REVIEW PAPER
Teaching Ethics and Professionalism in Plastic Surgery A Systematic Review Catherine de Blacam, MD* and Christian J. Vercler, MD, MAÞ Background: Maintenance of the highest ethical and professional standards in plastic surgery is in the best interests of our profession and the public whom we serve. Both the American Board of Medical Specialties and the Accreditation Council on Graduate Medical Education mandate training in ethics and professionalism for all residents. Presently there is no gold standard in ethics and professionalism education. Methods: A systematic review on teaching ethics and professionalism in plastic surgery was performed for all articles from inception to May 23, 2013 in MEDLINE, Scopus, EMBASE, CENTRAL, and ERIC. References of relevant publications were searched for additional papers. Key journals were hand searched and relevant conference proceedings were also reviewed. Duplicate and non-English articles were excluded. Inclusion and exclusion criteria were applied to find articles that described a curriculum in ethics and/or professionalism in plastic surgery. Results: Two hundred twenty-seven relevant articles were identified. One hundred seventy-four did not meet inclusion criteria based on screening of the title, and 39 of those did not meet inclusion criteria based on screening of the abstract or introductory paragraph. Of the 14 identified for full text review, only 2 articles described a set curriculum in ethics and/or professionalism in plastic surgery training and reported outcomes. Conclusions: A paucity of data exists regarding the structure, content, or relevant measures that can be applied to assess outcomes of a curriculum to teach ethics and professionalism to plastic surgery trainees. Endeavors to teach ethics and professionalism to plastic surgery trainees must rigorously document the process and outcomes to facilitate the maintenance of our profession. Key Words: ethics, ethics education, professionalism, moral development, resident education, ACGME core competencies (Ann Plast Surg 2014;72: 484Y488)
profile breaches in patient safety, overt commercialization, and reality television. Never before has defining our professionalism mattered so much.2 In fact, the American Council of Academic Plastic Surgeons, the American Board of Plastic Surgery, the American Society of Plastic Surgery, and the Plastic Surgery Foundation have convened a Joint Committee to develop a curriculum on ethics and professionalism in plastic surgery. The Accreditation Council on Graduate Medical Education (ACGME) has included professionalism in its list of core competencies for residency training in all medical disciplines.3,4 As educators, we are obliged to ensure that residents completing our training programs manifest an acceptable level of professionalism. For generations, the traits that define professionalism were considered innate to the individual. Only recently have medical educators recognized that there are concrete components of professionalism that can be taught and assessed in a standardized fashion.5Y7 In spite of a potentially greater need for formalized professionalism training in plastic surgery, there is a dearth of information available to guide program directors in providing focused training in this important competency. In this systematic review, we sought to investigate the existing experience of teaching ethics and professionalism in plastic surgery residency programs.
METHODS Hypothesis We hypothesized that there are few published data to act as guidelines for developing a curriculum for teaching medical ethics and professionalism to plastic surgery residents.
Data Sources and Searches
S
ince the time of Hippocrates, the profession of medicine has long held adherence to a code of ethics constitutive of the practice. The American Board of Medical Specialties (ABMS) has prescribed professionalism as one of the six core competencies which must be attained and sustained by all doctors practicing in the United States.1 Plastic surgeons endeavor to restore or enhance form and function to that which is considered normal. To establish ethical standards in a field that is largely based on the subjective opinions of both surgeon and patient is challenging and has been the subject of much discussion in the plastic surgery literature. In recent years, the ethical image of plastic surgery has been called in to question as a result of high-
Received October 11, 2013, and accepted for publication, after revision, December 10, 2013. From the *Plastic Surgery Higher Surgical Training Program, Royal College of Surgeons in Ireland, Dublin, Ireland; and †Section of Plastic Surgery, University of Michigan, Ann Arbor, MI. Conflicts of interest and sources of funding: none declared. Reprints: Christian J. Vercler, MD, MA, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, 1540 East Hospital Drive, C.S. Mott Children’s Hospital, Suite 4-730, Ann Arbor, MI 48109-4219. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7204-0484 DOI: 10.1097/SAP.0000000000000126
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The topic ‘‘teaching medical ethics and professionalism in plastic surgery residency programs’’ was explored to determine significant issues (conceptual mapping). From this, a search strategy was devised using the following key terms: plastic surgery AND (ethics OR medical ethics OR professionalism) AND (curriculum OR training OR education). Using these key terms, an electronic bibliographic search was conducted in the following databases from inception until May 23, 2013: MEDLINE, Scopus, EMBASE, CENTRAL (The Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health), and ERIC (Education Resources Information Center). Limits were placed on each search to exclude non-English citations. Reference lists of all relevant publications were searched for additional papers. Hand searching of key journals was undertaken and relevant conference proceedings were also examined.
