Priorities for professionalism: what do surgeons think?

Professionalism underpins the commitment made between a profession and society. This social contract balances the benefit to a profession of a monopoly over the use of its knowledge base, its right to considerable autonomy of practice, and the privilege of self-regulation with responsibilities and accountabilities to the community.

Medical practitioners have embraced professionalism over the millennia, from the Hippocratic Oath1 to the 19th century2 and the present day. Professionalism has recently been highlighted,3 but there have been concerns that not all its components are viewed as important4,5 or are reflected appropriately in surgical training endeavours.6

Definitions of professionalism are abundant, contested and reflect educational, sociocultural and historical contexts.7,8 Core elements include mastery of a complex body of knowledge and skills, service to others, commitment to competence, integrity, altruism and promotion of public good, autonomy, self-regulation and accountability to society.9 Given the dynamic and changing context, it is important to understand how professionalism is evolving.

Little is currently known about how surgeons involved in training and surgical trainees perceive the importance, priority or value of the different areas that they need to master to be competent and to perform well. In Australia and New Zealand, the Royal Australasian College of Surgeons (RACS) has defined the competencies required for surgical practice. The RACS surgical competence and performance guide is the basis of the curriculum that leads to the Fellowship of the College.10 It is based on the competencies developed by the Royal College of Physicians and Surgeons of Canada — the CanMEDS model.11 Local adaptation since 2001 has seen the RACS develop nine competencies to reflect the technical expertise and decision making required in surgical practice. Three attributes per competence provide further detail, although not comprehensiveness, to the overall requirements. Given the broad and changing definitions of professionalism, we evaluated the RACS competencies and associated attributes for importance.

Our study explored systematically what surgeons and surgical trainees understand as priorities for competent professional practice. It was undertaken within the broader context of developing system-wide training programs to enable surgeons to demonstrate their professionalism more fully.

Methods

Ethics approval for the study was obtained from the human research ethics committees of the University of Melbourne and the RACS. The overall research design included a detailed questionnaire comprising a number of question banks, with some free-text fields, distributed to 3054 RACS trainees and Fellows who were actively involved in the educational activities of the College. Separately and consequently, a semistructured interview was undertaken with a smaller number of the questionnaire respondents who volunteered for the interview stage. This article relates to the bank of RACS competency questions.

Participants

At the time of the distribution of the questionnaire, from 9 August to 30 September 2010, there were 1222 trainees and 4763 actively practising Fellows within the RACS. All trainees were invited to complete the questionnaire, and all Fellows recorded in the membership database as being involved in educational activities were also selected. Fellows who were not involved in surgical educational activities did not receive a questionnaire. The final number invited was 1222 trainees and 1832 Fellows from all regions of Australia and New Zealand. Although all questionnaires were identified with a unique identifier to allow for follow-up, anonymity and confidentiality were assured.

Materials and procedures

The questionnaire incorporated the nine RACS competencies and the associated three attributes per competency (Box 1), with modification for brevity and clarity. The questionnaire was content valid as it was directly based on the established RACS competency framework. Within the questionnaire, all participants were informed that the intent of the research was to progress the understanding of professionalism and the way it is supported, taught and learnt. Participants were instructed to rate the importance of each attribute for professionals on a 5-point Likert scale (1 = not at all important, 5 = very important).

The questionnaire was disseminated electronically with a follow-up email. A hard copy of the questionnaire was sent to those who had not responded and was then followed up by a telephone call.

Statistical analysis

Neither the nine competencies nor the 27 attributes have previously been confirmed statistically as independent factors. Analysis was undertaken to compare the importance of the attributes at an individual and grouped level, and to determine whether they were independent and whether the RACS groupings were confirmed by the data.

The data were coded and entered into SPSS version 17 (SPSS Inc). We also applied tests of skewness and kurtosis.12 Because of the skewed nature of the data, we conducted non-parametric statistical tests to analyse subgroups: the Mann–Whitney U test for pair comparisons and the Kruskal–Wallis test for comparison of more than two groups. The results for all attributes were assessed within their respective competencies to gain a relative understanding of the importance of that competency. Comparisons were made between Fellow and trainee, genders, age groups, specialties and regions. In this article, we present our findings for Fellows and trainees, and by gender.

We also applied tests of reliability, with internal consistency being calculated through use of Cronbach α value (theoretical values between 0 and 1). Inferential statistics were then used to identify differences between groups and to look for relationships between attributes. Groups for comparison had a sample size greater than 100. Correlation studies were structured to investigate relationships between particular characteristics of the subgroups.

We undertook multivariate analysis to establish the independence of the variables and also to determine whether the groupings of attributes proposed by the RACS within the competency framework could be validated in the context of our questionnaire. The exploratory factor analysis used an extraction method of unweighted least squares.

Results

In total, 1834 of 3054 questionnaires were returned (60%): 1204 of 1832 Fellows (66%) and 630 of 1222 trainees (52%); 1521 of 2566 (59%) male and 313 of 488 (64%) female trainees and Fellows. Seven hundred and nine (39%) responses were from general surgery Fellows and trainees and 357 (19%) were from orthopaedic surgery Fellows and trainees, the largest two of the nine surgical specialties.

The results were skewed to the more important. This was confirmed by tests for both skewness and kurtosis, both of which were evident to a high degree. Testing of reliability was undertaken, with a resultant Cronbach α value of 0.971.

