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ELEMENTS OF CONTEMPORARY PRACTICE
ACS Surgery: Principles and Practice
1 Professionalism in Surgery
— 1
1
PROFESSIONALISM IN SURGERY
Wiley W. Souba,
M.D.
,
SC.D.
,
F.A.C.S.
Over the past decade, the American health care system has had to
cope with and manage an unprecedented amount of change. As a
consequence, the medical profession has been challenged along
the entire range of its cultural values and its traditional roles and
responsibilities. It would be difficult, if not impossible, to find
another social issue directly affecting all Americans that has under-
gone as rapid and remarkable a transformation—and oddly, a
transformation in which the most important protagonists (i.e., the
patients and the doctors) remain dissatisfied.
1
Nowhere is this metamorphosis more evident than in the field
of surgery. Marked reductions in reimbursement, explosions in
surgical device biotechnology, a national medical malpractice cri-
sis, and the disturbing emphasis on commercialized medicine have
forever changed the surgical landscape, or so it seems. The very
foundation of patient care—the doctor-patient relationship—is in
jeopardy. Surgeons find it increasingly difficult to meet their
responsibilities to patients and to society as a whole. In these cir-
cumstances, it is critical for us to reaffirm our commitment to the
fundamental and universal principles and values of medical
professionalism.
The concept of medicine as a profession grounded in com-
passion and sympathy for the sick has come under serious chal-
lenge.
2
One eroding force has been the growth and sovereignty
of biomedical research. Given the high position of science and
technology in our societal hierarchy, we may be headed for a
form of medicine that includes little caring but becomes exclu-
sively focused on the mechanics of treatment, so that we deal
with sick patients much as we would a flat tire or a leaky faucet.
In such a form of medicine, healing becomes little more than a
technical exercise, and any talk of morality that is unsubstantiat-
ed by hard facts is considered mere opinion and therefore car-
ries little weight.
The rise of entrepreneurialism and the growing corporatization
of medicine also challenge the traditions of virtue-based medical
care. When these processes are allowed to dominate medicine,
health care becomes a commodity. As Pellegrino and Thomasma
remark, “When economics and entrepreneurism drive the profes-
sions, they admit only self-interest and the working of the market-
place as the motives for professional activity. In a free-market
economy, effacement of self-interest, or any conduct shaped pri-
marily by the idea of altruism or virtue, is simply inconsistent with
survival.”
2
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
policy in the future. The risks to the public are that issues of cost
will take precedence over issues of quality and access to care and
that health care will be treated as a commodity—that is, as a priv-
ilege rather than a right.
of technical and specialized knowledge that it both teaches and
advances; it sets and enforces its own standards; and it has a ser-
vice orientation, rather than a profit orientation, enshrined in a
code of ethics.
3-5
To put it more succinctly, a profession has cogni-
tive, collegial, and moral attributes. These qualities are well
expressed in the familiar sentence from the Hippocratic oath: “I
will practice my art with purity and holiness and for the benefit of
the sick.”
The escalating commercialization and secularization of medicine
have evoked in many physicians a passionate desire to reconnect
with the core values, practices, and behaviors that they see as exem-
plifying the very best of what medicine is about. This tension
between commercialism on the one hand and humanism and
altruism on the other is a central part of the professionalism chal-
lenge we face today.
6
As the journalist Loretta McLaughlin once
wrote, “The rush to transform patients into units on an assembly
line demeans medicine as a caring as well as curative field, demeans
the respect due every patient and ultimately demeans illness itself
as a significant human condition.”
7
Historically, the legitimacy of medical authority is based on
three distinct claims
2,8
: first, that the knowledge and competence
of the professional have been validated by a community of peers;
second, that this knowledge has a scientific basis; and third, that
the professional’s judgment and advice are oriented toward a set
of values. These aspects of legitimacy correspond to the collegial,
cognitive, and moral attributes that define a profession.
