Professionalism — connecting the past and the present and a blueprint for the Canadian Association of General Surgeons
========================================================================================================================

* Francis Christian
* Dennis F. Pitt
* James Bond
* Patrick Davison
* Anthony Gomes

## Definition and explanation of terms

*Merriam-Webster’s Collegiate Dictionary* defines professionalism as “the conduct, aims and qualities that characterize or mark a profession or a professional person.”1

Within the context of the physician professional, there is a serious but largely unwritten understanding, both within the profession and among the public at large, that physicians must hold themselves up to high ethical and clinical standards.2–5

In essence, the basics of professionalism are quite easy to articulate. In return for professional autonomy, self-regulation and a recognition of their unique place in society, the public demands of physicians accountability, ethical standards and an altruistic manner of delivering care.4–6

Altruism, or the putting of the interest of patients and society consistently ahead of one’s own, is the bedrock of professionalism for the physician and has been recognized as a key, unifying concept by several professional bodies.7–11 Altruism has also been defined as going “above and beyond” one’s call of duty.12

## Historical perspectives and the current increased interest in codification

The different great ancient civilizations have all made clear attempts to define a code of conduct for the medical profession.13–15

The Oath of Hippocrates deriving from ancient Greece was required of all Western medical students on graduation until very recently in the latter half of the 20th century.13,16 In ancient India, the surgeon-teacher Sushruta laid down a code of ethical and clinical conduct for his pupils embodied in an oath or promise that students had to undertake to graduate from his school of surgery.17

The Canadian physician William Osler made seminal contributions to the development of professionalism and to the promotion of medicine as a calling rather than a business.18–21 Osler urged physicians to live and to treat patients by the golden rule and to practise medicine with compassion and competence.22–24

Although the ideals championed by William Osler have been recognized by generations of physicians as defining the basic tenets of professionalism, there has been a recent surge of interest in defining these principles anew for a new generation of doctors. Changing clinical guidelines for the practice of medicine,25,26 differences in perceptions regarding physicians’ financial expectations,7,8,27–30 an evolving legal framework in the context of well-publicized medical errors and justifiably increased patient expectations8,31,32 and the increasingly nebulous boundaries of the relation between physicians and the medical-surgical-commercial complex33–35 have all had their part in shaping the current debate about professionalism for today’s physician.

Increasingly, most such revisiting of the historical and contemporary obligations of the profession toward the public and toward one another has confirmed the basic validity of timeless values as espoused by the classical oaths and by such champions of professionalism as William Osler.9,10,36–39 In 1903 Osler himself, with uncanny insight, predicted that these ideals would remain the same:

> The times have changed, conditions of practice altered and are altering rapidly, but the ideals which inspired our earlier physicians are ours today — ideals which are ever old, yet always fresh and new.22

These ideals have been reinterpreted for today’s physicians in a manner that addresses the particular concerns arising from the progress of our science and art to the present time, but major medical societies, associations and licensing bodies continue to espouse principles and values similar to those that have guided past generations, thus linking the past with the present in a meaningful, practical way.36–39

## Recognition of the importance of teaching professionalism

Even though medical students and residents read about and hear principles of professionalism described in various informal forums, evidence suggests that they tend to do as their teachers do and not as their teachers or forebears say.40–42

The contemporary medical student tends to become more cynical and less idealistic by his fourth medical year,43 and students and residents react to belittling, harshness, negative role models and the pressures of overwork by incorporating those same behaviours into their lives and practices.43

The need to reflect and contemplate on one’s own actions and the experiences of the patient, as advocated by William Osler, has been recognized as one of the key components of the teaching and learning of professionalism by students and residents. 43–45 Charon defines this component of learning as “the ability to acknowledge, absorb, interpret and act on the stories and plights of others.”46

Recognizing the importance of providing positive role models and treating students humanely has been shown to significantly increase the chance of producing humane, compassionate physicians,47 and much effort is now being expended to incorporate formal and informal teaching and assessment of professionalism in medical schools and hospitals around the world.41,43

## Development of a code of professionalism for Canadian surgeons

In February 2006, the Canadian Association of General Surgeons (CAGS) Board of Directors tasked the Committee on Professionalism with preparing a position paper on professionalism for Canadian surgeons.