Study Selection Inclusion and exclusion criteria for selection are listed in Table 1. To avoid selection bias and minimize omissions,8 the article selection was conducted independently and in duplicate by 2 assessors (C.de B. and C.V.), with results compared and reconciled at each stage. The process of selection is summarized diagrammatically in Figure 1. Duplicate articles were excluded at the first stage. A staged review of article titles and abstracts was performed to select all studies that met Annals of Plastic Surgery
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full-text review are listed in Table 2. At this final stage, articles were eliminated on the basis of exclusion criteria.
TABLE 1. Inclusion and Exclusion Criteria Inclusion Criteria
Exclusion Criteria
Studies that describe a prescribed curriculum in ethics and/or professionalism Prospective and retrospective observational studies Studies involving plastic surgery residency/higher specialty training/fellowship programs
Teaching Ethics and Professionalism
Review articles Editorial/commentary/ opinion papers Studies pertaining to fields other than plastic surgery
Data Extraction, Synthesis, and Analysis Data extraction and quality assessment were performed independently by 2 reviewers (C.de B. and C.V.). The following variables were recorded from each study: number of participants, participant demographics, instructional technique(s) employed, and outcome(s) achieved. The papers included in our final analysis were heterogeneous in their methodology and results, thus precluding a formal pooled analysis. Therefore, a narrative summary of results was performed.
RESULTS the inclusion criteria. Abstracts of studies identified in the title search were obtained and reviewed and once again studies meeting the inclusion criteria were identified. Studies whose abstracts met the inclusion criteria were retrieved and the full text was analyzed. Papers selected for
Potentially relevant papers were retrieved from 3 out of the 6 electronic databases queried. The largest number of papers was retrieved from EMBASE, followed by Scopus and MEDLINE. There were no studies matching our key terms retrieved from CENTRAL, CINAHL, or ERIC. Excluding duplicates, 227 papers were identified
FIGURE 1. Selection of studies examining formal teaching in ethics and professionalism in plastic surgery. * 2014 Lippincott Williams & Wilkins
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TABLE 2. Papers Meeting Inclusion Criteria That Were Selected for Full Text Review (One Duplicate Paper Excluded) Author
Journal and Year
Title
Hultman10
Journal of Surgical Research 2013
Kim27 Wagner28
Archives of Plastic Surgery 2013 Annals of Plastic Surgery 2013
Sometimes you can’t make it on your own: the impact of a professionalism curriculum on the attitudes, knowledge, and behaviors of an academic plastic surgery practice Survey of attitudes on professionalism in plastic and reconstructive surgery Elevation: developing a mentorship model to raise the next generation of plastic surgery professionals The use of standardized patients in the plastic surgery residency curriculum: teaching core competencies with objective structured clinical examinations Ethical issues in plastic and reconstructive surgery Career development resource for plastic and reconstructive surgery Outcome-based residency education: teaching and evaluating the core competencies in plastic surgery Idealized mentoring and role modeling in facial plastic and reconstructive surgery training Professionalism: the end product of the medical professionVreply Professionalism: the end product of the medical profession Sharing knowledge On learning medical ethics
Davis9
Plastic and Reconstructive Surgery 2011
Sterodimas13 Walden44 Bancroft45
Aesthetic Plastic Surgery 2011 American Journal of Surgery 2010 Plastic and Reconstructive Surgery 2008
Holt17
Archives of Facial Plastic Surgery 2008
Lineaweaver24 Rohrich15 Spencer46 Ward47
Plastic and Reconstructive Surgery 2007 Plastic and Reconstructive Surgery 2006 Cosmetic Dermatology 2005 British Journal of Plastic Surgery 1994
and subjected to selection as demonstrated in Figure 1. The papers selected for full-text review are listed in Table 2. The majority of these publications were editorials or commentary pieces. The criteria resulting in the exclusion of each are also presented in Table 1. Having completed the study selection process, only 2 papers were eligible for inclusion in our review (Table 3). The first of these, by Davis et al, was published in Plastic and Reconstructive Surgery in July 2011.9 In response to the ACGME’s establishment of 6 core competencies, the authors designed a plastic surgeryYspecific objective structured clinical examination (OSCE) to address all 6 competencies. The topic selected was melanoma and the examination included an encounter with a standardized patient and a separate written exercise. Six plastic surgery residents from postgraduate years 4, 5, and 6 completed the OSCE and were graded on their performance in each core competency by both the standardized patients and by faculty experts. A 3-point rating scale was used (1 = novice, 2 = moderately skilled, 3 = proficient). Professionalism was specifically addressed in the standardized patient encounter, which was designed to simulate a new-patient referral for melanoma. Residents were asked to explain the diagnosis and treatment recommendations, complete an informed consent discussion, and answer the patient’s questions. Standardized patients were given an evaluation form to assess the resident in 3 out of the 6 competencies, including professionalism. The wording used to assess professionalism was as follows: ‘‘[The resident] appeared professionally competentVseemed to know what s/he was doing; inspired my confidence; appeared to have my interests at heart’’. Standardized patients rated the residents on a scale from 1 (below expectations) to 6 (exceeds expectations). Though the patient encounters were videotaped and reviewed by faculty, it was the standardized patients’
