Translation of Theory into Practice

The American College of Surgeons (ACS) Task Force on Professionalism 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 related, professionalism also incorporates surgeons' relationships with patients and society.

3. Unprofessional behavior must have consequences.

4. Professional organizations are responsible for fostering professionalism in their membership.

If professionalism is indeed embodied in the principles discussed [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, professionalism, clinical excellence, and communication skills required for provision of high-quality patient-centered care. Furthermore, this expertise must be demonstrated to the satisfaction of the profession 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 knowledge, (3) practice-based learning and improvement, (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice. These competencies are now being integrated 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 coworkers, 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 personal 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 residents 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 fraudulent 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 neurosurgery 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 atmosphere of fear in the neurosurgery department. According to the United States Attorney in Seattle, University of Washington employees destroyed reports revealing that University doctors submitted 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 medical journal about billing errors. The University spent many millions 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 professionals to prevent such behaviors from developing and from being reinforced. To this end, we must lead by example. A study published in 2004 demonstrated an association between displays of unprofessional behavior in medical school and subsequent disciplinary 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?

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