The development of professionalism in surgeons

© 2013 Dr. David HillisProfessionalism underpins the commitment made between a profession and society. This social contract balances the benefits to a profession of a monopoly over the use of its knowledge base, its right to considerable autonomy of practice and the privilege of self-regulation, with responsibilities and accountabilities to the community. However, it is the challenge in further defining professionalism, particularly in day-to-day activities, that has propelled analysis beyond values and beliefs to include behaviours and attributes and the understanding of them within work-based culture and educational programs. This is particularly so in healthcare where unprofessional behaviour ranging from disrespect or rudeness to florid abuse is now being associated with poorer outcomes for the individual client, in this case, the patient. The overall approach to and understanding of professionalism remains variable, patchy and inconsistent in spite of its importance as an area of educational endeavour. This thesis contributes further to this analysis, particularly with regard to surgeons and trainees practising in Australia and New Zealand. This study is an intensive review of the understanding, perceived importance, capacity for improvement and possible educational activities that can support professionalism within the Royal Australasian College of Surgeons and the surgical community of Australia and New Zealand. It combines an extensive literature review, with a questionnaire that was distributed to 3000 Fellows and Trainees. With a commendable 60 per cent return rate, analysis has been undertaken across the categories of Fellows / Trainees, Specialties, Regions, Gender and Age Groups. Following this, semi-structured interviews involved 15 Fellows and Trainees in discussing case studies around issues of reflection and planning, pausing in action, providing feedback, dealing with rudeness and seeking feedback. Key issues that emerged include the importance of the ‘codification’ of professionalism that has seen the development of curricula around a topic that was unclear and even previously regarded as ‘non-cognitive’; the proliferation of assessment tools; and an increasing understanding of the cultural and socialisation issues that are necessarily intertwined with the more normative aspects. Surgeons do regard professionalism as important but vary in the priority they give to the various attributes. This puts ‘at risk’ the attributes that are not rated as highly, but which are nonetheless desirable. Surgeons are immersed in a world where unprofessional behaviour is prevalent and they also contribute to this. The fieldwork showed that the role of educator, mentor and role model is vital, not only in demonstrating professionalism, but also in correcting areas of unprofessional behaviour. To more fully undertake these tasks, relationality, resilience and reflection have been highlighted as important concepts that need deeper understanding by Educators and Trainees. The role of the College needs to be more prominent in this regard. It is not viewed as well engaged, nor as providing effective leadership. This can be addressed in the healthcare sector by more clearly identifying areas where ‘signature pedagogies’ can provide effective experiences and education. Examples of signature pedagogies include morbidity and mortality meetings, ward rounds and operating theatre sessions. The main implication of this study is that the College needs to provide education and professional development to increase capacity across a number of areas. At the individual level, this includes the skills that build resilience; the ability to more effectively ask the pragmatic questions that will assist reflection; and the understanding of the importance of relationality, which acts as a bond between a professional and their more senior and experienced colleague. Within the community of practice, through which much of the learning of professionalism occurs, capacity around these issues also needs to be improved. It is again at this level that the importance of providing leadership to nurture professionalism and address unprofessional behaviour within organisations such as hospitals and the broader environment of healthcare will be profiled. Activities to promote this capacity development can particularly occur within the areas where signature pedagogies flourish. There are important policy issues to be considered, as well as the development of educational programs. The policies will influence and then reflect the importance that the College of Surgeons places on professionalism and addressing unprofessional behaviour. Its commitment to both training and assessment of professionalism needs to be incorporated into a model of lifelong learning that particularly influences the workplace and the multiple communities of surgical practice