Maintaining surgical professionalism

An RCP working party defined professionalism as ‘a set of values, behaviours and relationships that underpins the trust the public has in doctors.’¹ Professionalism, in relation to surgical practice, incorporates competence, consistency, honesty and integrity. Surgeons have a responsibility to maintain the highest level of public trust and confidence in the profession. This can be demonstrated by ensuring that each of the components of professionalism is clearly identified and validated.

Demonstrating knowledge and skills

Confidence in the profession demands that surgeons demonstrate competence. Societal indifference is being increasingly challenged as the public becomes better informed and more assertive. Patients are more and more unwilling to accept clinical judgements in a passive and unquestioning manner. Communication and interpersonal skills are thus increasingly relevant. The public has a right to expect the highest standards of professional practice, especially where interventional skill is required.

Both knowledge and skill must be demonstrated, with an emphasis on patient safety. Surgeons should not operate outside their sphere of competence; appropriate referral when necessary and multidisciplinary discussion are essential.

Surgical professionalism demands regular reflection and appraisal of one's clinical practice; annual appraisal is now obligatory in the UK. Appraisal should not only incorporate surgical performance but also set out personal and professional development needs, as well as career paths and goals.

Involvement in clinical governance is essential and should be used to identify and deal with poor performance by an individual surgeon or team. Accordingly, surgeons must participate in CPD and clinical audit. If national audits exist, then surgeons should include their patients in them. All surgeons must ensure accurate collection and analysis of their clinical outcomes as a means of providing evidence and giving confidence to patients that their standard of practice is satisfactory. The SCTS has demonstrated an overall improvement in the quality of care utilising these measures.² Such outcome measures can be used as an indicator of the need for CPD as well as demonstrating serious reflection on personal development.

Non clinical professional attributes

Good medial practice requires the highest levels of integrity, conduct and behaviour from surgeons. In a stressful working environment, interpersonal relationships and communication between colleagues, as well as between patients and surgeons, can become increasingly fraught. However, this cannot be used as an excuse to condone or mitigate unprofessional behaviour. When concerns relating to conduct and behaviour are raised, they must be investigated and dealt with expeditiously.

It is no longer acceptable to be a ‘maverick and proud of it’, to bully or harass vulnerable staff or to demonstrate poor awareness, with inappropriate maintenance of boundaries. In dealing with bad behaviour a number of myths have been identified by NCAS and others.³ These include assuming that if a team has good clinical results then ‘a bit of bad behaviour’ is acceptable; containing bad behaviour of a good practitioner by putting in strong management; mediating between two practitioners when they work in a ‘toxic’ team; and hoping that emerging problems will go away if left alone. Obviously any suggestion of dishonesty or fraud could require referral to the regulator and might have an impact on fitness to practise.

Early warning signs of lapses relating to conduct and behaviour do exist, should be recognisable and must be dealt with as soon as possible. They include poor handover, difficulty in communicating, poor meeting discipline, playing off one colleague against another and refusing to cover members of the team. A well functioning and effective team can avoid lapses in professionalism and improve the quality and effectiveness of a service.

Supporting professional activity

An often-cited reason given in mitigation for a lapse in professionalism is a lack of dedicated time within a hectic surgical working week. It is for this reason that the consultant contract incorporates time for SPAs so that professional issues can be reflected upon and overall patient care and standards raised. The Royal College of Surgeons supports the maintenance of 2.5 SPA sessions (1 session being 4 hours) within a 10-session consultant contract within the working week. Such key and crucial activities include teaching, training, CPD, audit, appraisal, research, clinical governance and service development.

Conclusion

Lack of time to pursue professional activity or maintain professionalism should not be used as a mitigating factor for lapses. Time for professionalism should be made available and is an essential component of the consultant contract to ensure a professional contribution by the surgeon. (An extended version of this contribution is published in this month's issue of the Bulletin (page 270).)