Over the past decade, the American health care system has had to cope with and manage an unprecedented amount of change. As a consequence, the medical profession has been challenged along the entire range of its cultural values and its traditional roles and responsibilities. It would be difficult, if not impossible, to find another social issue directly affecting all Americans that has undergone as rapid and remarkable a transformation—and oddly, a transformation in which the most important protagonists (i.e., the patients and the doctors) remain dissatisfied. ¹

Nowhere is this metamorphosis more evident than in the field of surgery. Marked reductions in reimbursement, explosions in surgical device biotechnology, a national medical malpractice crisis, and the disturbing emphasis on commercialized medicine have forever changed the surgical landscape, or so it seems. The very foundation of patient care—the doctor-patient relationship—is in jeopardy. Surgeons find it increasingly difficult to meet their responsibilities to patients and to society as a whole. In these circumstances, it is critical for us to reaffirm our commitment to the fundamental and universal principles and values of medical professionalism.

The concept of medicine as a profession grounded in compassion and sympathy for the sick has come under serious challenge. ² One eroding force has been the growth and sovereignty of biomedical research. Given the high position of science and technology in our societal hierarchy, we may be headed for a form of medicine that includes little caring but becomes exclusively focused on the mechanics of treatment, so that we deal with sick patients much as we would a flat tire or a leaky faucet. In such a form of medicine, healing becomes little more than a technical exercise, and any talk of morality that is unsubstantiated by hard facts is considered mere opinion and therefore carries little weight.

The rise of entrepreneurialism and the growing corporatization of medicine also challenge the traditions of virtue-based medical care. When these processes are allowed to dominate medicine, health care becomes a commodity. As Pellegrino and Thomasma remark, “When economics and entrepreneurism drive the professions, they admit only self-interest and the working of the marketplace as the motives for professional activity. In a free-market economy, effacement of self-interest, or any conduct shaped primarily by the idea of altruism or virtue, is simply inconsistent with survival.” ²

These changes have caused a great deal of anxiety and fear among both patients and surgeons nationwide. The risk to the profession is that it will lose its sovereignty, becoming a passive rather than an active participant in shaping and formulating health policy in the future. The risks to the public are that issues of cost will take precedence over issues of quality and access to care and that health care will be treated as a commodity—that is, as a privilege rather than a right.

The Meaning of Professionalism

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The escalating commercialization and secularization of medicine have evoked in many physicians a passionate desire to reconnect with the core values, practices, and behaviors that they see as exemplifying the very best of what medicine is about. This tension between commercialism on the one hand and humanism and altruism on the other is a central part of the professionalism challenge we face today. ⁶ As the journalist Loretta McLaughlin once wrote, “The rush to transform patients into units on an assembly line demeans medicine as a caring as well as curative field, demeans the respect due every patient and ultimately demeans illness itself as a significant human condition.” ⁷

Historically, the legitimacy of medical authority is based on three distinct claims ^2,8 : first, that the knowledge and competence of the professional have been validated by a community of peers; second, that this knowledge has a scientific basis; and third, that the professional’s judgment and advice are oriented toward a set of values. These aspects of legitimacy correspond to the collegial, cognitive, and moral attributes that define a profession.

Competence and expertise are certainly the basis of patient care, but other characteristics of a profession are equally important [see Table 1 ]. Being a professional implies a commitment to excellence and integrity in all undertakings. It places the responsibility to serve (care for) others above self-interest and reward. Accordingly, we, as practicing medical professionals, must act as role models by exemplifying this commitment and responsibility, so that medical students and residents are exposed to and learn the kinds of behaviors that constitute professionalism [see Sidebar Elizabeth Blackwell: A Model of Professionalism].

