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Attitudes and Habits of Highly Humanistic Surgeons

A Single-Institution, Mixed-Methods Study

Swendiman, Robert A. MD, MPP; Marcaccio, Christina L. MD; Han, Jason MD; Hoffman, Daniel I.; Weiner, Timothy M. MD; Nance, Michael L. MD, and; Chou, Carol M. MD

doi: 10.1097/ACM.0000000000002690
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Purpose Humanism in medicine is associated with increased patient satisfaction, trust of patients in their doctors, and better outcomes. The authors sought to identify attitudes, habits, and other factors that sustain humanism in academic surgical faculty, and compare these with attributes determined from a previous study of internal medicine faculty.

Method A mixed-methods study design at University of Pennsylvania Health System was employed from 2016 to 2018 using a survey instrument and semistructured interviews. Surgical residents nominated faculty who exemplified humanism. In-depth interviews were then conducted with surgeons receiving the most nominations. The interviews were transcribed, and common themes were identified using the grounded theory method. These were compared with findings from a previous internal medicine study.

Results Ten faculty described three strongly shared attitudes: humility, responsibility, and a desire to live up to a high standard of professional behavior. Five habits were found important to sustaining these attitudes and their practice: self-reflection, finding deep connections with patients, maintaining personal and professional relationships, “having fun” at work, and paying it forward to surgical trainees. Surgeons also cited the importance of past role models in developing humanistic attitudes and sustaining practice. Responses were compared with previously documented attitudes and habits of humanistic internal medicine faculty at the institution.

Conclusions This study identified recurring attitudes and habits that characterize humanistic behaviors in a cohort of academic surgeons. Learning from these exemplary humanistic surgeons may inform the development of future educational programs for residents and faculty in sustaining humanism.

R.A. Swendiman is a general surgery resident, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

C.L. Marcaccio is a vascular surgery resident, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

J. Han is a cardiothoracic surgery resident, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

D.I. Hoffman is a medical student, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

T.M. Weiner is a pediatric surgeon, New Hanover Regional Medical Center, Wilmington, North Carolina, and adjunct professor of surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.

M.L. Nance is Josephine J. and John M. Templeton Jr. Endowed Chair in Pediatric Trauma, Children’s Hospital of Philadelphia, and professor of pediatric surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

C.M. Chou is associate professor of clinical medicine, Department of Medicine, Division of General Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Funding/Support: The Bach Fund at Penn Presbyterian Medical Center, which seeks to support faculty members with small grants for research projects within the University of Pennsylvania Health System, provided funding support for the transcription services.

Other disclosures: None reported.

Ethical approval: This study was approved by the institutional review board at the University of Pennsylvania.

Previous presentations: This research was presented as an oral abstract at the International Conference on Communication in Healthcare, Baltimore, Maryland, October 9, 2017 (sponsored by the American Academy on Communication in Healthcare).

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A648.

Correspondence should be addressed to Robert A. Swendiman, 3400 Spruce St., Philadelphia, PA 19104; telephone: (215) 662-6156; email: robert.swendiman@uphs.upenn.edu; Twitter: @RobertSwendiman.

Humanism in medicine is widely recognized as a core value in both practice and training. Humanism is defined as the application of scientific knowledge and technical skills with acknowledgment of and respect for the emotional, social, and cultural needs of individual patients and their families.1,2 Studies have demonstrated that humanistic treatment of patients optimizes care by improving their satisfaction, adherence to medications, trust in their doctors, and clinical outcomes.1,3–5 Though intrinsic to the medical profession, the medical humanism movement has only gained traction relatively recently, with professional and medical educational organizations now placing increased emphasis on core humanistic values: professionalism, cultural competency, and empathy.6 In 2003, the Accreditation Council for Graduate Medical Education mandated that two of the six core competencies for all residency training programs would be interpersonal and communication skills and professionalism. Since then, numerous studies have focused on understanding and encouraging these two competencies,7–11 which are fundamental to providing humanistic care.1

