Professionalism within trauma and orthopaedic surgery

Lisa Kells, Marieta D Franklin and Cronan Kerin

Lisa Kells is an FY2 doctor at the University Hospital Aintree having graduated with her MBChB from the University of Liverpool. She is due to commence her core surgical training in August 2022 at the Royal Stoke Hospital.

Marieta Franklin is an ST7 registrar in Mersey where she is newly on the Surgery Training Committee. She is on the BOTA committee as the Women in Surgery Representative and forms part of their Culture & Diversity subgroup. She is also a member of the British Hip Society’s Culture & Diversity Committee and sits on the Royal College of Surgeons of England Women in Surgery Forum.

Cronan Kerin is a Consultant T&O Surgeon for Liverpool University Hospitals. He has a MA in Medical Education and is a Fellow of the Academy of Medical Educators. Since 2019 he has been the TPD in Mersey. He is also an examiner and a member of the Specialist Advisory Committee for Trauma & Orthopaedics.

In recent decades there has been an exponential growth in clinical knowledge and technological development in trauma and orthopaedic surgery. Over the same time period there have been significant changes in work-place culture. Trainees spend approximately ten years between core and speciality training, more if they take time out of programme for family, research or, as is increasingly popular if they choose to go less than full time.

Therefore, a greater gulf than ever exists between the speciality’s consultant body and their junior training colleagues. This issue is not exclusive to orthopaedic surgery and is increasingly reported, often in the context of professional behaviour. Surgical teams work best when there is good integration. If trainers better understand their trainees, they can offer better guidance; spot and guard against burnout; and foster and develop a stronger working relationship. Similarly, if trainees better understand their trainers and mentors, they will be better placed to get the most out of their training. This is increasingly important given the current challenges within training brought about by the COVID-19 pandemic working practices. Optimising one’s training opportunities is key. To work well together for our patients, and for future generations of skilled surgeons to care for them, there is a need for mutual respect within the trainertrainee relationship and professional behaviour is required.

Professionalism has, and continues to be, a well-discussed topic within medicine and beyond. It is a widely agreed core attribute for all doctors regardless of their level of career progression [1,2]. Both the Royal College of Surgeons of England and the Royal College of Physicians have released guidance to help doctors in the development of their professionalism [1,2]. However, unlike operative numbers, professionalism is harder to quantify. Dictionary definitions exist, but how professionalism applies to doctor-patient and doctor-doctor interactions on a practical level is blurred by the lens through which the observer perceives the interaction. Generational theory goes some way to explaining the sometimes differing viewpoints of trainers and trainees on what constitutes professionalism.

Generation theory postulates that cohorts born within common time periods, largely accepted as twenty-year intervals, share common core beliefs as shaped by the socio-economic events that occurred during their early and adolescent years [3,4]. There are six generational groups discussed in the literature:

1. ‘The Greatest Generation’ – Born before 1928

2. ‘Silent Generation’ – Born between 1928 and 1945

3. ‘Baby Boomers’ – Born between 1946 and 1964

4. ‘Generation X’ – Born between 1965 and 1981

5. ‘Generation Y’ / ‘Millennials’ – Born between 1982 and 2000

6. ‘Generation Z’ – Born after 2000

It is worth noting that there is some discrepancy in the literature regarding the upper year end limit for the generation Y group[4,5]. This discrepancy highlights that there will of course be overlap in generational beliefs at the extremes of the denoted time periods.

Each of these generational cohorts will have experienced different socio-economic and global events compared to the other and this has led to trends in certain characteristics and character archetypes in these cohorts.

The bulk of the current UK NHS work force is comprised of the following generations: Baby Boomer, Generation X, Generation Y, and Generation Z. Recent research exists that has explored how generational theory can cause discrepancy in how these cohorts view each other’s actions in the workplace, including, but not limited to professionalism [4,5]. A study amongst occupational therapists noted: mentors reported that juniors were often seeking immediate feedback, focusing on the positives; they also felt that electronic (non-face-to-face) methods of delivering performance review feedback were most desired by the juniors. However, the juniors disagreed regarding the method of delivering performance review feedback and largely agreed that they would prefer face-to-face feedback [4].