The medical profession is not infrequently referred to as a vocation. For most people, this word merely refers to what one does for a living; indeed, its common definition implies income-generating activity. Literally, however, the word vocation means “calling,” and

the application of this definition to the medical profession yields a more profound meaning. According to Webster’s Third New International Dictionary, ⁹ a profession may be defined as a calling requiring specialized knowledge and often long academic preparation, including instruction in skills and methods as well as in the scientific, historical, or scholarly principles underlying such skills and methods, maintaining by force of organization or concerted opinion high standards of achievement and conduct, and committing its members to continued study and to a kind of work which has for its prime purpose the rendering of a public service[.]

Most of us went to medical school because we wanted to help and care for people who are ill. This genuine desire to care is unambiguously apparent in the vast majority of personal statements that medical students prepare as part of their application process. To quote William Osler, “You are in this profession as a

calling, not as a business; as a calling which extracts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow man. We must work in the missionary spirit with a breath of charity that raises you far above the petty jealousies of life.” ¹⁰ To keep medicine a calling, we must explicitly incorporate into the meaning of professionalism those nontechnical practices, habits, and attributes that the compassionate, caring, and competent physician exemplifies. We must remind ourselves that a true professional places service to the patient above self-interest and above reward.

Professionalism is the basis of our contract with society. To maintain our professionalism, and thus to preserve the contract with society, it is essential to reestablish the doctor-patient relationship as the foundation of patient care.

The Surgeon-Patient Relationship

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The underpinning of medicine as a compassionate, caring profession is the doctor-patient relationship, a relationship that has become jeopardized and sometimes fractured over the past decade. Our individual perceptions of what this relationship is and how it should work will inevitably have a great impact on how we approach the care of our patients. ²

The fundamental question to be answered is, what should the surgeon-patient relationship be governed by? If this relationship is viewed solely as a contract for services rendered, it is subject to the law and the courts; if it is viewed simply as an issue of applied biology, it is governed by science; and if it is viewed exclusively as a commercially driven business transaction, it is regulated by the marketplace. If, however, our relationship with our patients is understood as going beyond basic delivery of care and as constituting a covenant in which we act in the patient’s best interest even if that means providing free care, it is based on the virtue of charity. Such a perspective transcends questions of contracts, politics, economics, physiology, and molecular genetics—all of which rightly influence treatment strategies but none of which is any substitute for authentic caring.

The view of the physician-patient relationship as a covenant does not demand devotion to medicine to the exclusion of other responsibilities, and it is not inconsistent with the fact that medicine is also a science, an art, and a business. ² Nevertheless, in our struggle to remain viable in a health care environment that has become a commercial enterprise, efforts to preserve market share cannot take precedence over the provision of care that is grounded in charity and compassion. It is exactly for this reason that medicine always will be, and should be, a relationship between people. To fracture that relationship by exchanging a covenant based on charity and compassion for a contract based solely on the delivery of goods and services is something none of us would want for ourselves. The nature of the healing relationship is itself the foundation of the special obligations of physicians as physicians. ²

Translation of Theory into Practice

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The American College of Surgeons (ACS) Task Force on Professionalism has developed a Code of Professional Conduct, ¹¹ which emphasizes the following four aspects of professionalism:

1. A competent surgeon is more than a competent technician.

2. Whereas ethical practice and professionalism are closely related, professionalism also incorporates surgeons’ relationships with patients and society.

3. Unprofessional behavior must have consequences.

4. Professional organizations are responsible for fostering professionalism in their membership.

Specifically, the ACS Code of Professional Conduct includes tenets of professionalism that relate both to our care of individual patients and to our role in society [see Table 2 ].

If professionalism is indeed embodied in the principles discussed [see Tables 1 and 2 ], the next question that arises is, how do we translate theory into practice? That is, what do these principles look like in action? To begin with, a competent surgeon must possess the medical knowledge, judgment, technical ability, professionalism, clinical excellence, and communication skills required for provision of high-quality patient-centered care. Furthermore, this expertise must be demonstrated to the satisfaction of the profession as a whole. The Accreditation Council on Graduate Medical Education (ACGME) has identified six competencies that must be demonstrated by the surgeon: (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice. These competencies are now being integrated into the training programs of all accredited surgical residencies.