Humanism is most often taught by example,1,12 and teaching faculty are thus charged with modeling humanistic behavior to physicians-in-training. Though burnout and declining empathy have been documented in other specialties,13 rates of burnout and attrition are particularly high among surgery residents. Approximately 70% report burnout, and one out of every four general surgery residents fails to complete their surgical residency, a number far higher than for other specialties.14 As the high prevalence of burnout can erode humanism, surgical trainees may especially benefit from teachers who demonstrate humanistic behavior in their care of patients.15,16

Prior studies have identified factors that contribute to creating humanistic physicians,17 and a study we conducted previously highlighted common themes and attitudes shared among humanistic internal medicine faculty.15 However, to our knowledge no research has focused on the attitudes of surgeons, who encounter a practice environment and culture different from those of their medical colleagues. With increasing demands and pressures on teaching faculty, it can be difficult to sustain humanism, much less to model this behavior to learners. Thus, we sought to identify attitudes and habits of a group of highly humanistic surgeons; the impact of these behaviors on empathy, burnout, and professionalism; and how they aid in the provision of compassionate care for the surgical patient. We also aimed to compare and contrast the factors that sustain humanism in surgeons with those previously identified by internal medicine physicians.

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Method

We conducted a mixed-methods study employing both a survey and an interview instrument (Supplemental Digital Appendices 1 and 2, available at http://links.lww.com/ACADMED/A648). An electronic survey (SurveyMonkey Inc., San Mateo, California) was sent to 77 surgery residents, including all categorical and preliminary general surgery residents, as well as residents in the integrated vascular surgery and plastic surgery programs, at the Hospital of the University of Pennsylvania in June 2016. We selected these residents because they share common core rotations over the first three years of training and work with attending surgeons in the core surgical specialties (general surgery, colorectal, transplant, vascular, etc.) at the three major University of Pennsylvania Health System (UPHS) teaching hospitals. We did not include other surgical subspecialty residents because they spend less than one year in core general surgery rotations. Residents were asked to nominate up to three faculty members who served as exemplary models of humanistic care, as defined.2 The 72 surgical faculty (58 men, 14 women) were listed in alphabetical order as potential choices.

We invited the most frequently nominated surgeons to participate in one-on-one semistructured interviews with one of our investigators (C.M., J.H., D.H.). We conducted initial interviews from September 2016 to March 2017, with a second round of interviews completed in February 2018. Humanism was defined as above, and we asked open-ended questions in a semistructured format to assess the attitudes, habits, and experiences that contributed to developing and sustaining humanism in participants’ practice. We also collected demographic information (see Supplemental Digital Appendix 2, available at http://links.lww.com/ACADMED/A648). The interviews were then transcribed verbatim and anonymized. We employed grounded theory to identify common themes that emerged through reviews of the data. Readings were performed by four investigators (C.C., R.S., C.M., and J.H.). All four investigators agreed that thematic saturation was reached after 7 interviews; however, an additional 3 interviews were conducted given the team’s concern that 7 was insufficient for a robust qualitative study. Increasing the number of interviews beyond 10, however, would have included faculty who received few nominations, thus diminishing internal validity. No new themes emerged upon reading of the additional transcripts. We conducted the analysis by an iterative approach until the investigators reached consensus regarding the themes and the overall conceptual model.

This research was approved by the institutional review board of the University of Pennsylvania.

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Results

A total of 43 (55.8%) residents responded to the survey, and of the 72 surgical faculty members in the Department of Surgery at UPHS, 36 (50%) received at least one nomination. Ten (13.8%) attending physicians, who had between 4 and 12 nominations each, were chosen for interviews. Table 1 displays the demographic data for these participants. Interviewees described three strongly shared attitudes and five habits that were important to sustaining the practice of these humanistic behaviors. We also identified two additional separate themes that emerged.