scores alone that were used to evaluate professionalism. The average score for professionalism among the residents, as assessed by standardized patients, was high at 86%. The authors also elicited participant feedback. All resident participants reported that they found the OSCE to be realistic and of educational benefit. The second paper to present a structured approach to teaching professionalism in plastic surgery was published in the Journal of Surgical Research by Hultman et al in 2013.10 Acknowledging that few models exist that define, teach, and assess professionalism in plastic surgery, the authors evaluated the effectiveness of a novel professionalism curriculum in an academic plastic surgery practice. Using the robust Analysis, Design, Development, Implementation, and Evaluation model of instructional design, a 6-week, 12-hour course in professionalism was developed.11 The course comprised didactic lectures, journal club, small group discussions, and book review, with participants required to complete 1 to 2 hours of self-study before each learning encounter. The program was delivered to a group of 30 health care professionals, including faculty, residents, nurses, and medical students. The specific topics addressed were Professionalism in Our Culture, Leadership Styles, Modeling Professional Behavior, Leading your Team, Managing Oneself, and Leading While You Work. The course was evaluated using Kirkpatrick methodology to measure impact on 4 levels of learning: reaction (ie, participants’ perception of course), knowledge (ie, change in participants’ capability before and after course), behavior (ie, transfer of knowledge and skills acquired from classroom to workplace), and results (ie, impact of the intervention on the organization).12 On completion of a questionnaire to assess perception of the course, all respondents were neutral or positive about the course. Participants demonstrated a statistically significant increase in knowledge when pre- and post-course multiple-choice test
TABLE 3. Summary of the Results of Papers that Analyzed a Specific Curriculum for Teaching Ethics and/or Professionalism in Plastic Surgery Paper Hultman J Surg Res 201310 Davis PRS 20119
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Participants
Instructional Technique
Outcome
30 healthcare professionals working in a plastic surgery practice 6 plastic surgery residents
Lectures, journal club, small group teaching OSCE using standardized patients
Decrease in number of reported incidences of unprofessional behavior in department Residents scored highly in professionalism and deemed assessment a valuable adjunct to their training
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Teaching Ethics and Professionalism
scores were compared. To assess impact of the course on conduct, the authors examined the number of recorded incidences of unprofessional behavior in the practice. A decrease from 12 to 3 was noted in the 6 months before and after the course, respectively. Finally, impact on the organization was measured by analyzing patient complaints in the periods before and after delivery of the course. The number of complaints fell from 14 in the 6 months before the course to 8 in the postcourse period.
conclusions from this however, as different assessment tools were used, with 1 group being assessed using a single score (awarded by standardized patients) and the other receiving a faculty-designed preand post-course test. The difference in scores was significant, with candidates improving from an average of 48% pre-course to 70% post-course, thus demonstrating the effectiveness of the intervention. Professionalism curricula are somewhat more established in general surgery with several review articles published in the last number of years.29Y31 Programs at the New York University Department of Surgery were successful in improving both self-perceived and objectively assessed mastery of the 6 ACGME domains of professionalism.6,7 Rowland et al demonstrated the utility of a focused professionalism course in preparing for the American Board of Surgery examination.32 Professionalism training has been incorporated into intern induction or so-called boot camp courses in certain general surgery and neurosurgery programs.33Y35 The importance of professionalism training has also been recognized in the cardiothoracic, pediatric, and orthopedic surgery literature.36Y38 Outside of the United States, the Canadian CanMEDS competencies and the UK’s Intercollegiate Surgical Curriculum Project also include professionalism as a crucial component of surgical practice.39,40 Similar themes have emerged to those seen in the US literature, with Dreyer et al debating the importance of a clear definition of professionalism as it relates to surgical practice.41 The same authors proposed multisource feedback as the most useful method of assessing professionalism. The need for further formalized professionalism training has also been highlighted.42 In Ireland, a human factors curriculum, which incorporates professionalism, has been established and is integrated into the surgical training program of all surgical subspecialties.43 The current study is limited by the small number of papers included in the final analysis. Broadening our search to include other surgical subspecialties would have yielded more papers, but we felt that the ethical and professionalism concerns in plastic surgery are unique and therefore chose to limit the selection in this way. Furthermore, as cited above, the literature regarding professionalism curricula in general surgery has recently been reviewed and an additional study is not warranted at this time.