Discrepancies were also highlighted regarding written correspondence, be it via a messaging app or email, where text abbreviation was used (example: BTW – by the way) [4]. Through this work, further supportive and practical guidance has been issued to help bridge the generation and working gap within the occupational therapy community [5]. No such work currently exists within trauma and orthopaedics.

We believe that the generational diversity in trauma and orthopaedic surgery is a strength and that we all as colleagues, mentors, seniors, and trainees now more than ever need to breed a culture of better understanding through strong working relationships to create an efficient, sustainable, and pleasant work environment.

The expectation should not be for one group to change their behaviours to revolve around the others, but rather for all generational groups to increase their awareness and appreciation of the generational diversity among us. The Kennedy report published 16 fundamental recommendations for the Royal College of Surgeons of England with a goal of achieving symbolic change, institutionalised good practice, and building on strength – chief to this is increasing and celebrating diversity [6]. Recently, great strides have been made to fight racism and sexism within surgery yet more work needs to be done. A culture change has been called for [7] – we feel understanding the perceptions around what constitutes professional behaviour is key to achieving it.

We want to explore the attitudes to professionalism that exist in trauma and orthopaedic surgery. This work will build on a regional pilot study we conducted in June 2021. Participants took part in a 10 minute anonymised online questionnaire that explored attitudes on good and bad professionalism, leadership, first impressions, clinicians as teachers and students, and advocating for others.

57% of respondents were core or ST38 specialist trainees. The other 43% of responses were medical students (4%), FY1s (21%) and consultants (18%) all working in the trauma and orthopaedic environment. Of the core and ST3-8 responders, twothirds defined professionalism as being ‘a set of behaviours and attitudes defined by societal or workplace etiquette’ rather than selecting dictionary definitions. Expectations around attitudes to leadership, learning and teaching changed as responders’ grade became more senior. Over 60% cited a fear of damaging relationships with colleagues as a deterrent against advocating for themselves, a patient or colleague. Core trainees and below were more likely to introduce themselves to a new supervisor by email or in person on the first day of a placement, whereas registrars and above were more likely to email an introduction with a CV or to telephone ahead. It seems attitudes around professionalism in orthopaedics are dynamic though clear core themes transcend grades. Following our pilot survey, modifications have been made and we are now rolling it out nationally. You can join in with one easy click by following the QR code.

1. Generational perspective/experiences can be mutually beneficial.

2. When not accounted for, differences in generational perspectives can weaken professional relationships.

3. A shared mental model of professionalism should be outlined between generational groups.

4. Open dialogue is encouraged between seniors and juniors to establish expectations surrounding feedback and communication methods.

5. Further national roll out of the survey will better inform further recommendations and drive change.

1. Tweedie J, Hordern J, Dacre J. Advancing medical professionalism. London: Royal College of Physicians, 2018.

2. Royal College of Surgeons of England. Professional code of conduct. Available at: www.rcseng.ac.uk/standards-and-research/ standards-and-guidance/service-standards/ surgical-care-team-guidance/professionalcode-of-conduct. [Accessed March 2022].

3. Lepeyko TI, Blyznyuk TP. Generational Theory: Value-Oriented Approach. Business Inform, 2016. Available at: www.businessinform.net/search/?qu=Generations+Theory %3A+Value-oriented+approach&x=0&y=0.

4. Whitney RE, Morris ML, Harney J. Perspectives on the Professional Communication and needs of emerging occupational therapists of the millennial generation: A comparison study. The Open Journal of Occupational Therapy. 2021;9(1):1-16.

5. Deluliis ED, Saylor E. Bridging the Gap: Three Strategies to Optimize Professional Relationships with Generation Y and Z. The Open Journal of Occupational Therapy. 2021;9(1):1-13.

6. The Royal College of Surgeons of England (2021). An independent review on diversity and inclusion for the Royal College of Surgeons of England. Available at: www. rcseng.ac.uk/about-the-rcs/about-ourmission/diversity-review-2021.

7. Hamilton LC, Haddad FS. Getting the Culture Right. Bone Joint J. 2022;104-B(4):413-5.