Table 1

Table 1

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Attitudes of humanistic surgeons

Three themes represent attitudes shared among humanistic surgeons: humility, responsibility, and upholding a high standard of behavior.

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Humility.

Most surgeons (7/10) identified an attitude of humility in their practice. For instance:

I connect [humanism] with the philosophy that—unlike many people who get dressed and go to work every day.… I’ve been fortunate enough that I’m able do things for other people that most workers couldn’t imagine. (Interview 2)

Central to this attitude of humility, surgeons specifically described the “privilege” of caring for patients. For these surgeons, humility helped shape their patient interactions, enabling them to be respectful and compassionate in addressing their patients’ needs:

People come here because they need us. Nobody wants to go to the doctor. So I just remind [my]self that it’s a very privileged position to be able to help people in need at a time when they are vulnerable and don’t know you. And that that privilege should be met with a level of respect that demands a human touch. (Interview 3)

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Responsibility as a surgeon.

More than half of the surgeons (6/10) commented that they perceive that humanistic practice is actually part of their responsibility as a physician. This is separate from an attitude of humility, which was more self-focused. The interviewees talked about how humanistic care was “owed” to patients, coming from a position of power:

There’s a focus on the fact that as a physician … you’re part of the world, you’re part of society. You owe something to your community. You owe something to each individual patient. (Interview 7)

Some surgeons viewed the act of behaving in a humanistic manner toward their patients as an integral part of being a surgeon—perhaps as essential as the technical skills required to successfully perform any given operation:

If you’re talking about the way you communicate with patients, the way you express things, the way you convey that you’re caring about people.… That’s not really in my mind a separate issue from the actual technical aspects of doing the operation, or the [clinical] judgment or any of that. It’s all part of the same process in my mind. (Interview 6)

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Standard of behavior.

The majority of surgeons (7/10) acknowledged that their humanistic practice arises from a desire to uphold “the basic tenants of civility” or a certain standard of behavior—specifically, the “Golden Rule”:

You want to live by the saying “Do unto others what you would have others do unto you.” Treat everyone the way you would want to be treated. Have the kind of consideration for others whether it’s their clinical problem, their socioeconomic status, their ethnic or cultural status. (Interview 4)

Some physicians actively engaged with this principle and suggested that putting themselves in their patients’ shoes is a central component of their practice and influences how they interact with individual patients. This drive to model respect for everyone improves the ability of these surgeons to relate to their patients.

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Habits that sustain humanism

Collectively, the surgeons we interviewed identified five key factors that help them to sustain humanistic attitudes in caring for patients.

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Self-reflection.

Almost all of the surgeons (8/10) described actively engaging in self-reflection:

I would say that I try to remind myself as often as possible about my intrinsic motivation for surgery, [the] purpose behind why I do what I do.… Without that sort of touchstone and those reminders, then you sometimes can’t see the forest for the trees. (Interview 10)

One interviewee engaged in self-reflection at the end of each day:

Whether I drive [home] or I seclude [myself] in my office, I always grade myself [on my patient interactions]. I always find peace in myself if I do that reflection.… I need that reflection to put everything together … that gives me energy and takes the pressure out of my whole being frankly. (Interview 5)

Self-reflection provided these surgeons with an opportunity to constructively evaluate their practice, including both the technical elements of surgery and the nature of their interactions with patients. Beyond self-reflection, two surgeons cited active mindfulness as a part of their practice. These surgeons felt that anticipating and actively preparing for potential challenges helps to improve and sustain their ability to provide humanistic patient care.

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Meaningful connections with patients.