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DISCUSSION In this systematic review, we sought to investigate the extent of formalized teaching in ethics and professionalism that exists in plastic surgery training programs. We found only 2 studies describing such educational interventions. In spite of the increased emphasis placed on ethics and professionalism both by the ABMS and the ACGME, it appears that plastic surgery as a specialty is falling short in terms of providing structured education in this core competency to its trainees. There has been no shortage of discussion of professionalism and ethics in the plastic surgery literature, however. A concise history of ethics in plastic surgery was provided by Sterodimas et al in their 2011 paper, which outlines the competing interests of personal finance, outside regulations and professional duty as factors which influence decision making in modern plastic surgery.13 A number of surgeons have contributed valuable opinion pieces to the literature.14Y20 Specific ethical issues, which have prompted such discussions, include flamboyant commercial advertising, raffling of cosmetic procedures, ‘‘out-of-field’’ cosmetic practice by unqualified practitioners, current procedural terminology coding aberrations, and billing malpractice.14,16,19 Cosmetic surgery in particular has been the subject of a number of thought-provoking commentaries.20Y22 Preminger et al have pointed out the inherent difficulty in defining professional standards that are based on objective norms when much of plastic surgery is governed by rather subjective norms.22 The bioethicist Franklin Miller has even gone so far as to argue that cosmetic surgery ‘‘lie(s) far outside the core domain of medicine as a profession dedicated to saving lives, healing and promoting health’’.23 Further controversy arises when it comes to teaching professionalism and the notion that this is a trait that is inherent to the individual and cannot be taught.15,24 Indeed several authors have stated that attempts should be made to psychologically evaluate applicants to plastic surgery programs to identify ‘‘unethical candidates’’.16,25 The importance of mentoring in teaching ethical practice has also been discussed.17 Aside from commentary articles, a number of authors have explored attitudes of plastic surgeons towards ethics and professionalism.26Y28 Kim et al found that a group of 300 plastic surgeons demonstrated more entrepreneurial than altruistic characteristics and concluded that vocational education in professionalism was therefore warranted.27 To date, efforts in this area have been limited. In the current study, we identified only 1 group that has developed a comprehensive professionalism curriculum specific to plastic surgery. Employing standardized techniques for curriculum design and evaluation, the model provided by Hultman et al is an excellent reference for units seeking guidance on how to go about establishing such a program.10 The second study we selected, by Davis et al, did not provide a set professionalism curriculum per se.9 We included this paper in our review nonetheless, as we felt that the inclusion of professionalism as a formally assessed competency in their OSCE examination met our inclusion criteria and was commendable. Together with the previous paper, these 2 studies comprise the only published reports of formalized assessment of professionalism in a plastic surgery training program. Both studies identified a satisfactory level of professionalism in the majority of candidates assessedVwith only the Hultman group having received formalized training. It is difficult to draw * 2014 Lippincott Williams & Wilkins
CONCLUSION Having applied the strict inclusion and exclusion criteria of a systematic review, an area of deficiency in the plastic surgery literature has been identified. We suggest that further research is warranted and that curricula should be in place to provide formalized training in professionalism and ethics to all plastic surgery residents. Guidance from the papers identified in this review, as well as the experience of other surgical specialties both nationally and internationally, could be used to inform such initiatives. REFERENCES 1. Maintenance of Certification Competencies and Criteria. 2012. (Accessed 13 August, 2013, at http://www.abms.org/Maintenance_of_Certification/MOC_ competencies.aspx.) 2. Chung KC, Clapham PJ, Lalonde DH. Maintenance of certification, maintenance of public trust. Plast Reconstr Surg. 2011;127:967Y973. 3. Ludwig S, Day S. New standards for resident professionalism. In: Philibert I, Amis S, eds. The ACGME 2011 Duty Hour Standards: Enhancing Quality of Care, Supervision, and Resident Professional Development. Chicago: ACGME Press; 2011:47Y51. 4. Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach. 2007;29:648Y654. 5. Copeland EM 3rd. Professionalism and ethics in the current resident training paradigm. Bull Am Coll Surg. 2008;93:8Y12. 6. Hochberg MS, Berman RS, Kalet AL, et al. The professionalism curriculum as a cultural change agent in surgical residency education. Am J Surg. 2012; 203:14Y20.