Competence and expertise are certainly the basis of patient
care, but other characteristics of a profession are equally important
[
see Table 1
]. Being a professional implies a commitment to excel-
lence and integrity in all undertakings. It places the responsibility
to serve (care for) others above self-interest and reward. Accord-
ingly, we, as practicing medical professionals, must act as role
models by exemplifying this commitment and responsibility, so
that medical students and residents are exposed to and learn the
kinds of behaviors that constitute professionalism [
see Sidebar
Elizabeth Blackwell: A Model of Professionalism].
The medical profession is not infrequently referred to as a voca-
tion. For most people, this word merely refers to what one does for
a living; indeed, its common definition implies income-generating
activity. Literally, however, the word vocation means “calling,” and
the application of this definition to the medical profession yields a
Table 1
—
Elements of a Profession
A profession
•
Is a learned discipline with high standards of knowledge and
performance
•
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
A profession is a collegial discipline that regulates itself by
means of mandatory, systematic training. It has a base in a body
•
Is practiced with unwavering personal integrity and compassion
•
Requires role-modeling of right behavior
•
Is more than a job—it is a calling and a privilege
© 2005 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE
ACS Surgery: Principles and Practice
1 Professionalism in Surgery
— 2
more profound meaning. According to
Webster’s Third New
International Dictionary,
9
a profession may be defined as
a calling requiring specialized knowledge and often long acade-
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-
tion or concerted opinion high standards of achievement and
conduct, and committing its members to continued study and to
a kind of work which has for its prime purpose the rendering of
a public service[.]
Most of us went to medical school because we wanted to help and
care for people who are ill. This genuine desire to care is unam-
biguously apparent in the vast majority of personal statements
that medical students prepare as part of their application process.
To quote William Osler, “You are in this profession as a calling,
not as a business; as a calling which extracts from you at every
turn self-sacrifice, devotion, love and tenderness to your fellow
man.We must work in the missionary spirit with a breath of char-
ity that raises you far above the petty jealousies of life.”
10
To keep
medicine a calling, we must explicitly incorporate into the mean-
ing of professionalism those nontechnical practices, habits, and
attributes that the compassionate, caring, and competent physi-
cian exemplifies. We must remind ourselves that a true profes-
sional places service to the patient above self-interest and above
reward.
Professionalism is the basis of our contract with society. To
maintain our professionalism, and thus to preserve the contract
with society, it is essential to reestablish the doctor-patient rela-
tionship as the foundation of patient care.
Elizabeth Blackwell: A Model of Professionalism
17
Elizabeth Blackwell was born in England in 1821, the daughter of a sug-
ar refiner. When she was 10 years old, her family emigrated to New York
City. Discovering in herself a strong desire to practice medicine and care
for the underserved, she took up residence in a physician’s household,
using her time there to study using books in the family’s medical library.
As a young woman, Blackwell applied to several prominent medical
schools but was snubbed by all of them. After 29 rejections, she sent her
second round of applications to smaller colleges, including Geneva Col-
lege in New York. She was accepted at Geneva—according to an anec-
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
of the professors and students to complete her training, eventually rank-
ing first in her class. On January 23, 1849, at the age of 27, Elizabeth
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
a naturalized citizen of the United States, Blackwell traveled to Paris,
where she hoped to study with one of the leading French surgeons. De-
nied access to Parisian hospitals because of her gender, she enrolled in-
stead at La Maternité, a highly regarded midwifery school, in the summer
of 1849. While attending to a child some 4 months after enrolling, Black-
well inadvertently spattered some pus from the child’s eyes into her own
left eye. The child was infected with gonorrhea, and Blackwell contracted
a severe case of ophthalmia neonatorum, which later necessitated the
removal of the infected eye. Although the loss of an eye made it impossi-
ble for her to become a surgeon, it did not dampen her passion for be-
coming a practicing physician.
By mid-1851, when Blackwell returned to the United States, she was
well prepared for private practice. However, no male doctor would even
consider the idea of a female associate, no matter how well trained.
Barred from practice in most hospitals, Blackwell founded her own infir-
mary, the New York Infirmary for Indigent Women and Children, in 1857.