Most surgeons (8/10) discussed that looking to form meaningful relationships with patients actually serves as positive feedback and sustains their humanistic practice:

People [who] are not interested to really get to know patients and take care of them—they shouldn’t be in this business.… I also tell [patients] about myself. I think it is really important to say that I also have weaknesses, that I also have been sick. And that I also have emotions, that I also have made mistakes … the basic principle is to engender trust. I believe once you have trust, you can get the respect, and believe you really provide the best care for your patients. (Interview 5)

Another surgeon felt that patient relationships are the most rewarding aspect of the work as a surgeon:

In surgery, you get so close to your patients because it’s such an important relationship … you get to meet thousands of people over a lifetime, which is really a gift. (Interview 3)

For these surgeons, connecting with patients as fellow human beings rather than in the context of a strict doctor–patient relationship or purely technical context improved their ability to provide high-quality and compassionate patient care.

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Personal and professional relationships.

In addition to forming meaningful relationships with patients, nearly all surgeons (8/10) felt that relationships with their family, friends, and colleagues were important to sustaining humanistic practice. Some surgeons commented that these relationships provide emotional support, which enables them to persevere through challenging circumstances that would otherwise have potential to thwart their humanism. For others, relationships with colleagues strengthen their commitment to their patients and to their field as a whole:

I have long-standing professional relationships here that I value tremendously. And we have a large team, many of whom we’ve been working with year after year. And their commitment … bolsters my commitment and vice versa. (Interview 2)

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Having fun at work.

Half of surgeons (5/10) explicitly commented that having “fun” at work helps them to sustain their humanistic practice. Surgeons cited three ways that promote their enjoyment in the workplace. First, two surgeons stated that they value having variability in their practice, which they cited as actually helping prevent burnout and sustain humanism:

I think that what we do in academics probably, to some degree, prevents [burnout] because every day is, from a clinical, academic and teaching perspective, very different, unlike perhaps practitioners who are in private practice. (Interview 1)

Another surgeon suggested that matching expectations with reality when pursuing a career in surgery improves the likelihood that surgeons will enjoy their work. Setting realistic daily and professional expectations was key to fulfillment. Finally, two surgeons said that they actively stopped “tracking professional accomplishments” because it prevented them from finding enjoyment in their work. These three strategies were suggested as keys to sustaining their humanistic practice and empathy and preventing burnout.

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Pay-it-forward to trainees.

Most surgeons (7/10) believed that teaching surgical trainees helps to sustain their humanism. In fact, three surgeons cited working with trainees as the most meaningful aspect of their work. For instance:

I really enjoy working with students and residents in the operating room [and on] rounds and talking with them. I like to see the progression of their acquisition of knowledge and [it’s] just wonderful … when you’re in rounds or the OR and you can … just see that the “light bulb” goes on in somebody. (Interview 1)

Beyond teaching, many surgeons found deep satisfaction in watching trainees progress in their knowledge and practice:

At some point you realize that it becomes less and less about you as you get older and more and more about the people that you’re training and your faculty. (Interview 2)

Through teaching and mentorship, these surgeons described passing on their legacy and influence to the next generation. This opportunity not only provides meaning to their work but also motivates continued humanistic behavior.

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Other themes

Two additional themes emerged which relate to both the development of humanistic attitudes and the sustainability of humanistic practices, but were not specific attitudes or habits themselves.

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Importance of physician role models.

Given the known importance of role modeling in learning humanism, as expected, all surgeons (10/10) cited the importance of physician role models in developing humanistic attitudes and practice:

There are a number of people who have [served as] a significant role model for me with respect not only to their professional skills, but also to professionalism and humanism.… Each one of them really taught me a degree of humanity as you approach patients regardless of what their disease is, regardless of what the stage of the disease [or] how grave their prognosis is. (Interview 5)

Most surgeons identified specific individuals who served as humanistic role models who have considerably influenced their practice. Surgeons valued both positive and negative role models, citing the importance of taking “little bits of lessons from what has happened to you in your life from the various people you come in contact with” (Interview 1) and then actively deciding which attitudes and behaviors to adopt.

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Relative low priority of work–life balance.

