Professionalism in 2014

Professionalism has evolved to where it rivals technical competence as a priority for surgeons and it is a major topic for teaching in medical schools, residency training programs and faculty development seminars. Professionalism is a frequent component of lawsuits and complaints against surgeons and this creates challenges in assessment and remediation for hospital administrators, universities and regulatory authorities. Much of the increasing importance of professionalism is driven by the public who expect much more of modern surgeons than of our predecessors, both inside and outside the operating room.

What is professionalism?

Like pornography, professionalism is easy to recognize when it is deficient but difficult to specifically define. Canadian courts have defined a profession as “A self–disciplined group of individuals who hold themselves out to the public as possessing a special skill derived from training or education and who are prepared to exercise that skill primarily in the interests of others” [1].

A more elaborate definition is “An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism and the promotion of public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to consider autonomy in practice and the privilege of self–regulation. Professions and their numbers are accountable to those served, to the profession and to society” [2].

Another way to understand professionalism is to break it down into individual components. Those common to all professions include autonomy, accountability, self–regulation, team–work, competence, commitment, confidentiality and responsibility to society. Components specific to the medical profession are altruism, caring, compassion, empathy, insight, respect for patient dignity, patient autonomy, presence for the patient and humility.

I have collection of many different written definitions, ranging from elaborate, all–inclusive essays to amusing one–liners. I think it best for each surgeon to have their own definition appropriate for their situation.

Why is it important?

Surveys of the public consistently place us at the top in professional respect and we benefit greatly from this high regard the public has for us.

Our financial remuneration is excellent and I can say from personal experience on the negotiating team for a master contract between our profession and the provincial government that professionalism was a significant factor when the government attempted to impose anunsatisfactory contract on us.

Patients trust us to perform major surgery on them after only a short consultation and it is unusual for them to request second opinions. Even those who have perused the internet extensively still rely on our advice.

Attracting referrals from family physicians is facilitated by a solid reputation for professionalism, especially as a new surgeon starting to build a practice. Referring physicians and patients usually have no idea how competent a surgeon is and there is truth in the adage that “The success of a surgeon in practice depends on availability, affability and ability, in that order”.

Although we are highly accountable, independent professional practice is a great privilege where we are our own bosses and make clinical decisions as we judge best. This is a major benefit from the long years of education and training on the road to becoming a surgeon.

The Canadian Medical Protective Association and the Canadian regulatory agencies have clearly recorded the importance of rofessional behaviour in the prevention of lawsuits and complaints from patients.

Professionalism is a well recognized component, both written and unwritten in evaluations, appointments and promotions.

Despite the work of political cartoonists, our political leaders all know the value of their professional image in leadership. A classic sociology experiment compared the number of people who followed a man jay–walking dressed as a blue collar worker versus a man dressed in a business suit and consistently observed an advantage for the professional attire.

We are generally respected everywhere we go and the title of surgeon garners admiration and deference, something we often take for granted.

Is our professional status in society threatened?

A 2013 legal decision in Great Britain sent a surgeon to jail for manslaughter due to his mismanagement of a patient with a bowel perforation. Let’s hope our traditional morbidly and mortality rounds are not replaced by criminal justice proceedings and that the Code of Hammurabi remains ancient history.

We hear about financial restraints almost daily in hospitals and the lack of OR time and cancellation of elective surgery is a major irritation. Patients expect the very best care we can provide for them regardless of cost while hospital and government administrators emphasize stewardship and push us to minimize costs. It can be difficult to balance these competing demands.

Bureaucracy seems to always be expanding with more and more demands on our time and effort. There is sometimes a disconnect between patient care and paper care.

Although all surgeon deny being influenced by the sponsorship of programs and events by pharmaceutical companies and equipment manufacturers, all the research papers say otherwise. We have to be conscious of these potential conflicts of interest.

Surgeon frustrations with the work environment can lead to unprofessional behaviour and create problems with our professional and personal lives. We have to remember to look after ourselves.

It is not unusual for patients requiring emergency surgery to have the names of several surgeons on their consent form as they wait for a place in the OR and the operating surgeon may only have a brief discussion with their patient. There is a danger of us becoming mere technicians as our personal interaction with patients is reduced.

In Canada the negotiations with government for our fee schedule have been ruled by the courts to be under the labour laws, similar to union contracts and our work by law is not considered an essential service. Our professional status will not benefit if the public views us as just another labour union fighting with an employer over moneyfor its members.

Depending on how we respond to threats, they could be opportunities to augment our professional status.

Summary

Professionalism has wide application to many aspects of surgery and the submission of manuscripts in this field to the Austin Journal of Surgery is encouraged. Teaching, assessment and remediation of professionalism are prime targets for investigation.

References

1. Wright P. What is a profession? Canadian Bar Review. 1951; 29: 748-757.
2. Cruess RL, Cruess SR, Steinert Y. Teaching Medical Professionalism. New York: Cambridge University Press. 2009; 326.