A surgical professional must also be willing and able to take responsibility. Such responsibility includes, but is not necessarily limited to, the following three areas: (1) provision of the highestquality care, (2) maintenance of the dignity of patients and coworkers, and (3) open, honest communication. Assumption of responsibility as a professional involves leading by example, placing the delivery of quality care above the patient’s ability to pay, and displaying compassion. Cassell reminds us that a sick person is not just “a well person with a knapsack of illness strapped to his back” ¹² and that whereas “it is possible to know the suffering of others, to help them, and to relieve their distress, [it is not possible] to become one with them in their torment.” ¹³ Illness and suffering are not just biologic problems to be solved by biomedical research and technology: they are also enigmas that can serve to point out the limitations, vulnerabilities, and frailties that we want so much to deny, as well as to reaffirm our links with one another.

Most important, professionalism demands unwavering personal integrity. Regrettably, examples of unprofessional behavior exist. An excerpt from a note from a third-year medical student to the core clerkship director reads as follows: “I have seen attendings make sexist, racist jokes or remarks during surgery. I have met residents who joke about deaf patients and female patients with facial hair. [I have encountered] teams joking and counting down the days until patients die.” This kind of exposure to unprofessional conduct and language can influence young people negatively, and it must change.

Fortunately, such extreme cases of unprofessionalism are quite uncommon. Nevertheless, it remains our responsibility as professionals to prevent such behaviors from developing and from being reinforced. To this end, we must lead by example. A study published in 2004 demonstrated an association between displays of unprofessional behavior in medical school and subsequent disciplinary action by a state medical board. ¹⁴ The authors concluded that professionalism is an essential competency that students must demonstrate to graduate from medical school. Who could disagree?

In addition to the reports recounting acts of unprofessional behavior, various publications describing methods of teaching and assessing professionalism have begun to appear in the past few years. As an example, Kumar and colleagues found that using ACS case-based multimedia materials enhanced the ability of residents to recognize and discuss matters related to professional behavior. ¹⁵ Surgical residents who viewed these materials scored higher on an assessment tool than did residents with the same level of experience who did not use the materials. An additional encouraging finding was that residents of all years were able to define the components of professionalism. In another publication, Gauger

and coauthors described an evaluation instrument used to evaluate residents with respect to the aspects of professionalism. ¹⁶ They divided the concept of professionalism into 15 domains [see Table 3 ] and modified a standard resident evaluation form to assess the faculty’s perception of resident performance in each of these domains. This evaluation tool proved to be internally consistent, but in the absence of any other gold standard tools with which to compare it, its validity could not be determined.

The Future of Surgical Professionalism

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In the near future, maintenance of certification for surgeons will involve much more than taking an examination every decade. The ACS is taking the lead in helping to develop new measures of competence. Whatever specific form such measures may take, displaying professionalism and living up to a set of uncompromisable core values ¹⁷ will always be central indicators of the performance of the individual surgeon and the integrity of the discipline of surgery as a whole.

Although surgeons vary enormously with respect to personality, practice preferences, areas of specialization, and style of relating to others, they all have one role in common: that of healer. Indeed, it is the highest of privileges to be able to care for the sick. As the playwright Howard Sackler once wrote, “To intervene, even briefly, between our fellow creatures and their suffering or death, is our most authentic answer to the question of our humanity.” Inseparable from this privilege is a set of responsibilities that are not to be taken lightly: a pledge to offer our patients the best care possible and a commitment to teach and advance the science and practice of medicine. Commitment to the practice of patient-centered, high-quality, cost-effective care is what gives our work meaning and provides us with a sense of purpose. ¹⁸ We as surgeons must participate actively in the current evolution of integrated health care. By doing so, we help build our own future.