Over half of the surgeons (6/10) stated that achieving work–life balance—traditionally conceptualized as including “lifestyle” choices in addition to work as a priority in one’s life18—was not particularly important in developing and sustaining humanistic practice. In fact, two surgeons rejected the concept of work–life balance altogether and preferred the idea of work–life “integration” or “coexistence.” Many described the balance in their own lives as “poor”:

There’s a lot of talk about work–life balance and what that all means. And for some people it means spending a lot of time out of work. For some people, it means just finding the right balance for you personally … there’s no right answer and there’s no wrong answer. So I hate it when people talk about work–life balance … it’s not balance, it’s coexistence. And it’s finding out how to make that work. (Interview 4)

Only one surgeon specifically valued work–life balance as important to sustaining humanistic practice. Another surgeon felt that work–life balance was important to overall success and happiness but qualified that “balance” should be attained over a career rather than at any given stage:

Your career is a marathon, not a sprint. Things evolve and happen over a long period of time. And if you’re going to avoid burnout—which is common amongst physicians—then you have to look at the long-term picture and how you’re going to be satisfied in your career over the long term, as opposed to just finite, very short-term sprint. (Interview 2)

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Discussion

This is the first study that we know of to characterize humanistic attitudes and habits that are shared among a group of academic surgical faculty. Surveying residents identified highly humanistic surgeons. Our interviews with these 10 faculty yielded three shared attitudes: humility, responsibility, and a desire to live up to a high standard of professional behavior. Five habits—self-reflection; finding deep connections with patients; maintaining personal and professional relationships; having fun at work; and paying it forward to surgical trainees—were described as important to sustaining these attitudes and their practice. Surgeons cited specific role models who were indispensable in how they think of humanism and provide humanistic care. Some pointed out the relatively low prioritization of work–life balance as a component of maintaining their humanistic practices, and others reframed work–life balance as a concept to be understood over the long term.

Given recent attention to burnout and high rates of attrition in surgery,14 the need for demonstrating, sustaining, and perpetuating humanism has become more important than ever. Burnout is directly associated with physical and emotional exhaustion, depersonalization (e.g., dehumanization of patients, increase in nonclinical tasks in the care of patients), and suboptimal patient care,19–22 and the surgeons we interviewed noted the need to avoid burnout in order to sustain humanism. Given the amount of time that surgeons spend at work (see Table 1), it is perhaps not surprising that the interviewees provided mostly “work-centric” strategies for sustaining humanism. “Having fun” at work, teaching trainees, and the relative unimportance of work–life balance attest to this. Most traditional wellness initiatives focus on time spent outside the hospital or mentoring, but few focus on “social resilience” and a physician’s need for meaningful human connection in the workplace.23 Our findings may inform the development of curricula that focus on improving aspects of the work environment to promote wellness.

Our prior study, which used similar methodology, identified humanistic attitudes and habits of 16 internal medicine teaching faculty at a single institution.15 Internal medicine attending physicians noted that humility, curiosity about patients, a high standard of behavior, humanism as medically important for the physician and patient, and the role of a physician as treating more than just a disease were important to sustaining humanism. These correlate well with the attitudes espoused by our surgical cohort (see Table 2 for a comparison). Humility and living up to a high standard of behavior were identified by both groups of physicians. Regarding responsibility, for instance, the surgeons noted the importance of humanism to patients, and that the care of the patient involves more than “actual technical aspects of doing the operation.” Though the importance of curiosity as a habit was not discussed specifically, surgeons noted the important practice of developing meaningful relationships with patients beyond the operating room, echoing this patient-centered theme.

