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Editorial: Is Professionalism a Character Trait, or Can We “Forgive and Remember”?

Leopold, Seth S. MD

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Clinical Orthopaedics and Related Research: January 2021 - Volume 479 - Issue 1 - p 1-3
doi: 10.1097/CORR.0000000000001588
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Six feet from my right hand sits a small shelf of books that have changed my thinking. Some are novels, for narratives of all kinds contain powerful truths [8]. Admixed with those volumes, I have some nonfiction, a philosophy book or two, and a couple biographies and memoirs (Fig. 1). A while back, I decided—entirely arbitrarily—that I would never expand the shelf, but rather if I want to add a book, I’d need to remove another.

Fig. 1
Fig. 1:
I maintain a small shelf of books that have changed my thinking. Rather than expand the number of books on the shelf, some time ago I decided that if I wanted to add a book, I’d need to remove another. One book, Forgive and Remember [4], has been on the shelf since I bought it nearly 30 years ago.

One book, Forgive and Remember (Fig. 2) [4], has been on the shelf since I first read it early in my residency, nearly 30 years ago. From that moment on, I've been a fan of its author, sociologist Charles L. Bosk PhD. Dr. Bosk’s recent passing [3] caused me to revisit my ideas about professionalism—many of which were formed when I read his book back then—and see how they’ve changed in the three decades since. What I thought I knew about this subject was wrong in pretty fundamental ways, or at least it doesn’t fit me now.

Fig. 2
Fig. 2:
I’ve been a fan of sociologist Charles L. Bosk PhD, the author of Forgive and Remember [4], since I first read his book early in my residency; my much-loaned, dog-eared, original copy is shown here.

To write his seminal work, Dr. Bosk immersed himself full-time for 18 months with surgical residents in one training program in the 1970s to answer the question, “On precisely what kinds of behavior does a houseofficer’s good name rest [4]?” From his vantage point as participant-observer (his term), he categorized the kinds of errors surgeons make, and concluded that some mistakes are much more forgivable than others. He suggested that lapses in technique and even judgment are part of life as a surgical learner; we need to remember them, because if the same ones recur over and over, that points to a deeper problem. By contrast, what he called normative error—derelictions that violate foundational professional values, like honesty and integrity—are offenses we cannot forgive in our colleagues, and few would admit to ourselves.

Last year, I was fortunate enough to interview Dr. Bosk for CORR® [7]. As a lifelong fan, I count this conversation among my career highlights. We talked about how his views about normative error had changed over his 40-plus years of studying doctors’ mistakes. We explored the underlying concept—professionalism in medicine—from the perch of someone who has spent a lifetime studying it. If you haven’t seen what he had to say in that interview [7], I recommend it.

Perhaps because of the rigidity of the concept of normative error (the idea that certain lapses are unforgivable), as well as the fact that professionalism can has been codified in such detail [1] and often is spoken of in concrete terms—as in, “he is so unprofessional”—I’d always viewed it among those traits that you either got or you ain’t.

Maybe I should have scratched at that harder. Although our Academy’s standards on the topic run 23 pages single-spaced, that document includes elements that seem both situational and entirely subjective [1]. Others have suggested that despite their belief that professionalism is virtue-based and character-driven, it nonetheless can be taught to and learned by adults [2, 5]; so much for All I Really Need to Know I Learned in Kindergarten [6]. And the fact that thought-leaders have proposed systems and structures for its practical implementation and assessment [9] suggests that it may be variably present or absent in different people and at different stages.

Still, as I mentioned, I have long labored under the idea that professionalism generally is binary. But an error I made a few months ago has caused me to reclassify several mistakes I’d earlier made, forced me to admit that I now characterize them as professional lapses, and pushed me to revise my previous two-bucket schema for professionalism: Either I don’t have it, or it’s more complicated than that. I now wonder whether there may be instances where judgment error and normative error—things like honesty, integrity, hard work—can meet, and perhaps blur.

A Lifetime Ago (But Character is Character, Right?)

