Acs0001 Professionalism In Surgery

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Acs0001 Professionalism In Surgery

  1. 1. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 1 PROFESSIONALISM IN SURGERY — 1 1 PROFESSIONALISM IN SURGERY Wiley W Souba, M.D., Sc.D., F.A.C.S., and Steven M. Steinberg, M.D., F.A.C.S. . Over the past decade, the American health care system has had to of technical and specialized knowledge that it both teaches and cope with and manage an unprecedented amount of change. As a advances; it sets and enforces its own standards; and it has a ser- consequence, the medical profession has been challenged along vice orientation, rather than a profit orientation, enshrined in a the entire range of its cultural values and its traditional roles and code of ethics.3-5 To put it more succinctly, a profession has cogni- responsibilities. It would be difficult, if not impossible, to find tive, collegial, and moral attributes. These qualities are well another social issue directly affecting all Americans that has under- expressed in the familiar sentence from the Hippocratic oath: “I gone as rapid and remarkable a transformation—and oddly, a will practice my art with purity and holiness and for the benefit of transformation in which the most important protagonists (i.e., the the sick.” patients and the doctors) remain dissatisfied.1 The escalating commercialization and secularization of medi- Nowhere is this metamorphosis more evident than in the field cine have evoked in many physicians a passionate desire to recon- of surgery. Marked reductions in reimbursement, explosions in nect with the core values, practices, and behaviors that they see as surgical device biotechnology, a national medical malpractice cri- exemplifying the very best of what medicine is about.This tension sis, and the disturbing emphasis on commercialized medicine have between commercialism on the one hand and humanism and forever changed the surgical landscape, or so it seems. The very altruism on the other is a central part of the professionalism chal- foundation of patient care—the doctor-patient relationship—is in lenge we face today.6 As the journalist Loretta McLaughlin once jeopardy. Surgeons find it increasingly difficult to meet their wrote, “The rush to transform patients into units on an assembly responsibilities to patients and to society as a whole. In these cir- line demeans medicine as a caring as well as curative field, cumstances, it is critical for us to reaffirm our commitment to demeans the respect due every patient and ultimately demeans ill- the fundamental and universal principles and values of medical ness itself as a significant human condition.”7 professionalism. Historically, the legitimacy of medical authority is based on The concept of medicine as a profession grounded in compas- three distinct claims2,8: first, that the knowledge and competence sion and sympathy for the sick has come under serious challenge.2 of the professional have been validated by a community of peers; One eroding force has been the growth and sovereignty of bio- second, that this knowledge has a scientific basis; and third, that medical research. Given the high position of science and technol- the professional’s judgment and advice are oriented toward a set ogy in our societal hierarchy, we may be headed for a form of med- of values. These aspects of legitimacy correspond to the collegial, icine that includes little caring but becomes exclusively focused on cognitive, and moral attributes that define a profession. the mechanics of treatment, so that we deal with sick patients Competence and expertise are certainly the basis of patient much as we would a flat tire or a leaky faucet. In such a form of care, but other characteristics of a profession are equally impor- medicine, healing becomes little more than a technical exercise, tant [see Table 1]. Being a professional implies a commitment to and any talk of morality that is unsubstantiated by hard facts is excellence and integrity in all undertakings. It places the considered mere opinion and therefore carries little weight. responsibility to serve (care for) others above self-interest and The rise of entrepreneurialism and the growing corporatization reward. Accordingly, we, as practicing medical professionals, of medicine also challenge the traditions of virtue-based medical must act as role models by exemplifying this commitment and care. When these processes are allowed to dominate medicine, responsibility, so that medical students and residents are health care becomes a commodity. As Pellegrino and Thomasma exposed to and learn the kinds of behaviors that constitute pro- remark, “When economics and entrepreneurism drive the profes- fessionalism [see Sidebar Elizabeth Blackwell: A Model of sions, they admit only self-interest and the working of the market- Professionalism]. place as the motives for professional activity. In a free-market The medical profession is not infrequently referred to as a voca- economy, effacement of self-interest, or any conduct shaped pri- tion. For most people, this word merely refers to what one does for marily by the idea of altruism or virtue, is simply inconsistent with a living; indeed, its common definition implies income-generating survival.”2 activity. Literally, however, the word vocation means “calling,” and These changes have caused a great deal of anxiety and fear