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7. Hochberg MS, Kalet A, Zabar S, et al. Can professionalism be taught? Encouraging evidence. Am J Surg. 2010;199:86Y93. 8. Margaliot Z, Chung KC. Systematic reviews: a primer for plastic surgery research. Plast Reconstr Surg. 2007;120:1834Y1841. 9. Davis D, Lee G. The use of standardized patients in the plastic surgery residency curriculum: teaching core competencies with objective structured clinical examinations. Plast Reconstr Surg. 2011;128:291Y298. 10. Hultman CS, Halvorson EG, Kaye D, et al. Sometimes you can’t make it on your own: the impact of a professionalism curriculum on the attitudes, knowledge, and behaviors of an academic plastic surgery practice. J Surg Res. 2013;180:8Y14. 11. ADDIE Model. 2013. (Accessed 13 August, 2013, at http://en.wikipedia.org/ wiki/ADDIE_Model.) 12. The Kirkpatrick Model. 2013. (Accessed 13 August, 2013, at http://www.kirkpatrick partners.com/OurPhilosophy/TheKirkpatrickModel/tabid/302/Default.aspx.) 13. Sterodimas A, Radwanski HN, Pitanguy I. Ethical issues in plastic and reconstructive surgery. Aesthetic Plast Surg. 2011;35:262Y267. 14. Wray RC Jr. On morality, ethics, and the American Board of Plastic Surgery. Plast Reconstr Surg. 1994;93:1506Y1507. 15. Rohrich RJ. Professionalism: the end product of the medical profession. Plast Reconstr Surg. 2006;118:1487Y1488. 16. Puckett CL. An ethical dilemma: some will get through. Plast Reconstr Surg. 1994;93:852Y853. 17. Holt GR. Idealized mentoring and role modeling in facial plastic and reconstructive surgery training. Arch Facial Plast Surg. 2008;10:421Y426. 18. Rohrich RJ. The sandbox rules for plastic surgery. Plast Reconstr Surg. 2008; 122:303Y305. 19. Gatti JE. My modest proposal. Plast Reconstr Surg. 1999;104:1553Y1554. 20. Murray JE. On ethics and the training of the plastic surgeon. Plast Reconstr Surg. 1978;61:270Y271. 21. Spear M. The ethical dilemmas of aesthetic medicine: what every provider should consider. Plast Surg Nurs. 2010;30:152Y155; quiz 6. 22. Preminger BA, Fins JJ. Plastic surgery, aesthetics, and medical professionalism: beauty and the eye of the beholder. Ann Plast Surg. 2009;62:340Y343. 23. Miller FG, Brody H, Chung KC. Cosmetic surgery and the internal morality of medicine. Camb Q Healthc Ethics. 2000;9:353Y364. 24. Lineaweaver WC. Professionalism: the end product of the medical profession. Plast Reconstr Surg. 2007;120:1440; author reply 1. 25. May JW Jr. The honor and responsibility of teaching in plastic surgery. Plast Reconstr Surg. 1991;88:869Y873. 26. Hayran O, Gursoy A, Akcay F, et al. Turkish physicians’ attitudes to ethical issues. Bull Med Ethics. 1994;No. 102:16Y21. 27. Kim JY, Kang SJ, Kim JW, et al. Survey of attitudes on professionalism in plastic and reconstructive surgery. Arch Plast Surg. 2013;40:134Y140. 28. Wagner IJ, Hultman CS. Elevation: developing a mentorship model to raise the next generation of plastic surgery professionals. Ann Plast Surg. 2013;70:606Y612.
29. Deptula P, Chun MB. A literature review of professionalism in surgical education: suggested components for development of a curriculum. J Surg Educ. 2013;70:408Y422.
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30. Iramaneerat C. Instruction and assessment of professionalism for surgery residents. J Surg Educ. 2009;66:158Y162. 31. Helft PR, Eckles RE, Torbeck L. Ethics education in surgical residency programs: a review of the literature. J Surg Educ. 2009;66:35Y42. 32. Rowland PA, Trus TL, Lang NP, et al. The certifying examination of the American Board of Surgery: the effect of improving communication and professional competency: twenty-year results. J Surg Educ. 2012;69:118Y125. 33. Todd SR, Fahy BN, Paukert J, et al. Surgical intern survival skills curriculum as an intern: does it help? Am J Surg. 2011;202:713Y718; discussion 8Y9. 34. Selden NR, Origitano TC, Burchiel KJ, et al. A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses. Neurosurgery. 2012;70:971Y981; discussion 81. 35. Dehmer JJ, Stafford RE, Marshall HP, et al. Boot camp: a method of introducing the competency of professionalism to surgical residents. Am Surg. 2011;77:960Y961. 36. Wang TT, Ahmed K, Patel VM, et al. A competency framework in cardiothoracic surgery for training and revalidationVan international comparison. Eur J Cardiothorac Surg. 2011;40:816Y825. 37. Nwomeh BC, Caniano DA. Emerging ethical issues in pediatric surgery. Pediatr Surg Int. 2011;27:555Y562. 38. Patel P, Robinson BS, Novicoff WM, et al. The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability. J Bone Joint Surg Am. 2011;93:e1261Y6. 39. CanMEDS 2005 Framework. 2005. (Accessed 12 August, 2013, at http:// www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/the_7_canmeds_roles_e.pdf.) 40. ISCP Surgical Curriculum Version 9.6. 2013. (Accessed 13 August, 2013, at https://www.iscp.ac.uk/surgical/syllabus.aspx.) 41. Dreyer JS. Assessing professionalism in surgeons. Surgeon. 2010;8:20Y27. 42. Patel VM, Warren O, Humphris P, et al. What does leadership in surgery entail? ANZ J Surg. 2010;80:876Y883. 43. Doherty E, O’Keeffe D, Traynor O. Developing a human factors and patient safety programme at the Royal College of Surgeons in Ireland. Surgeon. 2011;9(suppl 1):S38YS39. 44. Walden JL, Phillips LG. Career development resource for plastic and reconstructive surgery. Am J Surg. 2010;199:271Y274. 45. Bancroft GN, Basu CB, Leong M, et al. Outcome-based residency education: teaching and evaluating the core competencies in plastic surgery. Plast Reconstr Surg. 2008;121:441eY448e 46. Spencer JM. Sharing knowledge. Cosmet Dermatol. 2005;18:266 47. Ward CM. On learning medical ethics. Brit J Plast Surg. 1994;47:507Y511.