Table 2

Table 2

Both cohorts self-reported similar habits of sustaining humanism. Internal medicine faculty noted regularly practicing self-reflection, seeking connection with patients, role modeling humanism, mindfulness, and striving to achieve balance. The first four themes are concordant with findings from this study. However, two major distinctions should be noted that may provide insight into how medicine physicians and surgeons sustain humanism differently. We learned that for the internal medicine cohort, active role modeling for students and trainees was a constant reminder to provide humanistic care.15 This surgical cohort did not emphasize role modeling for trainees, but instead, all 10 interviewees described individuals—usually providing names and specific events—and told stories of role models they had encountered earlier in their careers. This reinforces previous studies showing the importance of role modeling in propagating humanism and professionalism,1,13,17 and further supports curriculum development that teaches how to effectively role model humanism.24,25

The second distinction is in regard to work–life balance. Internal medicine physicians shared the perception that this was an important aspect of sustaining humanism. In our surgical cohort, most suggested that work–life balance was a relatively low priority, favoring work–life “integration” or “coexistence” to sustain humanism. This may have to do with the different demands of surgical practice, or it may reflect an attitude ingrained in the surgical or institutional culture our participants inhabit.26 It could also represent a reframing of the concept altogether, where “balance” is perceived as an illusory goal, but “integration” is achievable and thus preferable.27 The surgeons we interviewed acknowledged the importance of avoiding burnout, noting its threat to humanism, so how they interpreted this question may explain the incongruence of their response compared with the internal medicine cohort. Again, the development of work-centric strategies for sustaining humanism is notable. Finding meaning in one’s work is highly correlated with job satisfaction and stress reduction,21,28–30 and surgeons place a great deal of emphasis on this factor.27 This may explain the perception that the traditional concept of work–life balance was not important in sustaining humanism in this cohort of surgeons. However, in a large study of U.S. surgeons, the prevalence of burnout was 40% less in those who stressed the importance of lifestyle activities and balance,28 and thus further investigation into the relationship between humanism and burnout is warranted given the high rates of burnout not only in surgery but across all medical specialties.

This study was limited to surgical faculty at a single academic institution. Thus, our findings may not be generalizable to other institutions. Many of the interviewees noted how much they enjoyed teaching residents and mentoring junior faculty, so some themes may be limited to teaching hospitals. We chose residents as a convenience sample to identify humanistic faculty because they spend a substantial amount of time with attending surgeons in the inpatient and outpatient settings, and have the opportunity to observe surgeons interacting with patients, ancillary staff, and other providers from the operating room to the clinic. However, as part of the medical system, residents may be acculturated to the system’s values, and see humanism through this lens. It should be noted that patients, other health care providers, or other faculty members may have reached different conclusions regarding who best demonstrated humanistic care. Selection bias also may be present based on the preferences of survey respondents versus nonrespondents. We conducted only 10 interviews, which is a relatively small sample size. However, during the first analysis of these interviews, representing the top 10th percentile of faculty, all four investigators believed thematic saturation was reached. The concordance of values between surgical and medical faculty is also notable.15 We believe that attempting to expand the cohort would have diluted the sample, as those receiving fewer nominations may not have been widely recognized as humanistic. There may be philosophical differences in humanistic attitudes as the culture of surgery has changed over time, but with only 10 surgeons, we were unable to identify differences between early-career versus senior surgeons. Finally, interviewees self-reported these habits and attitudes. These perceptions of their own behaviors may not actually be observed in daily practice. At a minimum, however, each surgeon aspired to these attitudes and habits over time.

Humanism is vital to the care of the surgical patient and to the appropriate development of trainees. In this study, a group of surgeons identified multiple habits and attitudes that contribute to sustaining and perpetuating humanism, many of which are in concordance with those described by faculty in other medical specialties. The importance of role models in propagating humanism was particularly apparent, while differences between how humanism was sustained in this surgical cohort and other subspecialties demonstrate the importance of specialty and culture in promoting and sustaining humanism. Further investigations may focus on what factors are important in other specialties and at nonteaching institutions, as well as curriculum development for trainees and faculty members in humanism and professionalism.

Acknowledgments: The authors would like to thank all the residents who participated in the survey and the 10 attending surgeons who graciously participated in the interviews, as well as Dr. Judy Shea for her editorial guidance.

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