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Surgical Professionalism

The Inspiring Surgeon of the Modern Era

Berian, Julia R. MD; Ko, Clifford Y. MD, MS, MSHS, FACS; Angelos, Peter MD, PhD, FACS

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doi: 10.1097/SLA.0000000000001425
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Before the development of general anesthesia, barber surgeons operated with the patient screaming and strapped to the operative table. Understandably, the historical surgeon was valued for technical ability above all else, with little regard for bedside manner. However till today, surgeons are perceived as the specialty most likely to exhibit disruptive behavior.1 In the modern world of patient-cantered care, however, tolerating disruptive behavior in exchange for technical mastery is no longer an option. The American College of Surgeons defines professionalism in surgery by stating: “a good surgeon is more than a technician, and reliance on technical expertise alone as the basis of professionalism might weaken our claim to public legitimacy.”2 Deft fingers and a steady hand may be required for surgical excellence, but professionalism in surgery demands something more.

The latter half of the 20th century saw a major shift in the physician-patient relationship, moving from paternalism to an era of shared medical decision making. The magnitude of this change can be fully appreciated by contrasting 2 similar studies on medical communication, performed just 18 years apart. In 1961, Dr Donald Oken3 surveyed physicians at Chicago's Michael Reese hospital, asking whether they regularly disclose a cancer diagnosis to their patients. Overall, 88% of physicians, and the same fraction of surgeons, indicated that they did not. A follow-up survey in 1977 revealed a reversal of this policy with 98% of physicians indicating they disclose the diagnosis to cancer patients.4 This remarkable shift in concept and behavior informs our ideal of the surgical professional in the modern age.

Patient-centeredness has placed emphasis not only on communication skills, but also on transparency of practice outcomes and publically available patient satisfaction scores. Modern surgical practice requires engagement with multiple reporting regulations, such as the Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting System; or the inpatient, outpatient, and ambulatory surgery quality programs; the Joint Commission's Surgical Care Improvement Project; the Agency for Healthcare Research and Quality's (ARQH) Patient Safety Indicators; or the joint CMS and ARQH Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS), which is publically reported on the internet.

Though surgical practice in the modern world is dominated by regulatory requirements, surgeons often report that these metrics do not reflect the true character of the surgical profession. A recent meta-synthesis of 51 qualitative articles identified the surgeon-patient relationship and surgical culture as central components of modern surgical practice. Surgeons described high-intensity personal and emotional dimensions in the surgeon-patient relationship. Performing meaningful work was identified as a shared value among surgeons; additional traits that are perceived as part of the professional culture included strength, self-confidence, independence, coping-skills, decisiveness, and a “moral imperative” to not give up when faced with difficulty. Many surgeons expressed the view that the myriad rules, guidelines, and checklists did not seem to fit the surgical model of care. The unpredictability of any given operation and the perceived unique-ness of any surgeon's practice were cited as reasons that evidence-based guidelines do not fit well into surgical practice.5

Tension exists between how surgeons define themselves and how they are measured by external agencies. If the ideal, professional surgeon is defined by more than our current metrics, it is time to change the measurement system. The challenge is to define the inspiring surgeon, able to practice in the contemporary health care environment, and delineate measures that are congruent with that definition. More than a simple writing exercise, defining the ideal professional will allow us to identify a better way to measure professionalism. The aspirational goal that surgeons set for their professional lives should also play a role in public expectations for these same surgeons. If surgeons accept the ideal surgeon as a purely technical master, lacking interpersonal skills or the ability to communicate with patients, ultimately our own goals will shape the public's expectations. Alternatively, if surgeons identify a more complete ideal, by encompassing the value of clear and compassionate interactions with patients, we can influence what patients expect of us.

We propose that the professional goal for surgeons should be to become an “inspiring surgeon”—that is, a surgeon who inspires the confidence of our patients, the trust of our colleagues, and the satisfaction that comes with achieving excellence in patient care. These are the elements that make the practice of surgery a fulfilling profession. Though it may be a challenge, we maintain that these elements can be measured.

