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Education about professionalism requires not only positive role
modelling (by all of us) but also:
teaching of skills in areas such as situational awareness, decision-
making and communication;
addressing in a positive but zero-tolerance manner, issues of
disruptive or non-professional behaviour; and,
the ability to ensure this is addressed by our peers within their
Colleges and Societies and also within their places of employment.
THE PROFESSIONALISM CURRICULUM
So, what should be covered by a programme that teaches
professionalism? The key areas can be divided into two main strands
of study: the cognitive base of professionalism and the skills of
professionalism. In addressing the cognitive base, areas of study
should include: principles of ethics, risk management, self-regulation,
medico-legal issues, principles of teaching, physician health
and sustainable practice. Skills to be focused on should include:
communications, teamwork, conflict resolution and mentorship.
The shaping of a professionalism curriculum at the Royal Australasian
College of Surgeons has resulted in a range of courses that include:
Surgical Teachers' Course;
Non-technical Skills for Surgeons (NOTSS);
Keeping Trainees on Track (KTOT);
Training in Professional Skills (TIPS);
Supervisors and Trainers Surgical Education and Training (SAT
SET);
Surgical Education and Training Selection Interview Training
(SET SIT);
Early Management of Severe Trauma (EMST); and,
Care of the Critically ill Surgical Patient (CCrISP).
The establishment of such courses is part of an ongoing and
developing process to move beyond traditional areas, recognising
professionalism as a complex and adaptive process requiring
teachable skills that enhance professional resiliency; skills such as
self-control, alternative strategy development (what options exist
for managing a situation), crisis communication and peer coaching
(what is the best way of preventing my colleague from committing a
relapse?).
More broadly, from an organisational perspective, it's necessary to
define a shared vision of professionalism and how it will be taught
and evaluated and to then create opportunities for teaching and
learning professionalism. Organisations also need to address systems
issues that impede the teaching and learning of professionalism in
formal, informal and `hidden' curricula.
LEADERSHIP
For organisations to effectively respond to the professionalism
challenge, individuals within those organisations must lead.
Clinicians are the leaders of the health system but, to be legitimate as
leaders, we need to:
be evidence-based in our care, and practice in an effective and
patient-oriented manner;
deal with the harder issues of confronting our colleagues in ways
to improve the health services of our countries; and,
re-build the bridges across the management divide of our health
sector.
Most importantly, we have to ask are we prepared to lead? As
membership-based organisations, do we just do the thing right,
or are we going to do the right thing? We have responsibilities as
individuals, which have been well described and enacted over many
years, but we have a growing and more urgently critical role to act as a
collective, bringing our colleagues with us, to address the concerns of
the health sectors.
SELF-REGULATION
Have we reached the threshold where the public and public policy
is now saying that, without better self-regulation, increased re-
regulation will occur? How do we `honour' our social contract?
The exclusive right to practice with autonomy in a defined area of
endeavour must be balanced by the duty, individually and collectively,
to put the interests of patients ahead of our own. This implies a wider
duty of public service.
I have seen first-hand in Australia that there is a close relationship
between what the public thinks, what the media think and how
government responds. Perceptions can quickly form in the media
that surgeons are greedy or obstructive to change, unwilling to self-
regulate, or not patient-centric. The consolidation of a `triangle of
trust' between the profession, the public and the government is
essential if we are to maintain autonomy and the exclusive right to
practice.
In Australia, the recognition of this vital requirement has led to the
establishment of the Health Practitioner Regulation National Law
Acts 2009. There is a national registration and accreditation scheme
in place and the profession is now controlled by a Board that reports
to a Council of Ministers. There is a need to further develop initiatives
such as the Australian and New Zealand Vulvovaginal Society
(ANZVS) audit, which gathers data, not simply for its own sake
but to ensure surgeons are accountable for their competence to the
public. The profession needs to be seen to identify and, if appropriate,
remediate outliers. The next objective in Australia is to establish a
system of peer review of competence and conduct that will withstand
public scrutiny.
THE INDIVIDUAL AND THE TEAM
The established emphasis on the individual professional must be
accompanied and contextualised by a focus on teamwork, enlarging
partnerships between organisations and society. Of course, within
the community of practice, role models remain very potent at
transmitting the intangibles of the `art' of medicine and are important
for the development and maintenance of professionalism. Role
models are central to the collegiality that serves to obtain agreement
on common goals and encourage compliance. Equally, the destructive
effects of role models who do not meet acceptable standards is
very strong. Institutional cultures that tolerate poor interpersonal
relationships inhibit positive modeling, as do administrative decisions
that do not support the exemplary.
Health-related organisations, including Colleges, should be regarded
as `complex adaptive systems that operate in a professional milieu'
rather than bureaucracies in need of a reductionist notion of rational
administration. Ultimately, the task before Colleges is no less than
to ensure that surgeons deliver quality care with integrity, honesty
and compassion, and exhibit appropriate personal and interpersonal
behaviours. The challenge is inescapable are we ready to meet it?
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