among both patients and surgeons nationwide. The risk to the profession is that it will lose its sovereignty, becoming a passive rather than an active participant in shaping and formulating health Table 1—Elements of a Profession policy in the future. The risks to the public are that issues of cost A profession will take precedence over issues of quality and access to care and • Is a learned discipline with high standards of knowledge and that health care will be treated as a commodity—that is, as a priv- performance ilege rather than a right. • Regulates itself via a social contract with society • Places responsibility for serving others above self-interest and reward • Is characterized by a commitment to excellence in all undertakings The Meaning of Professionalism • Is practiced with unwavering personal integrity and compassion • Requires role-modeling of right behavior A profession is a collegial discipline that regulates itself by • Is more than a job—it is a calling and a privilege means of mandatory, systematic training. It has a base in a body
  2. 2. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 1 PROFESSIONALISM IN SURGERY — 2 calling, not as a business; as a calling which extracts from you at Elizabeth Blackwell: A Model of Professionalism19 every turn self-sacrifice, devotion, love and tenderness to your fel- low man. We must work in the missionary spirit with a breath of Elizabeth Blackwell was born in England in 1821, the daughter of a sug- charity that raises you far above the petty jealousies of life.”10 To ar refiner. When she was 10 years old, her family emigrated to New York keep medicine a calling, we must explicitly incorporate into the City. Discovering in herself a strong desire to practice medicine and care for the underserved, she took up residence in a physician’s household, meaning of professionalism those nontechnical practices, habits, using her time there to study using books in the family’s medical library. and attributes that the compassionate, caring, and competent As a young woman, Blackwell applied to several prominent medical physician exemplifies. We must remind ourselves that a true pro- schools but was snubbed by all of them. After 29 rejections, she sent her fessional places service to the patient above self-interest and above second round of applications to smaller colleges, including Geneva Col- reward. lege in New York. She was accepted at Geneva—according to an anec- Professionalism is the basis of our contract with society. To dote, because the faculty put the matter to a student vote, and the stu- dents thought her application a hoax. She braved the prejudice of some maintain our professionalism, and thus to preserve the contract of the professors and students to complete her training, eventually rank- with society, it is essential to reestablish the doctor-patient rela- ing first in her class. On January 23, 1849, at the age of 27, Elizabeth tionship as the foundation of patient care. Blackwell became the first woman to earn a medical degree in the United States. Her goal was to become a surgeon. After several months in Pennsylvania, during which time she became The Surgeon-Patient Relationship a naturalized citizen of the United States, Blackwell traveled to Paris, where she hoped to study with one of the leading French surgeons. De- The underpinning of medicine as a compassionate, caring pro- nied access to Parisian hospitals because of her gender, she enrolled in- fession is the doctor-patient relationship, a relationship that has stead at La Maternité, a highly regarded midwifery school, in the summer become jeopardized and sometimes fractured over the past of 1849. While attending to a child some 4 months after enrolling, Black- decade. Our individual perceptions of what this relationship is and well inadvertently spattered some pus from the child’s eyes into her own how it should work will inevitably have a great impact on how we left eye. The child was infected with gonorrhea, and Blackwell contracted approach the care of our patients.2 a severe case of ophthalmia neonatorum, which later necessitated the removal of the infected eye. Although the loss of an eye made it impossi- The fundamental question to be answered is, what should the ble for her to become a surgeon, it did not dampen her passion for be- surgeon-patient relationship be governed by? If this relationship is coming a practicing physician. viewed solely as a contract for services rendered, it is subject to the By mid-1851, when Blackwell returned to the United States, she was law and the courts; if it is viewed simply as an issue of applied biol- well prepared for private practice. However, no male doctor would even ogy, it is governed by science; and if it is viewed exclusively as a consider the idea of a female associate, no matter how well trained. commercially driven business transaction, it is regulated by the Barred from practice in most hospitals, Blackwell founded her own infir- mary, the New York Infirmary for Indigent Women and Children, in 1857. marketplace. If, however, our relationship with our patients is When the American Civil War began, Blackwell trained nurses, and in understood as going beyond basic delivery of care and as consti- 1868 she founded a women’s medical college at the Infirmary so that tuting a covenant in which we act in the patient’s best interest even women could be formally trained as physicians. In 