For many years now, medical schools around the country have ceased using live animals to perform procedures as part of the curriculum. But in a minority of surgical residencies, residents operate on animals — often pigs — to practice techniques to be used on human patients. Oregon Health & Science University is in that minority. For years, People for the Ethical Treatment of Animals has been waging a campaign to get OHSU’s OB/GYN residency program to stop using pigs for doctors in training to practice reproductive surgeries. At the same time, the Physicians Committee for Responsible Medicine is asking the hospital to stop using the animals in all of its surgical residencies in all branches of the hospital.
OHSU declined to participate in this conversation, but Dr. Kerry Foley, a retired emergency medical doctor who volunteers for the Physicians Committee for Responsible Medicine, joins us to share her views on best practices for surgical training and why those do not include using animals.
The following transcript was created by a computer and edited by a volunteer:
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. For many years now, medical schools around the country have phased out the use of live animals for their training. But in a minority of teaching hospitals in the US, surgical residents still practice on animals, often pigs. Oregon Health and Science University is in that minority. Animal rights groups and other advocates have been trying to get OHSU to stop this practice. So far, that pressure has not worked.
OHSU declined to participate in this conversation. But Dr. Kerry Foley joins us to talk about this issue. She is a retired emergency medicine doctor who volunteers for the Physicians Committee for Responsible Medicine – that’s one of the groups that’s been pushing for OHSU to change. Dr. Foley, welcome to Think Out Loud.
Kerry Foley: Thank you very much.
Miller: As I noted, you were an emergency medicine doctor. How did you learn to perform surgeries?
Foley: I learned back in the ‘80s and in the ‘90s. We didn’t have all these cool simulators available to us then. We learned on cadavers primarily or we learned on the job. You watch somebody do a procedure, the next time you get to have a go at it, and after that, you’re teaching somebody else how to do it. That’s obviously not ideal. But I think people are quite fortunate now because we’ve got lots of other alternatives.
Miller: Would you have objected at the time, when you were, say, a first year resident to learning a procedure on a pig?
Foley: I would have objected, but probably for different reasons than I’m objecting today. I would have found it very unsettling and off putting to hurt an animal. And that’s still part of my ethos. But I also now see that there are better, different ways to do this.
Miller: You mentioned your own training. What about when you were an attending physician, or an established, in your career, physician? You worked at three different teaching hospitals over the course of your career?
Foley: I worked at three different Level 1 trauma centers that were all affiliates of Georgetown University Hospital, which is where I trained. Very well versed in training residents, training medical students, and in trauma medicine.
Miller: And what did that training entail when you were the one who was doing the training? Was that also the methods that you had experienced yourself as a trainee?
Foley: Yes, because again, we didn’t have any other options. It’s only been in the last decade or two that people have had simulators available to them which can replace animals. But cadavers were always a resource for us to learn procedures on.
Miller: This could get a little bit graphic. But how actually do you work on a cadaver? Because if it’s simply a dead body that has not been manipulated in any way, I imagine, for example, it’s not going to bleed the right way. So what does it mean to say that you worked on cadavers?
Foley: Back in the day, when I was working on cadavers and learning on cadavers, it was mostly a matter of learning the anatomy, and how to do a procedure with that anatomy. Now, we actually have something that is widely available – believe it or not – that are called perfused cadavers. And these are relatively fresh cadavers. There are pumps and IV lines that are set up to simulate an actual surgical setting in which the patient, if you will, will bleed. It’s much more anatomically true and correct, and gives a very good training situation for a young doctor.
Miller: We asked OHSU more than a week ago if they would join us on air in conversation, either separately or with you. They said there was no one available and interested in doing this interview. They did send us a statement though, which they have sent to other journalists dating back more than a year. I want to read you different parts of it to get your take on it. This is one of them:
“OHSU understands and embraces the responsibility to provide compassionate, quality care that comes with the privilege of working with animal models. We believe that the education and experience surgical trainees gained through the use of relevant animal models are essential to ensuring future surgeons have the knowledge and skills necessary to provide safe high quality care. Our views on this topic reflect those of other surgical training programs around the world.”
So how much does the use of animal models for surgical training reflect the practice of, as OHSU says, other surgical training programs around the world?
Foley: In the United States, the Physicians Committee for Responsible Medicine, which I’m a member of, has surveyed the existing surgical residencies. And we know that 79% of surgical residencies, which would be 221 out of 281 that we surveyed, had stopped using animals completely. And so we also know that 216 of OSU’s peer programs – such as Stanford, Yale, Mayo Clinic, Harvard, the Cleveland Clinic – have all stopped using animal models.