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Teaching Ethics and Professionalism in Plastic Surgery A Systematic Review Catherine de Blacam, MD* and Christian J. Vercler, MD, MAÞ Background: Maintenance of the highest ethical and professional standards in plastic surgery is in the best interests of our profession and the public whom we serve. Both the American Board of Medical Specialties and the Accreditation Council on Graduate Medical Education mandate training in ethics and professionalism for all residents. Presently there is no gold standard in ethics and professionalism education. Methods: A systematic review on teaching ethics and professionalism in plastic surgery was performed for all articles from inception to May 23, 2013 in MEDLINE, Scopus, EMBASE, CENTRAL, and ERIC. References of relevant publications were searched for additional papers. Key journals were hand searched and relevant conference proceedings were also reviewed. Duplicate and non-English articles were excluded. Inclusion and exclusion criteria were applied to find articles that described a curriculum in ethics and/or professionalism in plastic surgery. Results: Two hundred twenty-seven relevant articles were identified. One hundred seventy-four did not meet inclusion criteria based on screening of the title, and 39 of those did not meet inclusion criteria based on screening of the abstract or introductory paragraph. Of the 14 identified for full text review, only 2 articles described a set curriculum in ethics and/or professionalism in plastic surgery training and reported outcomes. Conclusions: A paucity of data exists regarding the structure, content, or relevant measures that can be applied to assess outcomes of a curriculum to teach ethics and professionalism to plastic surgery trainees. Endeavors to teach ethics and professionalism to plastic surgery trainees must rigorously document the process and outcomes to facilitate the maintenance of our profession. Key Words: ethics, ethics education, professionalism, moral development, resident education, ACGME core competencies (Ann Plast Surg 2014;72: 484Y488)
profile breaches in patient safety, overt commercialization, and reality television. Never before has defining our professionalism mattered so much.2 In fact, the American Council of Academic Plastic Surgeons, the American Board of Plastic Surgery, the American Society of Plastic Surgery, and the Plastic Surgery Foundation have convened a Joint Committee to develop a curriculum on ethics and professionalism in plastic surgery. The Accreditation Council on Graduate Medical Education (ACGME) has included professionalism in its list of core competencies for residency training in all medical disciplines.3,4 As educators, we are obliged to ensure that residents completing our training programs manifest an acceptable level of professionalism. For generations, the traits that define professionalism were considered innate to the individual. Only recently have medical educators recognized that there are concrete components of professionalism that can be taught and assessed in a standardized fashion.5Y7 In spite of a potentially greater need for formalized professionalism training in plastic surgery, there is a dearth of information available to guide program directors in providing focused training in this important competency. In this systematic review, we sought to investigate the existing experience of teaching ethics and professionalism in plastic surgery residency programs.
METHODS Hypothesis We hypothesized that there are few published data to act as guidelines for developing a curriculum for teaching medical ethics and professionalism to plastic surgery residents.