1869, she returned to if that means providing free care, it is based on the virtue of char- England and, with Florence Nightingale, opened the Women’s Medical ity. Such a perspective transcends questions of contracts, politics, College. Blackwell taught at the newly created London School of Medi- economics, physiology, and molecular genetics—all of which cine for Women and became the first female physician in the United Kingdom Medical Register. She set up a private practice in her own rightly influence treatment strategies but none of which is any home, where she saw women and children, many of whom were of less- substitute for authentic caring. er means and were unable to pay. In addition, Blackwell mentored other The view of the physician-patient relationship as a covenant women who subsequently pursued careers in medicine. She retired at does not demand devotion to medicine to the exclusion of other the age of 86. responsibilities, and it is not inconsistent with the fact that medi- In short, Elizabeth Blackwell embodied professionalism in her work. In cine is also a science, an art, and a business.2 Nevertheless, in our 1889 she wrote, “There is no career nobler than that of the physician. The progress and welfare of society is more intimately bound up with the struggle to remain viable in a health care environment that has prevailing tone and influence of the medical profession than with the sta- become a commercial enterprise, efforts to preserve market share tus of any other class.” cannot take precedence over the provision of care that is ground- ed in charity and compassion. It is exactly for this reason that med- icine always will be, and should be, a relationship between people. the application of this definition to the medical profession yields a To fracture that relationship by exchanging a covenant based on more profound meaning. According to Webster’s Third New charity and compassion for a contract based solely on the delivery International Dictionary,9 a profession may be defined as of goods and services is something none of us would want for our- selves. The nature of the healing relationship is itself the founda- a calling requiring specialized knowledge and often long acade- tion of the special obligations of physicians as physicians.2 mic preparation, including instruction in skills and methods as well as in the scientific, historical, or scholarly principles under- lying such skills and methods, maintaining by force of organiza- Translation of Theory into Practice tion or concerted opinion high standards of achievement and conduct, and committing its members to continued study and to The American College of Surgeons (ACS) Task Force on a kind of work which has for its prime purpose the rendering of Professionalism has developed a Code of Professional Conduct,11 a public service[.] which emphasizes the following four aspects of professionalism: Most of us went to medical school because we wanted to help 1. A competent surgeon is more than a competent technician. and care for people who are ill. This genuine desire to care is 2. Whereas ethical practice and professionalism are closely relat- unambiguously apparent in the vast majority of personal state- ed, professionalism also incorporates surgeons’ relationships ments that medical students prepare as part of their application with patients and society. process. To quote William Osler, “You are in this profession as a 3. Unprofessional behavior must have consequences.
  3. 3. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 1 PROFESSIONALISM IN SURGERY — 3 4. Professional organizations are responsible for fostering profes- form 1,000 hours of community service, and write an article in a sionalism in their membership. medical journal about billing errors. The University spent many millions in legal fees and eventually settled the billing issues with Specifically, the ACS Code of Professional Conduct includes the Federal government for one of the highest Physicians at tenets of professionalism that relate both to our care of individual Teaching Hospitals (PATH) settlements ever. patients and to our role in society [see Table 2]. Fortunately, such extreme cases of unprofessionalism are quite If professionalism is indeed embodied in the principles dis- uncommon. Nevertheless, it remains our responsibility as profes- cussed [see Tables 1 and 2], the next question that arises is, how do sionals to prevent such behaviors from developing and from being we translate theory into practice? That is, what do these principles reinforced. To this end, we must lead by example. A study pub- look like in action? To begin with, a competent surgeon must pos- lished in 2004 demonstrated an association between displays sess the medical knowledge, judgment, technical ability, profes- of unprofessional behavior in medical school and subsequent dis- sionalism, clinical excellence, and communication skills required ciplinary action by a state medical board.14 The authors conclud- for provision of high-quality patient-centered care. Furthermore, ed that professionalism is an essential competency that students this expertise must be demonstrated to the satisfaction of the pro- must demonstrate to graduate from medical school. Who could fession as a whole. The Accreditation Council on Graduate disagree? Medical Education (ACGME) has identified six competencies In addition to the reports recounting