Reflecting on principles of professionalism (2024)

In this issue, the members of the Committee on Professionalism of the Canadian Association of General Surgeons have undertaken to define a new position paper on professionalism for the general surgeon.¹ As stated by the Committee, it is essential to raise the awareness of professionalism in surgery, to define its importance and to be very aware of what constitutes unprofessional behaviour. It is hoped that this document will serve as a ready reference for students and residents — an appropriate objective, considering the aggressive expansion of education programs that are taking new learners into multiple communities distributed throughout the country. As part of this initiative, it is essential to reflect on the rights and responsibilities of learners and surgeons alike and also to reflect on processes that exist to support concerns that arise.

Why is professionalism so important? The primary rationale for professionalism and collaboration is to promote patient safety. Health care is delivered by teams of professionals who need to communicate well, respecting the principles of honesty, respect for others, confidentiality and responsibility for their actions. Further, the working environment in health care comprises multiple learners, among them fellow physicians, residents and nonphysicians, including students and patients.

How well are physicians doing in terms of professional behaviour? A good way to enquire about this behaviour is to conduct surveys of one's own undergraduate trainees. These trainees have the opportunity to observe perverse interactions such as belittlement or humiliation, threats of physical harm or discrimination arising from sexual, racial and sexual orientation sources. Recent surveys of graduating classes in our own and other schools show that these types of behaviour are observed in the health care environment and include behaviours arising from clinical faculty, nurses, residents and patients themselves. The surprising observation is that the leading numbers of perceived concerns arise from clinical faculty themselves (not necessarily surgeons!). Some forms of unprofessional behaviour may be subtle, such as instances of unintended disrespect for the judgments of peers, breaches of confidentiality and dishonesty in the disclosure of adverse events. A prime example is the electronic mail communication that criticizes another's actions and often invites a chain of equally unprofessional responses — a practice that has likely received stern warnings from medical advisory committees in many hospitals!

What are the rights and responsibilities of learners and surgeons? Learners have the right to be challenged to learn with freedom from abuse, harassment or humiliation. They also have the right to fair, respectful and objective evaluations. At the same time, learners have the responsibility to behave as professionally as their instructors. Faculty surgeons have an essential responsibility to model professional behaviour. They should challenge trainees without abuse and humiliation and respect personal boundaries. As role models, it is essential that faculty surgeons avoid discrediting the reputation of peers and other health professionals. An example of such negative role modelling is the highly critical rounds that disparage care provided at “St. Elsewhere,” particularly when all the local factors that lead to decisions at another site are unknown. These types of interactions need to be identified and resisted by experienced opinion leaders in our departments.

What processes are available for redress if there are concerns and complaints? Codes of professionalism such as the one developed by Bond and colleagues¹ are very helpful guidelines that complement those of regulatory colleges and several professional organizations. Many health authorities and hospitals have respectful workplace policies or policies on personal conflict that can apply to surgeons, patients, visitors, fellows, residents and medical staff. These organizations provide mechanisms for any who seek resolution if conflict should arise. Similarly, most academic institutions have developed professional standards guidelines for their faculty and learners. In our own university, all learners and faculty receive a copy that affirms the commitments of professionalism in the domains of honesty, respect for others, confidentiality and responsibility. At their initial appointment, new faculty and students are required to sign and date the copy of these standards that they have received and read. This formulates part of the appointment package. Although such a document does not enforce a rigid code of conduct, it can serve as the basis for discussion because it has been acknowledged by those joining our teams. In addition, it is essential to have a confidential process for receiving complaints. In hospital environments, this task is frequently shouldered by a senior medical director for the hospital. In the educational context, concerns can be taken forward confidentially to the head of an academic unit, for example, the head of the surgical division or the relevant department head. The university may also resource an Associate Dean of Equity, who may take the necessary steps to ensure the health, safety and security of any member of the university community.

In addition to these recognized processes for addressing complaints, it is also helpful for departments to consider educational rounds that involve case studies and scenarios reviewing simulated problems of unprofessional behaviour. Group discussion of these case studies can be most interactive in identifying issues, whether the behaviour led to significant impact on another person, potential power issues that led to harassment and, eventually, solutions. These studies may also identify resources available to mediate disputes.

The hope is that, with the excellent guidelines provided through professional organizations to define professionalism, fewer surgeons will need to confront issues of substandard professional behaviour in themselves and others. Unfortunately, these issues do arise, and several strategies may assist in identifying and resolving conflicts when they arise. First, it is important for everyone to examine his or her rights and responsibilities. Many of these are identified in professional standards documents. Surgeons also need to examine disparity in power, particularly when they hold leadership positions and positions as teachers themselves. It is always helpful to prepare psychologically and professionally to meet difficult situations. This can be done by gathering support and advice from peers and mentors. Communication should be in the presence of trusted colleagues, and the temptation to send inflammatory emails should be resisted! If interactions are difficult, these must be documented objectively and fairly. Above all, it is important to act with integrity and always to hone communication and conflict resolution skills.

In summary, principles of professionalism and collaboration are just as relevant to new generations of surgeons as they have been to those in the past. It is important to pursue a code of professionalism recognizing that there are rights and responsibilities for surgeons as well as for others in health care teams who interact with us on a daily basis. Surveys suggest that forms of unprofessional behaviour are more common than we may care to admit. It is through professional standards documents, respectful workplace policies and critical self-reflection that surgeons can maintain a welcoming environment that is conducive to the best clinical care, education and research.

Garth L. Warnock, MD Coeditor, Canadian Journal of Surgery

Notes

Competing interests: None declared.

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