As a surgical intern, my senior resident asked me to check the results of a test on a pre-op patient. I bumped into the medicine resident who was comanaging the patient with us. She said the test was fine, and based on that, I told my chief that it was. It wasn’t. He asked me about my lapse—the word “lapse” being a substantially more-generous term than the one he used—and I fessed up. He responded (again, somewhat more directly than this) that if he’d wanted the medicine resident to check the test, he’d have asked her to. Rookie error? Sure. Something many of us did? Perhaps. But my shortcut could have caused a death, and I was grateful my chief caught it; I remember the whole episode as though it happened this morning.

Let’s Fast Forward a Few Years

As a young faculty member, in at least one important way, I was a crummy partner. When surgeons at our trauma center asked me to see patients with post-traumatic arthritis in the office, I would not always accommodate them. If my chart review suggested the patient was not a good candidate for elective arthroplasty (usually because of ongoing alcohol or drug use), I thought the visits would not be worth the patient’s time or mine. This was, of course, wrong. It also was selfish, and it—appropriately—put my partners off. Though the visits wouldn’t have resulted in surgery, I now know I could have helped many of those patients to become better candidates for surgery, and, more importantly, healthier people. My selfishness also left my partners to explain my ill-considered decisions to their patients. Belatedly, I grew up, apologized to those partners I could identify as having snubbed, and since have tried to do better.

More Recently

I’m not a good call-taker. I’ve always found trauma intimidating, and I’m not a confident fracture surgeon. The result is that I have asked my partners—in some cases, the very same partners whom I did not treat well in my first couple of years at the university—for favors. Despite my earlier selfishness, they’ve never balked. I have tried to give back to our department in other ways, but I’m not at all sure that my account is square. Work in progress.

The Event Precipitating All This Introspection

A few months back, I made what I feel was a well-intentioned lapse in judgment, but one that could easily be perceived as a normative error. It was perceived by one person as exactly that. The details aren’t important now, but this colleague called me out, and I saw at once how bad my choice appeared, regardless of my intentions and explanations. Of course, I apologized, and made good on my bad choice. But the fact that I erred in the way that I did, particularly so far along in my career, caused me to question my own professionalism. I’d thought I’d had at least this one concept—professionalism—worked out by now, and that normative errors (or at least errors that could look like normative errors) were for other people. It seems I was wrong on both points.

Upon Reflection …

In order to achieve a measure of self-forgiveness, I’ve had to shift my general sense about professionalism from it being one of those “you either got it or you’re not” things to something more nuanced, if not frankly hazy. But I am unsure about whether I’m right to make this shift. It’s possible I’m letting myself off the hook too easily. The title Forgive and Remember, which I first encountered nearly 30 years ago, means more to me today than ever.

Acknowledgments

I would like to thank Joseph Bernstein MD, Terence J. Gioe MD, Clare M. Rimnac PhD, and Montri D. Wongworawat MD for their suggestions, which improved this essay.

References

1. American Academy of Orthopaedic Surgeons. Standards of Professionalism. American Academy of Orthopaedic Surgeons; 2009.
2. Arnold L. Responding to the professionalism of learners and faculty in orthopaedic surgery. Clin Orthop Relat Res. 2006;449;205-213.
3. Avril T. Charles Bosk, 72, studied ways to reduce errors in medicine. Sept. 9, 2020. Available at https://www.inquirer.com/obituaries/philadelphia-inquirer-obituaries-obituary-charles-bosk-penn-sociologist-reducing-medical-errors-20200909.html. Accessed September 17, 2020.
4. Bosk CL. Forgive and Remember: Managing Medical Failure. University of Chicago Press; 1979.
5. DeRosa GP. Professionalism and virtues. Clin Orthop Relat Res. 2006;449:28-33.
6. Fulghum R. All I Really Need to Know I Learned in Kindergarten. Villard Books; 1988.
7. Leopold SS. A Conversation with … Charles L. Bosk PhD, expert on surgical education and medical error, and author of Forgive and Remember: Managing Medical Failure. Clin Orthop Relat Res. 2020;478:1147-1151.
8. Leopold SS. Editorial: What is narrative medicine, and why should we use it in orthopaedic practice? Clin Orthop Relat Res. 2018;476:2105-2107.
9. Zuckerman JD, Holder JP, Mercuri JJ, Phillips DP, Egol KA. Teaching professionalism in orthopaedic surgery residency programs. J Bone Joint Surg Am. 2012;94;e51:1-7.
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