All of the civilian surgical residencies in Oregon and in the state of Washington have stopped using live animals. So that would be the University of Washington, Samaritan Health in Corvallis and the Swedish Medical Center. So it becomes very difficult, I believe, for OHSU to continue to defend this practice, when other very revered and esteemed training programs have stopped in favor of using human-identical simulators and perfuse cadavers.
Miller: What is a human identical simulator?
Foley: They’re very cool. There’s a variety of options. They’re very realistic, they have replaceable body parts. So there’s muscle layers, there’s fat layers, there’s tissue layers – all of which can be replaced and all of which allow for repetitive training. So if you learn how to do a surgical procedure, say a cricothyroidotomy, which is like a tracheotomy or a surgical airway in an emergency situation, if you learn that on a pig, you get one shot. And you better get it, you better learn how to do that. If you do it on a simulator, you can do it repeatedly until you master the skill. And then because it’s not something that’s necessary very frequently, you can go back to the simulator center every year and refresh your skill set so that you stay fresh.
And we have multiple studies to prove that the retention levels for skills are as good, if not better. The stress levels for the trainees are as good, if not better. And it just doesn’t seem defensible to me to continue using live animals, who, by the way, have a very different anatomy. They have important anatomical differences. I know if I needed to have a surgical airway or have my gallbladder removed or have any number of procedures done to me personally, I would really feel strongly that the person who did that trained on human identical anatomy.
Miller: I want to run another part of OHSU’s statement by you. They wrote this:
“When possible, OHSU uses inanimate simulators for training. Examples include an OHSU-developed simulator to train future brain surgeons, medical mannequins and a simulation center to train OHSU nursing students. OHSU looks forward to a time when non-animal surgical training methods are capable of faithfully modeling the complexity of a living system in all cases. However, technology currently does not exist to recreate some of the most complex procedures surgeons must regularly perform in humans.”
Are there, in your mind, specific procedures for which there is no good substitute for training on live animals?
Foley: I don’t believe that there are. I believe that since we’ve got Stanford, Harvard, Yale, the Mayo Clinic and the Cleveland Clinic leading the way here, I can’t see that they would accept substandard training for their surgical residents.
Miller: Another line that they told us is that they will keep monitoring and evaluating alternatives to using animal models, and they’re committed to adopting these techniques as soon as they are validated scientifically. How are medical training techniques evaluated scientifically?
Foley: Well, that goes back to the research that I was mentioning earlier and that we have actually supplied to all levels of the surgical residency training program, the university and the medical center. We’ve provided them with all of these research data, and we’re happy to send it to them again, but the research is out there. It’s no question. The military programs acknowledge the research, had in many cases done the research themselves, and shown that the outcomes are as good if not better when using simulators.
And actually, the Physicians Committee for Responsible Medicine has made an offer to OHSU to provide them with a demonstration using a perfused cadaver to show them actually what that experience is like. We’re willing to take on the $13,000 cost of that and to give them a demonstration. We’re hoping they take us up on it.
Miller: What kinds of behind the scenes conversations have you had, as opposed to, say, public billboards?
Foley: Well, we’ve kind of hit some dead ends here. This campaign’s been going on for quite a while. We initially reached out to the residency director for the surgical program, got no response. We reached out to the surgical department chair, got no response. We reached out to the interim medical dean. Again, no response. And on this round we are reaching out specifically to Dr. Danny Jacobs, who’s the president of the OHSU system.
Miller: You mentioned that you have offered to cover the cost of a simulator training as a kind of offer of goodwill and to demonstrate this. Is there a significant difference in the cost of supplying pigs for training compared to profused cadavers or these sophisticated models?
Foley: OHSU already has two simulator centers. You have to understand that for a medical campus such as they have, they are training medical students, they’re training residencies in all manner of specialties, they’re training nurses, as you mentioned earlier, they probably have some EMS training programs. So they already have two simulator centers that are up and running on their campus. It should not be any expense, not a significant amount of money if they do have to add something specific to the surgical program. They’ve already got what they need.
Miller: Dr. Kerry Foley, thanks very much for your time today. I appreciate it.
Foley: It’s been my pleasure. Thank you.
Miller: Kerry Foley is a retired emergency medicine doctor who worked at a number of teaching hospitals over the course of a 35-year career. She’s now a member of the Physicians Committee for Responsible Medicine.
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