In the fall of 2006, after much discussion and critique, the Committee submitted its final drafts to the Board.

The Committee subsequently received comments and recommendations from the Board that were incorporated into the position statement.

We present the latter document here. After further comments have been received from the members of CAGS at large, the Board intends to approve an final version of the position statement for Canadian surgeons. This official version is intended to meet the needs of practising surgeons, residents and medical students.

## CAGS position paper on professionalism and the general surgeon

### Preamble

Whereas the interest of the patient is paramount to the surgeon and whereas the surgeon’s contract with the public must make the surgeon’s commitment to professionalism transparent and accessible, the Canadian Association of General Surgeons believes that a position paper on professionalism for the general surgeon will inform both the public and the profession alike and be a ready reference for students and residents.

### Code of professionalism

#### Duty to consider first the well-being of the patient

The surgeon recognizes the patient’s ultimate trust in accepting evaluation for and submission to an operation and will always put the interests of the patient above his or her own.

Doing right by the patient will always trump the business or pecuniary interests of the surgeon.

#### Respect for patient and clinical autonomy and providing the highest quality of care

The surgeon will keep abreast of the latest advances in the science and art of surgery, including advances in the basic sciences, in clinical research and in technology, and will seek to apply these to the care of his or her patients.

Patient confidentiality and dignity will always be maintained.

The surgeon will consistently advocate for societal and patient needs, including access to care, equitable distribution of care, quality of care and patient safety.

Patient autonomy in decision making for surgical care and clinical autonomy in advising patients about surgical care will be respected and maintained.

#### The adoption of new technology, partnership with industry and participation in research that benefits the patient

When new and potentially expensive technology is being evaluated, the surgeon will use evidence-based and peer-reviewed criteria for its adoption, independent of the influence of corporate promotion. When such technology is deemed the standard of care, the surgeon will discuss it with the patient; if the surgeon is unable to provide the technology, the patient must be taken into confidence and referred to a colleague, if appropriate.

The surgeon welcomes partnership with industry and acknowledges industry-led initiatives to improve patient care. However, such partnership must only be accepted in the best interests of the patient and must be open to public scrutiny.

The goal of all research, whether basic or applied, must be the benefit of patients.

All research will be conducted in a manner that conforms to the highest ethical standards.

#### Care without discrimination

The patient’s ability to pay must not influence the surgeon’s decision to care, and surgeons must provide high-quality care without discrimination.

The surgeon will avoid discrimination as to sex, ethnoracial background, sexual orientation, disability, religion and social status.

#### Working with other health care professionals as a team for the benefit of patients

Recognizing that good teamwork improves patient care, the surgeon must strive to work with courtesy, respect, kindness and a mutual spirit of learning with fellow physicians and nonphysicians. The surgeon will not disparage a referring physician to fellow surgeons, residents, students or patients.

Recognizing that we are role models for the students, residents and nurses who work with us, the surgeon will strive to communicate to them his or her knowledge and enthusiasm for the specialty as well as the principles of professionalism outlined in this document. The surgeon will treat students and residents with respect, kindness and courtesy.

#### Openness and honesty with the patient and disclosure of adverse events

The surgeon will disclose adverse events and medical errors and will be open and honest with the patient at all times.

#### Accountability to the courts, licensing bodies, peers and hospitals

The surgeon must be a law-abiding citizen, and adherence to this code of professionalism in no way excuses the surgeon from his or her obligations to such institutions as the professional licensing body, local research and ethics committees and appropriate government and law enforcement agencies.

#### Balance between professional and private life

Recognizing that a healthy and happy surgeon will most often translate to better care for patients, the surgeon will strive to find a balance between professional life, personal and family life and other interests.

## Footnotes

*   **Competing interests:** None declared.

*   Accepted September 6, 2007.

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