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  Professionalism infers the code by which surgeons must conduct themselves amidst grueling training, long hours, fatigue, and stress

  
  
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  How will you respond as these forces threaten your ability to maintain yourself as a professional?

Professionalism infers the code by which surgeons must conduct themselves amidst grueling training, long hours, fatigue, and stressful situations. How will you respond as these forces threaten your ability to maintain yourself as a professional?

What is professionalism? The term professionalism encompasses so many ideas and applies to so many different activities that an easy definition is nearly impossible. While the exact definition may elude you, you may be thinking, “I know it when I see it” in the way Supreme Court Justice Potter Stewart so famously described obscenity in 1964. In your experience in the medical field, you can probably think of at least a few examples of situations in which you have seen physicians act in a manner that was unprofessional. The truth is that unprofessional behavior happens often in medicine—this is propagated by physicians and nonphysicians in times of stress, duress, and fatigue. Many great physicians have suffered lapses where they have behaved unprofessionally. The field of medicine is no different, in this regard, from any other field. Because you will inevitably be exposed to unprofessional behavior and may act in an unprofessional way at some point, planning for situations in which lapses may occur and what you will do will help prepare you for facing these challenges. In this chapter, we will explore challenges to professionalism and case examples to think about your role in being professional.

The landscape of professionalism has changed drastically over the past century. In past eras, the power of the physician was paramount and often unchallenged. More paternalistic medicine was the standard; much less attention was paid to how doctors ought to act with patients, peers, other employees, and physicians in training. Everyone expected doctors would act in what they considered the best interest of their patients, but decisions the doctor made would stand often without question from the patient or anyone else. Generally, no formal curricula existed for many generations for training young physicians to act professionally (except perhaps for remediation or for reentry into practice). Medical students and residents instead learned professionalism based on modeling by training physicians. In some cases, this model worked very well but, of course, it all depends on who is doing the modeling. While we now have curricula throughout the country on professionalism, students and residents still learn the majority of their professional characteristics from their teachers: residents from attending physicians and students from both the attending physicians and their residents. The new curricula on professionalism should help teach students how to look at those behaviors with a critical eye and decide what type of physician and, indeed, person they want to become.

More recently, the practice of medicine has been viewed as much more of a team sport: a partnership between the physician, patient, and medical team providing care. Of course, this is no different in surgery. The patient is clearly integral to the relationship, as is the surgeon. However, the many other members of the medical team are the cogs and wheels of surgical outcomes, quality, safety, and the patient experience. To perform the most successful surgery and, ultimately, have the most satisfied patient, professionalism is nearly as important as surgical skill. An extremely skilled cardiothoracic surgeon who yells at his staff may experience large turnover in employees. His newer, less experienced scrub techs will likely increase his operating room (OR) time for each procedure, in addition to being slower to respond with appropriate assistance in dire situations. Outcomes may suffer due to inconsistency in achieving the highest team performance. All members of the surgical team must work in concert to deliver the best care.

Professionalism has at times been dichotomized to a quality that a surgeon either had or lacked. You are probably familiar with the stereotypes naming bad doctors and bad surgeons who care little for patients and are driven more by money, reputation, or power. You probably also can think of examples of doctors who seem to be the most benevolent individuals in the world, often sacrificing their own needs for those of others. The majority of surgeons and physicians do not fall into these two categories. Most of us face day-to-day decisions that define who we are as practitioners, caregivers, and people. In fact, it is rare to meet physicians who practice wholly “professional” or “unprofessional” medicine.

The American College of Surgeons has created its professional Code of Conduct naming the following responsibilities of surgeons in surgical care and in society:

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  Serve as effective advocates for our patients’ needs;

  
  
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  Disclose therapeutic options including their risks and benefits;

  
  
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  Disclose and resolve any conflict of interest that might influence the decisions of care;

  
  
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  Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period;

  
  
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  Fully disclose adverse events and medical errors;

  
  
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  Acknowledge patients’ psychological, social, cultural, and spiritual needs;

  
  
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  Encompass within our surgical care the special needs of terminally ill patients;

  
  
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  Acknowledge and support the needs of patients’ families; and

  
  
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  Respect the knowledge, dignity, and perspective of other healthcare professionals.