Data Sources and Searches
S
ince the time of Hippocrates, the profession of medicine has long held adherence to a code of ethics constitutive of the practice. The American Board of Medical Specialties (ABMS) has prescribed professionalism as one of the six core competencies which must be attained and sustained by all doctors practicing in the United States.1 Plastic surgeons endeavor to restore or enhance form and function to that which is considered normal. To establish ethical standards in a field that is largely based on the subjective opinions of both surgeon and patient is challenging and has been the subject of much discussion in the plastic surgery literature. In recent years, the ethical image of plastic surgery has been called in to question as a result of high-
Received October 11, 2013, and accepted for publication, after revision, December 10, 2013. From the *Plastic Surgery Higher Surgical Training Program, Royal College of Surgeons in Ireland, Dublin, Ireland; and †Section of Plastic Surgery, University of Michigan, Ann Arbor, MI. Conflicts of interest and sources of funding: none declared. Reprints: Christian J. Vercler, MD, MA, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, 1540 East Hospital Drive, C.S. Mott Children’s Hospital, Suite 4-730, Ann Arbor, MI 48109-4219. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7204-0484 DOI: 10.1097/SAP.0000000000000126
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The topic ‘‘teaching medical ethics and professionalism in plastic surgery residency programs’’ was explored to determine significant issues (conceptual mapping). From this, a search strategy was devised using the following key terms: plastic surgery AND (ethics OR medical ethics OR professionalism) AND (curriculum OR training OR education). Using these key terms, an electronic bibliographic search was conducted in the following databases from inception until May 23, 2013: MEDLINE, Scopus, EMBASE, CENTRAL (The Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health), and ERIC (Education Resources Information Center). Limits were placed on each search to exclude non-English citations. Reference lists of all relevant publications were searched for additional papers. Hand searching of key journals was undertaken and relevant conference proceedings were also examined.
Study Selection Inclusion and exclusion criteria for selection are listed in Table 1. To avoid selection bias and minimize omissions,8 the article selection was conducted independently and in duplicate by 2 assessors (C.de B. and C.V.), with results compared and reconciled at each stage. The process of selection is summarized diagrammatically in Figure 1. Duplicate articles were excluded at the first stage. A staged review of article titles and abstracts was performed to select all studies that met Annals of Plastic Surgery
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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full-text review are listed in Table 2. At this final stage, articles were eliminated on the basis of exclusion criteria.
TABLE 1. Inclusion and Exclusion Criteria Inclusion Criteria
Exclusion Criteria
Studies that describe a prescribed curriculum in ethics and/or professionalism Prospective and retrospective observational studies Studies involving plastic surgery residency/higher specialty training/fellowship programs
Teaching Ethics and Professionalism
Review articles Editorial/commentary/ opinion papers Studies pertaining to fields other than plastic surgery
Data Extraction, Synthesis, and Analysis Data extraction and quality assessment were performed independently by 2 reviewers (C.de B. and C.V.). The following variables were recorded from each study: number of participants, participant demographics, instructional technique(s) employed, and outcome(s) achieved. The papers included in our final analysis were heterogeneous in their methodology and results, thus precluding a formal pooled analysis. Therefore, a narrative summary of results was performed.
RESULTS the inclusion criteria. Abstracts of studies identified in the title search were obtained and reviewed and once again studies meeting the inclusion criteria were identified. Studies whose abstracts met the inclusion criteria were retrieved and the full text was analyzed. Papers selected for
Potentially relevant papers were retrieved from 3 out of the 6 electronic databases queried. The largest number of papers was retrieved from EMBASE, followed by Scopus and MEDLINE. There were no studies matching our key terms retrieved from CENTRAL, CINAHL, or ERIC. Excluding duplicates, 227 papers were identified
FIGURE 1. Selection of studies examining formal teaching in ethics and professionalism in plastic surgery. * 2014 Lippincott Williams & Wilkins
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TABLE 2. Papers Meeting Inclusion Criteria That Were Selected for Full Text Review (One Duplicate Paper Excluded) Author
Journal and Year
Title
Hultman10
Journal of Surgical Research 2013
Kim27 Wagner28
Archives of Plastic Surgery 2013 Annals of Plastic Surgery 2013
Sometimes you can’t make it on your own: the impact of a professionalism curriculum on the attitudes, knowledge, and behaviors of an academic plastic surgery practice Survey of attitudes on professionalism in plastic and reconstructive surgery Elevation: developing a mentorship model to raise the next generation of plastic surgery professionals The use of standardized patients in the plastic surgery residency curriculum: teaching core competencies with objective structured clinical examinations Ethical issues in plastic and reconstructive surgery Career development resource for plastic and reconstructive surgery Outcome-based residency education: teaching and evaluating the core competencies in plastic surgery Idealized mentoring and role modeling in facial plastic and reconstructive surgery training Professionalism: the end product of the medical professionVreply Professionalism: the end product of the medical profession Sharing knowledge On learning medical ethics
Davis9
Plastic and Reconstructive Surgery 2011
