for veterinary surgery. J. Vet. Med. Ed. 16 (1): 11-14, 1989 (Spring).

"The use of large and in some cases unrealistic models were superior to live animals for demonstrating basic concepts and allowing the students to gain basic skills. ... Students readily accepted alternative models as long as clinical relevance had been demonstrated by the instructor."

"Basic psychomotor skills that are essential to the surgeon can be learned with inanimate models. In addition, motor proficiency can be achieved with repetition on models, making the use of models a superior alternative to live animals for learning basic motor skills."

9. Johnson, Ann L. and Farmer, James A.: Teaching veterinary surgery in the operating room. J. Vet. Med. Ed. 17 (1): 10-12, 1990 (Spring).

Discuss the methods of teaching surgery using patients.

10. Johnson, A.L.; Harari, J.; Lincoln, J.; Farmer, J.A. and Korvick, D.: Bone models of pathological conditions used for teaching veterinary orthopedic surgery. J. Vet. Med. Ed. 17 (1): 13-15, 1990 (Spring).

"Bone models simulating radius curvus and a femoral nonunion were developed. The models were used successfully in senior student orthopedic surgery rotations and in a continuing education laboratory. The models were ideal for demonstrating and teaching preoperative planning, operative principles and procedures, and postoperative results of corrective osteotomies to veterinary students, interns, residents, practitioners, and clients."

11. Pavletic, Michael M.; Schwartz, Anthony; Berg, John and Knapp, Deirdre: An assessment of the outcome of the alternative medical and surgical laboratory program at Tufts University. J. Am. Vet. Med. Assoc. 205 (1): 97-100, 1994 (1 July).

Surgical procedures assessed were: "Ovariohysterectomy, Castration, Laceration Abscess, Laparotomy, Gastrotomy, Eyelid surgery, Cystotomy, Intestinal anastomosis, Splenectomy, Gastric torsion/Gastropexy, Simple fracture repair, Cast/Splint application, Thoracotomy, Other"

Medical and diagnostic procedures assessed were: "Transtracheal aspirate, Urinary catheterization (male), Urinary catheterization (female), Bone marrow aspiration, Venipuncture, Needle aspirate, True cut needle biopsy, Ophthalmic examination, Otic examination, Cerebrospinal fluid tap, Cystocentesis, Venous catheter placement, Other"

"Our results suggest that use of cadavers during the third-year laboratory program, when supplemented with additional clinical training during the fourth year, can provide training comparable to that provided in a conventional laboratory program."

12. Smeak, D.D.: Simulator/media based teaching of basic surgical skills. Proceedings of the First Annual International Foundation for Ethical Research Workshop: Alternatives to Live Animals in Veterinary Medical Education: 10-12, 1989.

13. Smeak, D.D., Beck, M.L., Shaffer, C.A. and Gregg, C.G.: Evaluation of video tape and a simulator for instruction of basic surgical skills. Vet. Surg. 20: 30-36, 1991.

14. White, K.K., Wheaton, L.G. and Greene, S.A.: Curriculum change related to live animal use: A four-year surgical curriculum. J. Vet. Med. Ed. 19: 6-10, 1992.

"The small animal surgical faculty have noted that students from the alternative surgical laboratory program are more timid and hesitant the first time they incise living tissue. This hesitancy is only apparent on the first live tissue surgery. In all other segments of the 4th-year small animal surgery and anesthesia rotations, including patient care, the alternative students perform on a par with the students from the standard laboratory experience."

a Professor of Ophthalmology, University of California, School of Veterinary Medicine, Department of Surgical and Radiological Sciences, Davis, California 95616-8745; President, Association of Veterinarians for Animal Rights, P.O. Box 208, Davis, California 95617-0208; E-mail: ncbuyukmihci@ucdavis.edu; Copyright © 1989-1996 Nedim C. Buyukmihci.

This paper is part of a series on exploitation of nonhumans by humans. Please read the first paper, entitled 'Serious moral concern is not species-limited', prior to reading this paper in order to understand why certain arguments are being made.

b I realize one could argue that using this source of animals for spays and castrations is just as objectionable, in principle, if one depends upon this source. One might ask, If dog and cat overpopulation is eliminated, from where would individuals for surgical training come? I believe the situation needs to be seen as a temporary method until we alter our mind-set so that we simply would never consider it acceptable to allow the killing of healthy animals in education. When we rise to this plane of sensitivity and compassion, we will find other methods to teach surgery.