When the American Civil War began, Blackwell trained nurses, and in
1868 she founded a women’s medical college at the Infirmary so that
women could be formally trained as physicians. In 1869, she returned to
England and, with Florence Nightingale, opened the Women’s Medical
College. Blackwell taught at the newly created London School of Medi-
cine for Women and became the first female physician in the United
Kingdom Medical Register. She set up a private practice in her own
home, where she saw women and children, many of whom were of less-
er means and were unable to pay. In addition, Blackwell mentored other
women who subsequently pursued careers in medicine. She retired at
the age of 86.
In short, Elizabeth Blackwell embodied professionalism in her work. In
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
prevailing tone and influence of the medical profession than with the sta-
tus of any other class.”
The Surgeon-Patient Relationship
The underpinning of medicine as a compassionate, caring pro-
fession is the doctor-patient relationship, a relationship that has
become jeopardized and sometimes fractured over the past
decade. Our individual perceptions of what this relationship is and
how it should work will inevitably have a great impact on how we
approach the care of our patients.
2
The fundamental question to be answered is, what should the
surgeon-patient relationship be governed by? If this relationship is
viewed solely as a contract for services rendered, it is subject to the
law and the courts; if it is viewed simply as an issue of applied biol-
ogy, it is governed by science; and if it is viewed exclusively as a
commercially driven business transaction, it is regulated by the
marketplace. If, however, our relationship with our patients is
understood as going beyond basic delivery of care and as consti-
tuting a covenant in which we act in the patient’s best interest even
if that means providing free care, it is based on the virtue of char-
ity. Such a perspective transcends questions of contracts, politics,
economics, physiology, and molecular genetics—all of which
rightly influence treatment strategies but none of which is any
substitute for authentic caring.
The view of the physician-patient relationship as a covenant
does not demand devotion to medicine at the exclusion of other
responsibilities, and it is not inconsistent with the fact that medi-
cine is also a science, an art, and a business.
2
Nevertheless, in our
struggle to remain viable in a health care environment that has
become a commercial enterprise, efforts to preserve market share
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.
To fracture that relationship by exchanging a covenant based on
charity and compassion for a contract based solely on the delivery
of goods and services is something none of us would want for our-
selves. The nature of the healing relationship is itself the founda-
tion of the special obligations of physicians as physicians.
2
Translation of Theory into Practice
The American College of Surgeons (ACS) Task Force on Pro-
fessionalism has developed a Code of Professional Conduct,
11
which emphasizes the following four aspects of professionalism:
1. A competent surgeon is more than a competent technician.
2. Whereas ethical practice and professionalism are closely relat-
ed, professionalism also incorporates surgeons’ relationships
with patients and society.
3. Unprofessional behavior must have consequences.
© 2005 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE
ACS Surgery: Principles and Practice
1 Professionalism in Surgery
— 3
4. Professional organizations are responsible for fostering profes-
sionalism in their membership.
If professionalism is indeed embodied in the principles dis-
cussed [
see Table 1
], the next question that arises is, how do we
translate theory into practice? That is, what do these principles look
like in action? To begin with, a competent surgeon must possess
the medical knowledge, judgment, technical ability, professional-
ism, clinical excellence, and communication skills required for pro-
vision of high-quality patient-centered care. Furthermore, this
expertise must be demonstrated to the satisfaction of the profes-
sion as a whole. The Accreditation Council on Graduate Medical
Education (ACGME) has identified six competencies that must be
demonstrated by the surgeon: (1) patient care, (2) medical knowl-
edge, (3) practice-based learning and improvement, (4) interper-
sonal and communication skills, (5) professionalism, and (6) sys-
tems-based practice. These competencies are now being integrat-
ed into the training programs of all accredited surgical residencies.