acts of unprofessional that must be demonstrated by the surgeon: (1) patient care, (2) behavior, various publications describing methods of teaching and medical knowledge, (3) practice-based learning and improvement, assessing professionalism have begun to appear in the past few (4) interpersonal and communication skills, (5) professionalism, years. As an example, Kumar and colleagues found that using and (6) systems-based practice. These competencies are now ACS case-based multimedia materials enhanced the ability of res- being integrated into the training programs of all accredited surgi- idents to recognize and discuss matters related to professional cal residencies. behavior.15 Surgical residents who viewed these materials scored A surgical professional must also be willing and able to take higher on an assessment tool than did residents with the same level responsibility. Such responsibility includes, but is not necessarily of experience who did not use the materials. An additional encour- limited to, the following three areas: (1) provision of the highest- aging finding was that residents of all years were able to define the quality care, (2) maintenance of the dignity of patients and cowork- components of professionalism. In another publication, Gauger ers, and (3) open, honest communication. Assumption of respon- sibility as a professional involves leading by example, placing the delivery of quality care above the patient’s ability to pay, and dis- playing compassion. Cassell reminds us that a sick person is not Table 2—American College of Surgeons just “a well person with a knapsack of illness strapped to his back”12 Code of Professional Conduct and that whereas “it is possible to know the suffering of others, to help them, and to relieve their distress, [it is not possible] to become During the continuum of pre-, intra-, and postoperative care, we one with them in their torment.”13 Illness and suffering are not just accept responsibilities to • Serve as effective advocates for our patients’ needs; biologic problems to be solved by biomedical research and tech- • Disclose therapeutic options, including their risks and benefits; nology: they are also enigmas that can serve to point out the limi- • Disclose and resolve any conflict of interest that might influence tations, vulnerabilities, and frailties that we want so much to deny, the decisions of care; as well as to reaffirm our links with one another. • Be sensitive and respectful of patients, understanding their Most important, professionalism demands unwavering person- vulnerability during the perioperative period; • Fully disclose adverse events and medical errors; al integrity. Regrettably, examples of unprofessional behavior exist. • Acknowledge patients’ psychological, social, cultural, and An excerpt from a note from a third-year medical student to the spiritual needs; core clerkship director reads as follows: “I have seen attendings • Encompass within our surgical care the special needs of terminally make sexist, racist jokes or remarks during surgery. I have met res- ill patients; idents who joke about deaf patients and female patients with facial • Acknowledge and support the needs of patients’ families; and hair. [I have encountered] teams joking and counting down the • Respect the knowledge, dignity, and perspective of other healthcare professionals. days until patients die.” This kind of exposure to unprofessional conduct and language can influence young people negatively, and Our profession is also accountable to our communities and to society. In return for their trust, as Fellows of the American College of it must change. Surgeons, we accept responsibilities to It is encouraging to note that many instances of unprofessional • Provide the highest quality of surgical care; conduct that once were routinely overlooked—such as mistreating • Abide by the values of honesty, confidentiality, and altruism; medical students, speaking disrespectfully to coworkers, and • Participate in lifelong learning; fraudulent behavior—now are being dealt with. Still, from time to • Maintain competence throughout our surgical careers; time an incident is made public that makes us all feel shame. In • Participate in self-regulation by setting, maintaining, and enforcing practice standards; March 2003, the Seattle Times carried a story about the chief of • Improve care by evaluating its processes and outcomes; neurosurgery at the University of Washington, who pleaded guilty • Inform the public on subjects within our expertise; to a felony charge of obstructing the government’s investigation • Advocate strategies to improve individual and public health by and admitted that he asked others to lie for him and created an communicating with government, healthcare organizations, and industry; atmosphere of fear in the neurosurgery department. According to • Work with society to establish a just, effective, and efficient the United States Attorney in Seattle, University of Washington distribution of healthcare resources; employees destroyed reports revealing that University doctors sub- • Provide necessary surgical care without regard to gender, race, mitted inflated billings to Medicare and Medicaid. The depart- disability, religion, social status, or ability to pay; and ment chair lost his job, was barred from participation in Medicare, • Participate in educational programs addressing professionalism. and, as part of his plea bargain, had to pay a $500,000 fine, per-
