Residents who exhibit questionable ethical reasoning or behavior must be identified and not be allowed to finish their program. It is the responsibility of the program, not the board, to ensure that those entering practice exhibit a high degree of professionalism. Faculty must seriously recognize, every day, that everything they do is part of the hidden curriculum.
As noted, the academic medical environment can be inimical. Faculty who experience dissonance must be able to effectively confront administrative leadership to express their concerns, and they need to feel their concerns are recognized. Leaders of academic medical centers must guide their institutions in such a way that the day-to-day functions are compatible with the stated mission and values.31
Chervenak and colleagues32 forcefully stated that “appropriate ethical values” are the core component that academic leadership needs in order to respond to the opposing forces of increasing pressures of patient satisfaction, compliance, liability, and other administrative demands on one hand and diminishing resources on the other hand. They listed 4 “professional virtues” that characterize responsible professional leadership: self-effacement, which obligates physician leaders to be unbiased; self-sacrifice, the willingness to risk individual and organizational self-interest, especially in the economic domain; compassion, or “What can I do to help?”; and integrity. The principles of effective leadership are not that complicated, but implementing them requires conviction and courage.33
Physicians increasingly are practicing in the organization setting. They need to increase their involvement in the organization in order to promulgate the needs of physicians. Organizational executive leadership is primarily driven by budgetary and capital planning processes; physician input is essential to ensure resources are directed toward better patient care. A feeling of loss of control over one’s practice is a primary cause of physician dissatisfaction. The schism between physicians and administrators traditionally has been characterized by a lack of trust; a more trusting relationship, reinforced by frequent constructive dialogue, will result in more physician control of the practice.34 This will be difficult, but it is necessary for improving professional satisfaction.
For practicing physicians, Wynia35 made the compelling case that professionalism demands self-regulation, which involves identifying and reporting impaired or incompetent physicians—another task that requires conviction and courage.
But the core issue is how an orthopedist regards the day-to-day aspects of his or her practice. Shanafelt and colleagues36 concluded that surgeons are not very good at assessing their own well-being and stress levels. Certainly high stress can affect well-being, which in turn can affect professionalism. West and Shanafelt37 uniquely described this relationship: “The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency. Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.” This description sounds completely synchronized with the current career dissatisfaction of orthopedic surgeons.
Improving orthopedists’ status requires ethical and involved leadership, both in academia and in our professional organizations, which too often seem mired in the (not so effective) status quo. Recognizing that the resident selection process is fallible is the first step in taking action—engaging in scrupulous role modeling and insisting that residents demonstrate professionalism and communication skills in their daily work. Becoming involved in organizational management is preferable to becoming angry and dissatisfied. Getting to know one’s patients is its own reward in terms of career satisfaction. Orthopedic surgeons have a well-earned macho image—that image can be enhanced with a dose of humanism. The result would be a true professional who enjoys his or her practice and has a satisfying career.