A surgical professional must also be willing and able to take
responsibility. Such responsibility includes, but is not necessarily
limited to, the following three areas: (1) provision of the highest-
quality care, (2) maintenance of the dignity of patients and co-
workers, and (3) open, honest communication. Assumption of
responsibility as a professional involves leading by example, placing
the delivery of quality care above the patient’s ability to pay, and
displaying compassion. Cassell reminds us that a sick person is not
just “a well person with a knapsack of illness strapped to his back”
12
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 one with them in their torment.”
13
Illness and suffering are
not just biologic problems to be solved by biomedical research and
technology: they are also enigmas that can serve to point out the
limitations, vulnerabilities, and frailties that we want so much to
deny, as well as to reaffirm our links with one another.
Most important, professionalism demands unwavering person-
al integrity. Regrettably, examples of unprofessional behavior exist.
An excerpt from a note from a third-year medical student to the
core clerkship director reads as follows: “I have seen attendings
make sexist, racist jokes or remarks during surgery. I have met res-
idents who joke about deaf patients and female patients with facial
hair. [I have encountered] teams joking and counting down the
days until patients die.” This kind of exposure to unprofessional
conduct and language can influence young people negatively, and
it must change.
It is encouraging to note that many instances of unprofessional
conduct that once were routinely overlooked—such as mistreating
medical students, speaking disrespectfully to coworkers, and fraud-
ulent behavior—now are being dealt with. Still, from time to time
an incident is made public that makes us all feel shame. In March
2003, the
Seattle Times
carried a story about the chief of neuro-
surgery at the University of Washington, who pleaded guilty to a
felony charge of obstructing the government’s investigation and
admitted that he asked others to lie for him and created an atmos-
phere of fear in the neurosurgery department. According to the
United States Attorney in Seattle, University of Washington
employees destroyed reports revealing that University doctors sub-
mitted inflated billings to Medicare and Medicaid.The department
chair lost his job, was barred from participation in Medicare, and,
as part of his plea bargain, had to pay a $500,000 fine, perform
1,000 hours of community service, and write an article in a med-
ical journal about billing errors. The University spent many mil-
lions in legal fees and eventually settled the billing issues with the
Federal government for one of the highest Physicians at Teaching
Hospitals (PATH) settlements ever.
Fortunately, such extreme cases of unprofessionalism are quite
uncommon. Nevertheless, it remains our responsibility as profes-
sionals to prevent such behaviors from developing and from being
reinforced. To this end, we must lead by example. A study pub-
lished in 2004 demonstrated an association between displays of
unprofessional behavior in medical school and subsequent discipli-
nary action by a state medical board.
14
The authors concluded that
professionalism is an essential competency that students must
demonstrate to graduate from medical school.Who could disagree?
The Future of Surgical Professionalism
It is often subtly implied—or even candidly stated—that no
matter how well we adjust to the changing health care environ-
ment, the practice of surgery will never again be quite as reward-
ing as it once was. This need not be the case. The ongoing
advances in surgical technology, the increasing opportunities for
community-based surgeons to enroll their patients into clinical tri-
als, and the growing emphasis on lifelong learning as part of main-
tenance of certification are factors that not only help satisfy social
and organizational demands for quality care but also are in the
best interest of our patients.
In the near future, maintenance of certification for surgeons will
involve much more than taking an examination every decade. The
ACS is taking the lead in helping to develop new measures of com-
petence. Whatever specific form such measures may take, display-
ing professionalism and living up to a set of uncompromisable
core values
15
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 personali-
ty, practice preferences, areas of specialization, and style of relating
to others, they all have one role in common: that of healer. Indeed,
it is the highest of privileges to be able to care for the sick. As the
playwright Howard Sackler once wrote, “To intervene, even
briefly, between our fellow creatures and their suffering or death,
is our most authentic answer to the question of our humanity.”
Inseparable from this privilege is a set of responsibilities that are
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-
tered, high-quality, cost-effective care is what gives our work
meaning and provides us with a sense of purpose.
16
We as surgeons
must participate actively in the current evolution of integrated
health care; by doing so, we help build our own future.
© 2005 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE
ACS Surgery: Principles and Practice
1 Professionalism in Surgery
— 4
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