  4. 4. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 1 PROFESSIONALISM IN SURGERY — 4 once was.This need not be the case.The ongoing advances in sur- Table 3—Components of Professionalism gical technology, the increasing opportunities for community- Assessment in a Surgical Residency16 based surgeons to enroll their patients into clinical trials, and the growing emphasis on lifelong learning as part of maintenance of Punctuality Initiative/self-regulation certification are factors that not only help satisfy social and orga- Appearance nizational demands for quality care but also are in the best interest Altruism Honesty/accountability/response of our patients. Doctor/patient or doctor/family to error relationships In the near future, maintenance of certification for surgeons will Compulsiveness Interprofessional relationships involve much more than taking an examination every decade.The Responsibility/sense of duty ACS is taking the lead in helping to develop new measures of com- Trustworthiness/confidentiality Response to criticism petence. Whatever specific form such measures may take, display- Confidence and ability to Moral and ethical standards assess oneself ing professionalism and living up to a set of uncompromisable core Attitude toward medical Respect for others profession values17 will always be central indicators of the performance of the individual surgeon and the integrity of the discipline of surgery as a whole. Although surgeons vary enormously with respect to personality, and coauthors described an evaluation instrument used to evalu- practice preferences, areas of specialization, and style of relating to ate residents with respect to the aspects of professionalism.16 They others, they all have one role in common: that of healer. Indeed, it divided the concept of professionalism into 15 domains [see Table is the highest of privileges to be able to care for the sick. As the 3] and modified a standard resident evaluation form to assess the playwright Howard Sackler once wrote, “To intervene, even faculty’s perception of resident performance in each of these briefly, between our fellow creatures and their suffering or death, is domains. This evaluation tool proved to be internally consistent, our most authentic answer to the question of our humanity.” but in the absence of any other gold standard tools with which to Inseparable from this privilege is a set of responsibilities that are compare it, its validity could not be determined. not to be taken lightly: a pledge to offer our patients the best care possible and a commitment to teach and advance the science and practice of medicine. Commitment to the practice of patient-cen- The Future of Surgical Professionalism tered, high-quality, cost-effective care is what gives our work mean- It is often subtly implied—or even candidly stated—that no mat- ing and provides us with a sense of purpose.18 We as surgeons must ter how well we adjust to the changing health care environment, participate actively in the current evolution of integrated health the practice of surgery will never again be quite as rewarding as it care. By doing so, we help build our own future. References 1. Fein R: The HMO revolution. Dissent, spring Medicine. Basic Books, New York, 1982 associated with subsequent disciplinary action by 1998, p 29 9. Webster’s Third New International Dictionary of a state medical board. Acad Med 79:244, 2004 2. Pellegrino ED, Thomasma DC: Helping and the English Language, Unabridged. Gove PB, Ed. 15. Kumar A, Shibru D, Bullard K, et al: Case-based Healing. Georgetown University Press, Merriam-Webster Inc, Springfield, Massachusetts, multimedia program enhances the maturation of Washington, DC, 1997 1986, p 1811 surgical residents regarding the concepts of pro- 10. Osler’s “Way of Life” and Other Addresses, with fesionalism. J Surg Ed 64:194, 2007 3. Brandeis LD: Familiar medical quotations. Business—A Profession. Strauss M, Ed. Little Commentary and Annotations. Hinohara S, Niki 16. Gauger P, Gruppen L, Minter R, et al: Initial use Brown & Co, Boston, 1986 H, Eds. Duke University Press, Durham, North of a novel instrument to measure professionalism Carolina, 2001 in surgical residents. Am J Surg 189:479, 2005 4. Cogan ML: Toward a definition of profession. Harvard Educational Reviews 23:33, 1953 11. Gruen RI, Arya J, Cosgrove EM, et al: 17. Souba W: Academic medicine’s core values: what Professionalism in surgery. J Am Coll Surg do they mean? J Surg Res 115:171, 2003 5. Greenwood E: Attributes of a profession. Social 197:605, 2003 Work 22:44, 1957 18. Souba W: Academic medicine and our search for 12. Cassell EJ: The function of medicine. Hastings meaning and purpose. Acad Med 77:139, 2002 6. Souba WW, Day DV: Leadership values in acade- Center Report 7:16, 1977 mic medicine. Acad Med 81:20, 2006 19. Speigel R: Elizabeth Blackwell: the first woman 13. Cassell EJ: Recognizing suffering. Hastings doctor. Snapshots in Science and Medicine, 1998 7. McLaughlin L: The surgical express. Boston Center Report 21:24, 1991 http://science-education.nih.gov/snapshots. Globe, April 24, 1995 14. Papadakis M, Hodgson C, Teherani A, et al: nsf/story?openform&pds~Elizabeth_Blackwell_ 8. Starr PD:The Social Transformation of American Unprofessional behavior in medical school is Doctor

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