  
  
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  Provide the highest quality of surgical care;

  
  
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  Abide by the values of honesty, confidentiality, and altruism;

  
  
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  Participate in lifelong learning;

  
  
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  Maintain competence throughout our surgical careers;

  
  
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  Participate in self regulation by setting, maintaining, and enforcing practice standards;

  
  
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  Improve care by evaluating its processes and outcomes;

  
  
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  Inform the public on subjects within our expertise;

  
  
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  Advocate strategies to improve individual and public health by communicating with government, healthcare organizations, and industry;

  
  
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  Work with society to establish a just, effective, and efficient distribution of healthcare resources;

  
  
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  Provide necessary surgical care without regard to gender, race, disability, religion, social status, or ability to pay; and

  
  
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  Participate in educational programs addressing professionalism.

As you may have noticed, this list includes both things you would expect out of professionalism such as explaining risks and benefits of procedures prior to performing them but also some loftier goals for interaction with society. Most physicians probably agree with this as a list of ideals for their practice. However, performing the entire list may seem difficult. Perhaps thinking about these issues on a smaller scale will help you to imagine how some of them might be carried out on a daily basis.

Every day, physicians go through dozens of interactions with patients, peers, staff, physicians in training, and other members of society. Each of these individual interactions can be professional or unprofessional. In times of stress, our “best self” can slip into behaviors or actions that might not be the best expression of our altruism and/or professionalism—this is being human. When asked, the majority of physicians probably would like to act professionally at all times. If we all want to act professionally, why do we often and sometimes horribly slip? The challenges of the surgeon’s work compromise the equanimity that must undergird professionalism. Thinking about the various types of pressure a surgeon undergoes may help understand where lapses in professionalism occur and how they can be avoided.

Surgeons are placed in a tremendous amount of stress, perhaps more so than other medical specialists. The preeminent medical sociologist Charles Bosk poignantly explained the difference between surgeons and general internists. General internists care for a patient with a particular illness and may or may not make a difference in the ultimate outcome of the illness. When an internist’s patient dies, other physicians ask, “What happened?” On the other hand, surgeons deal with illnesses that require intervention in a more physically direct manner. When a surgeon’s patient dies, the question is much more frank: “What did you do?” Unlike many other physicians, surgeons see patients at their most vulnerable, with their internal organs exposed and in dire need of assistance. Patients have to place a tremendous amount of trust and faith in their surgeon. Of course, this stress is unique to surgeons, practitioners who spend their time invading the body in an attempt to heal it.

Historically, the very long hours of residency are beyond challenging. Resident physicians don’t sleep enough while simultaneously being assigned the responsibility of keeping patients alive amidst an onslaught of information and data that many have likened to “drinking from a fire hose.” This environment creates a form of stress most people will never experience nor be able to comprehend. Some of these problems come to a close, whereas others seem to have no horizon—this is no excuse to act unprofessionally toward others. Being fatigued promotes irritability and can reduce one’s ability to render medical decisions while maintaining a professional demeanor.

A resident physician on call through the night might become short with a patient repeatedly asking for pain medication who is legitimately in pain. Residents are often overwhelmed with many things to do at once. The patient may become frustrated with not being seen in what he or she considers a timely fashion. Keep in mind that being in pain makes it seem as though a great deal of time has passed when not much has passed at all. Understanding the patient’s point of view and responding appropriately when you arrive can help make a big difference. Acknowledging the patient’s pain, apologizing for your tardiness, and even explaining why you could not come sooner in a nice fashion can help maintain a professional atmosphere. The types of professional habits you develop during residency will shape who you are as a physician into the future.

Maintaining professional conduct can be difficult with nurses and other staff. While they can’t understand the unique stress that you experience, you can’t understand their unique stresses either. Try to understand the reason behind their actions—in so doing you may follow the maxim of assume noble intent. They may be calling repeatedly because they feel empathy for the patient who is in pain and cannot get any medication. They may feel annoyed with you for responding so slowly to something they consider important. If you work with senior residents or physicians who seem to work particularly well with staff and patients, take note of their methods. Alternatively, if you work with people showing examples of unprofessionalism, you can certainly learn from these as well. Pay attention to how staff members receive certain physicians well and others poorly. Think about what behavior provokes what response. You will find that acting nicely and looking at the problem from the other party’s point of view will help you be able to defuse situations more easily. In the end, interacting well leads to increased staff happiness and better patient care.