Professionalism in plastic surgery: Attitudes, knowledge, and behaviors in medical students compared to surgeons in training and practice - One, but not the same

Introduction: Professionalism is now recognized as a core competency of surgical education and is required for certification and licensure. However, best teaching methods remain elusive, because (1) ethical standards are not absolute, and (2) learning and teaching styles vary considerably - both of which are influenced by cultural and generational forces. We sought to compare attitudes, knowledge, and behaviors in fourth year medical students, compared to surgeons in training and practice, focusing on issues related to professionalism in plastic surgery. Methods: Fourth year medical students participating in a capstone course (n = 160), surgical residents (n = 219), and attending surgeons (n = 99) at a single institution were asked to complete a questionnaire regarding surgical professionalism. Participants (1) identified components of professionalism, (2) cited examples of unprofessional behavior, (3) ranked the egregiousness of 30 scenarios, and (4) indicated best educational practices. Cohorts were compared using t test and χ², with statistical significance assigned to P values less than 0.05. Results: Compared to surgeons in training or practice, medical students were younger (27.8 vs 38.0 years, P < 0.001) and more often female (51.1% vs 36.6%, P < 0.03). Both groups cited "a body of ethics" as the defining component of professionalism. Respondents from both groups agreed that professionalism could be taught, learned, and assessed. Surgeons (94.3%) had observed unprofessional behavior, as did 88.0% of students; "poor anger management," "dishonesty," and "bullying" were the most common examples. Compared to students, however, surgeons were more likely to witness substance and physical abuse (P < 0.05). From the list of 30 scenarios, both groups picked the following as the most egregious, although in different order: working while impaired, fraudulent billing, dating a patient, lying on rounds, self-prescribing, and sexual harassment. Both students and surgeons agreed that the following scenarios were unethical: "fraudulent billing while on a mission trip" (84% vs 90%, NS), "showing inaccurate preop/postop photos" (70% vs 75%, NS), and "failing to disclose a conflict of interest" (56% vs 57%). Students and surgeons disagreed that the following scenarios were egregious: "owning biotech stock in a company whose product the surgeon uses" (33% vs 13%, P < 0.01), and "offering a breast augmentation as part of a charity raffle" (45% vs 58%, P < 0.05). Both students and surgeons agreed "advertising on a highway billboard was NOT unprofessional (87% vs 85%, NS). Conclusions: Despite differences in age and sex, medical students and surgeons have similar attitudes about professionalism in plastic surgery, but differ in their knowledge and observations. Understanding cultural and generational factors may help educators teach and model cognitive and behavioral aspects of professionalism. The fact that some clearly egregious behaviors are not viewed as unethical by individual students, trainees, and surgeons, and that such behavior continues to be observed, indicates the need to improve our efforts in promoting professionalism in plastic surgery.