The 27 attributes identified by the RACS were all graded as individual attributes (Box 2) or grouped as competencies (Appendix 1). They were all regarded as important to very important, except for responding to community and cultural needs. The top five attributes shared a sense of strong individualism, with an emphasis on being able to communicate effectively. However, there was a clear gap to the more lowly ranked attributes, particularly responding to community and cultural needs, and supporting others.

We calculated differences in the mean ranking of importance for the 27 attributes (Box 2, Appendix 2, Appendix 3). The overall mean was 4.44 (4 = important, 5 = very important). There was a small but significant difference between genders, with women regarding the overall group of attributes as more important than did men (mean, 4.51 [SD, 0.37] v 4.43 [SD 0.37]; P = 0.001) There was no statistically significant difference between Fellows and trainees for the overall group of attributes (mean, 4.44 [SD, 0.41] v 4.44 [SD, 0.40], respectively; P = 0.99).

Competencies were ranked by priority for Fellows and trainees, and for males and females (Box 3). There was consistency in the top three priorities for Fellows and trainees overall, and for male Fellows and trainees, where technical expertise, communication and professionalism were prioritised. For female Fellows and trainees, the top three priorities were communication, technical expertise and medical expertise. The lowest priorities across all groups were health advocacy, management and leadership, and scholarship and teaching.

Among individual attributes, there were statistically significant differences in perceived importance at the subgroup level (Appendix 2). In comparing Fellows and trainees, the four attributes with statistically more significant differences were caring and compassion, documenting and exchanging information, setting and maintaining standards, and responding to community and cultural needs. In particular, trainees identified as more important the three attributes for collaboration and teamwork (teamwork, documenting and exchanging information, and establishing a shared understanding).

In our analysis by gender, female trainees and Fellows ranked all attributes as more important than did male trainees and Fellows. Statistical significance was most noted for teamwork, meeting patient, carer and family needs, documenting and exchanging information, establishing a shared understanding, and communicating effectively (Appendix 3).

Although the first nine factors identified through multivariate analysis accounted for 58.8% of the total variation in the data, further analysis did not demonstrate strong grouping to the nine categories. Indeed, the covariance values of six attributes exceeded 1.0, suggesting some overlap between the groupings. Also, as the Cronbach α value was high at 0.971, some redundancy in the items was indicated statistically.

Discussion

Our study looked at the breadth of professionalism among surgeons and surgical trainees by exploring the nine competencies defined by the RACS. Our findings confirmed a clear priority ranking for these competencies and their attributes.

All competencies were regarded as important; however, there were statistically significant differences between the nine competencies and 27 attributes. Although the multivariate analysis did not confirm the independent nature of these variables, there was a clear gap between the prioritised importance of technical expertise, communication, professionalism and medical expertise compared with health advocacy, and management and leadership. Our findings suggest an emphasis on individual skills rather than on achieving a common goal. Attributes relating more to society at large were prioritised less than individualised skills. Also important was the strong similarity between the responses of the trainees and Fellows who undertake educational roles on behalf of the RACS. This may indicate the socialisation of aspirations between trainees and their mentors and educators.

Similar studies have emphasised that values held in high regard by society, such as altruism, charity and communication, are not well appreciated.6,13 Another study, which also found that none of the factors of professionalism were regarded as unimportant, argued that this added little to the broader issue of the teaching of professionalism.14 However, we contend that the prioritisation does make a difference. In a conflicted and time-pressured professional existence, a higher priority will receive attention for training and learning compared with a lower priority. The nine competencies defined by the RACS reflect what every patient needs from a competent surgeon.11 Surgeons require expertise in each of these competencies, but it is the integration of all these attributes that will make a competent surgeon. In a health environment where collaboration and teamwork is regarded increasingly as a core skill, and where the ability to influence the health system through management, leadership and advocacy is becoming more desirable, these areas will require greater prioritisation among trainees and Fellows.

Skills such as teamwork and responding to the needs of the community involve complex interactions beyond individual excellence. Medical professionalism does not take place in a vacuum. It is situated within a social context and larger systems such as the education and health sectors, the national economy and broader international influences.8 The practice of medicine needs to be rethought more broadly.

Our study had some limitations. Surveys are limited in the information they provide. The study confirmed the importance of the attributes and their relative priorities but not the statistical independence of the nine competencies. Further qualitative studies are required to obtain greater clarity between the attributes.

With the exception of responding to community and cultural needs, we found that all RACS competencies and attributes were regarded as important. The priorities showed consistency across Fellows, trainees and genders, although there were some key statistically significant differences between the attributes. This may highlight gaps that need to be addressed in selection of trainees, in current surgical training and in ongoing professional development for surgeons. Certainly these areas need to be addressed urgently.5 Attributes, behaviours, judgement and skills are displayed as our professionalism in a complex and pressured working environment that demands prioritisation of activities. These priorities are also reflected in how trainees allocate their time, through the mentors they admire and the aspirations they develop. Professionally, well-rounded and truly competent surgeons are not a static phenomenon. We live in a complex world. The implications are clear: aspiring surgeons are likely to invest more in the development of competencies that they perceive as more important.15 Competencies that are not reinforced by educators, mentors, trainers and the broader peer group are more likely to be neglected, with possible detriment to clinical practice.16