Given the tremendous importance of the surgeon-patient relationship in modern practice, we propose that the informed consent process provides a perfect lens with which to view the surgeon-patient interaction. Informed consent is not a static event but a process, one that promotes a long-lasting professional relationship based on disclosure of information, patient understanding of the information, and finally a decision regarding how to proceed.6 Though these are key steps in the process, there is tremendous variability in how they are performed, the degree of risks/benefits disclosed and even the patient's retention of that information. Recent research has augmented our understanding of the informed consent discussion, the ways in which risks are addressed and the importance of explicitly establishing buy-in from patients.7

We believe that the adequacy of a patient's informed consent cannot be fully assessed by determining whether the patient remembers the risks, benefits, and alternatives of the operation. Disclosure of these items is necessary, but not sufficient for the informed consent process. The central component of informed consent, as any practicing surgeon will readily admit, is the opportunity for the patient to decide whether to trust the surgeon. The necessary degree of trust is significant for a patient to allow the surgeon to perform invasive actions, with the patient in a state of complete vulnerability. The informed consent process, in effect, is the opportunity for the surgeon to establish trust with the patient. We believe that this trust our patients have in us is the first important element of a professional, inspiring surgeon.

Surgical culture ingrains surgeons with a responsibility, or moral imperative, to do the right thing. The surgeon must put aside personal obligations, stress, exhaustion, and other such obstacles in favor of doing what's right for the patient. Indeed, many view the rigor and stress of surgical training as essential to preparing young surgeons to recognize, manage, and perform capably under fatigue.8 The ability to consistently provide medically and surgically appropriate care for one's patients may not be easily assessed by external reviewers, but it is readily apparent to one's surgical colleagues. In surgery departments around the country, morbidity and mortality conference displays the surgeon's adverse events and poor outcomes for reflection and analysis on a regular basis. We propose that this conference is the perfect entry point to assess appropriate actions. The surgeon's behavior, decisions, and professional demeanor are all clearly visible to his or her colleagues.

Finally, in the modern era of quality care, good patient outcomes, proven by data and benchmarking, are essential. No matter how thoughtful is the decision making or how empathetic is the communication, a pattern of poor outcomes cannot be tolerated. Most surgeons endorse the importance of public reporting at a hospital level, though public reporting at the surgeon level has yet to gain general acceptance.9 In the current health care market, public and private payers increasingly require public reporting of surgical outcomes and complications. The ideal professional surgeon employs impeccable surgical technique with excellent outcomes for the sake of his or her patients. The modern surgeon must embrace measurement and reporting of outcomes, as did Ernest A. Codman a century before, for the purpose of continuous improvement. Surgical excellence, characterized by good outcomes, becomes the final, measurable pillar of the modern professional surgeon.

Having mastered meticulous hemostasis and careful tissue handling, the modern surgeon has moved on to care for the whole patient. The key to surgical professionalism lies in patient trust, appropriate action, and excellence in outcomes. These elements can be measured with careful selection: the informed consent process as a window into the surgeon-patient relationship, morbidity and mortality conference as a means to examine appropriate actions, and objective outcomes reporting to verify surgical excellence. In his 2009 presidential address to the American College of Surgeons, Dr LaMar S. McGinnis, Jr10 reflected, “What greater trust and bond exists among humans than that between a patient and their surgeon? Perhaps this bond is only exceeded by that between a parent and a child. That is the joy of being a surgeon, a professional. Yet, that joy is bridled by the enormity of our responsibility. No assault by government, managed care, the insurance industry, trial lawyers, or other maligned entity will ever break that bond.” We owe it to ourselves, and more importantly to our patients, to align our professional identity and the metrics by which we are judged. Each must strive to become the “inspiring” surgeon, one who not only achieves high quality outcomes and deploys excellent clinical judgment, but who engenders trust in the patients we ultimately serve.


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physician-patient relationship; professionalism; surgical ethics

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