Two residents, wearing white coats with their names and "Department
of Orthopaedics" conspicuously embroidered on them, boarded
a hospital elevator crowded with physicians, employees, and visitors.
In a clearly audible voice, one resident began a story: "You
should have seen the patient I saw in my clinic the other day. She
was beautiful! I should send her to see Dr. W. He would love to
see her!" This comment drew the undivided attention of
everyone in the elevator and cast a ghastly silence over the rest
of the ride.
In recent years, interest has expanded regarding professionalism
and its importance in medicine and surgery1-5.
Orthopaedic surgery is no exception, as the topic has recently reached
prominence in our literature and policies1,3,6,7.
It is unlikely that professionalism is a universal and innate characteristic
of college students entering medical school, yet it becomes a necessary
value in medical practice. Somewhere in the ongoing process of medical education,
the issue must be addressed.
The tradition of residency training, at least in the surgical
fields, is not conducive to extensive philosophical exploration12,14. Much of residency training in orthopaedics
occurs in case conferences, where the patient is absent, or in the
operating room, where the patient is anesthetized. Teaching rounds,
with discussions at the patient’s bedside, have lost favor,
perhaps as a result, in part, of the ambulatory nature of many common
procedures and the rapid inpatient turnover. Similarly, in outpatient clinics,
time constraints have limited the opportunities for discussion of
all but the essential patient-care issues. As a result, the resident
is often minimally supervised in interactions with patients, and
an entire venue in which professionalism plays an important role
is not adequately utilized in residency education.
As difficult as it may seem to include the issue of professionalism
in the daily educational routine of the resident, it is even more
difficult to devote time to it in a didactic format. Thorough coverage
of the body of practical knowledge for which an orthopaedic resident
is held responsible is quite difficult in a one or even two-year
didactic curriculum; this leaves little room for discussion of such
issues as professionalism. At my institution, residents are given
the opportunity to meet with a hospital ethicist to discuss current
issues in medical ethics, but only for one hour each month. That
amount of time, divided among all of the issues of medical ethics,
cannot be expected to suffice.
Residency is one of the last great apprenticeships in today’s
society. As apprentices, residents learn by doing and by emulating role
models4,15. But how does one recognize professionalism?
Perhaps an analogy can provide some guidance. A common and particularly
crippling hazard of mountaineering is a "whiteout." A
white, cloud-covered sky meets a white, snow-covered horizon,
and all visual references are lost. The only way to regain spatial
orientation is to find something not white: a rock
outcropping, a crevasse, another person. Perhaps professionalism
is that same white; even though it surrounds residents in plain
view, one can neither recognize it nor define it until one finds
a lack of it. For example, when the clerk in an
emergency room announces over the public intercom system, "Whoever
dropped off the pregnancy-test results for patient Jane Smith, please
report to the desk," one should have no difficulty in recognizing
the behavior as unprofessional and a breach of patient confidentiality.
Many examples like this one surround residents and are often readily
apparent. However, it is not easy, and sometimes not politically
possible, to challenge the behavior of others, especially colleagues
and superiors. Nonetheless, residents enjoy a uniquely privileged
place in the medical hierarchy. As mature students, they are given
the opportunity, and are even encouraged, to critically examine their
surroundings. Conversely, as young teachers, they are given the
responsibility to critically examine themselves. Thus, residency
simultaneously offers the material, the opportunity, and the need
to address professionalism in a formal fashion.
As is true for any subject, no method of teaching professionalism
will succeed without instilling in residents the motivation to learn.
The impetus for the medical community as a whole to address professionalism
has been largely societal. Changing economic concerns have dramatically
altered the medical environment in recent decades. Philosophers,
politicians, and the general public have come to criticize the medical
profession’s maladaptation to this new environment, citing
a shift in motivation from altruism to financial self-preservation1,3,15,16. This criticism has effectively prompted
the medical community to reevaluate both its commitment to society
and the embodiment of this commitment in professionalism. Residents, however,
are largely shielded from these motivating factors. They do not
have an acute need to establish and maintain professional interpersonal
relationships with colleagues in order to secure referral sources
and thus to attain financial stability. Similarly, residents’ "practices" very often
consist of populations of patients without the wherewithal to shop
selectively for their care. Thus, residents may not feel the strong
pressure to excel in patient relations that highly discriminating
populations of patients exert on practicing orthopaedists. With
little pressure from society, colleagues, and patients, residents
depend to a great extent on their educators to convince them of
the importance of professional behavior. The manner in which individual educators
accomplish this goal will undoubtedly differ, but a recent study
by Rowley et al.4 supports adding
the evaluation of residents’ professional behavior to the
current means of evaluating residents’ performance. Not
only will this explicit emphasis on professional values provide
motivation for residents to behave professionally, but it will also
implicitly demonstrate to residents that their role models value
professionalism as much as they value technical clinical competence.
Once residents are made aware of the need to recognize, understand,
and aspire to professional values, the process of teaching professionalism
becomes feasible. If residents know that their program director
values and expects professional behavior, then they will strive
to excel in this area. Moreover, educators should institute disciplinary measures
for professional misconduct that match or even exceed those for
shortcomings in technical clinical performance. Such a division
of residents’ deficiencies into "normative" and "technical" errors,
with the former being considered far more serious, has been eloquently
described by Bosk15.
In orthopaedic surgery, diagnosis and treatment are often best taught
through discussion of specific cases. Case presentations of physician
behavior can be similarly instructive if they are combined with
a sense of value and importance. Discussion of cases of exceptional
professional behavior is not likely to be as effective as discussion
of professional misconduct, for several reasons. First, even if
one assumes that most physicians behave relatively professionally in
general, exemplary conduct does not stand out readily for examination
(the whiteout). However, professional misconduct is often quite
obvious (the crevasse). Second, discussion of the former may be
interpreted simply as praise and may not be taken seriously. Third,
just as case presentations of morbidity and mortality can provide
compelling teachings, discussion of misconduct may be the most effective
way to critically examine principles of professionalism. Finally,
regular discussion of problem cases in professional behavior allows
ongoing self-reflection among all of those involved that
does not carry the gravity of external, official, legal reviews
of conduct. In fact, it has been argued that this internal review
is itself an element of professionalism2,5.
These discussions need not usurp important didactic time or include
medical ethicists and philosophers. A simple ongoing dialogue, fueled
by conscientious faculty members and punctuated by infrequent but
regular formal conferences, should suffice. Through such discussions of
a variety of professional pitfalls, residents will learn to recognize
and emulate the role models of professional excellence that surround
them.
In summary, professionalism can and should be taught to residents in
orthopaedics. Of paramount importance in this process is the creation
of an awareness of professionalism among residents. Explicit evaluation
of residents’ conduct may be effective in establishing
this awareness while also providing a means to judge the success
of such an educational program. Discussion of specific examples
of professional misconduct utilizes a familiar didactic format to
cover unfamiliar concepts. Only after residents as a group are convinced
of the importance of rigorous professional behavior can methods
of teaching and evaluating professionalism be investigated. With continued
dedication to such goals, residents will become the leaders of tomorrow
and will have a firm understanding of the values that, centuries
ago, elevated the guild to a profession.