Sterodimas13 Walden44 Bancroft45
Aesthetic Plastic Surgery 2011 American Journal of Surgery 2010 Plastic and Reconstructive Surgery 2008
Holt17
Archives of Facial Plastic Surgery 2008
Lineaweaver24 Rohrich15 Spencer46 Ward47
Plastic and Reconstructive Surgery 2007 Plastic and Reconstructive Surgery 2006 Cosmetic Dermatology 2005 British Journal of Plastic Surgery 1994
and subjected to selection as demonstrated in Figure 1. The papers selected for full-text review are listed in Table 2. The majority of these publications were editorials or commentary pieces. The criteria resulting in the exclusion of each are also presented in Table 1. Having completed the study selection process, only 2 papers were eligible for inclusion in our review (Table 3). The first of these, by Davis et al, was published in Plastic and Reconstructive Surgery in July 2011.9 In response to the ACGME’s establishment of 6 core competencies, the authors designed a plastic surgeryYspecific objective structured clinical examination (OSCE) to address all 6 competencies. The topic selected was melanoma and the examination included an encounter with a standardized patient and a separate written exercise. Six plastic surgery residents from postgraduate years 4, 5, and 6 completed the OSCE and were graded on their performance in each core competency by both the standardized patients and by faculty experts. A 3-point rating scale was used (1 = novice, 2 = moderately skilled, 3 = proficient). Professionalism was specifically addressed in the standardized patient encounter, which was designed to simulate a new-patient referral for melanoma. Residents were asked to explain the diagnosis and treatment recommendations, complete an informed consent discussion, and answer the patient’s questions. Standardized patients were given an evaluation form to assess the resident in 3 out of the 6 competencies, including professionalism. The wording used to assess professionalism was as follows: ‘‘[The resident] appeared professionally competentVseemed to know what s/he was doing; inspired my confidence; appeared to have my interests at heart’’. Standardized patients rated the residents on a scale from 1 (below expectations) to 6 (exceeds expectations). Though the patient encounters were videotaped and reviewed by faculty, it was the standardized patients’
scores alone that were used to evaluate professionalism. The average score for professionalism among the residents, as assessed by standardized patients, was high at 86%. The authors also elicited participant feedback. All resident participants reported that they found the OSCE to be realistic and of educational benefit. The second paper to present a structured approach to teaching professionalism in plastic surgery was published in the Journal of Surgical Research by Hultman et al in 2013.10 Acknowledging that few models exist that define, teach, and assess professionalism in plastic surgery, the authors evaluated the effectiveness of a novel professionalism curriculum in an academic plastic surgery practice. Using the robust Analysis, Design, Development, Implementation, and Evaluation model of instructional design, a 6-week, 12-hour course in professionalism was developed.11 The course comprised didactic lectures, journal club, small group discussions, and book review, with participants required to complete 1 to 2 hours of self-study before each learning encounter. The program was delivered to a group of 30 health care professionals, including faculty, residents, nurses, and medical students. The specific topics addressed were Professionalism in Our Culture, Leadership Styles, Modeling Professional Behavior, Leading your Team, Managing Oneself, and Leading While You Work. The course was evaluated using Kirkpatrick methodology to measure impact on 4 levels of learning: reaction (ie, participants’ perception of course), knowledge (ie, change in participants’ capability before and after course), behavior (ie, transfer of knowledge and skills acquired from classroom to workplace), and results (ie, impact of the intervention on the organization).12 On completion of a questionnaire to assess perception of the course, all respondents were neutral or positive about the course. Participants demonstrated a statistically significant increase in knowledge when pre- and post-course multiple-choice test
TABLE 3. Summary of the Results of Papers that Analyzed a Specific Curriculum for Teaching Ethics and/or Professionalism in Plastic Surgery Paper Hultman J Surg Res 201310 Davis PRS 20119
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Participants
Instructional Technique
Outcome
30 healthcare professionals working in a plastic surgery practice 6 plastic surgery residents
Lectures, journal club, small group teaching OSCE using standardized patients
Decrease in number of reported incidences of unprofessional behavior in department Residents scored highly in professionalism and deemed assessment a valuable adjunct to their training
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Teaching Ethics and Professionalism
scores were compared. To assess impact of the course on conduct, the authors examined the number of recorded incidences of unprofessional behavior in the practice. A decrease from 12 to 3 was noted in the 6 months before and after the course, respectively. Finally, impact on the organization was measured by analyzing patient complaints in the periods before and after delivery of the course. The number of complaints fell from 14 in the 6 months before the course to 8 in the postcourse period.
conclusions from this however, as different assessment tools were used, with 1 group being assessed using a single score (awarded by standardized patients) and the other receiving a faculty-designed preand post-course test. The difference in scores was significant, with candidates improving from an average of 48% pre-course to 70% post-course, thus demonstrating the effectiveness of the intervention. Professionalism curricula are somewhat more established in general surgery with several review articles published in the last number of years.29Y31 Programs at the New York University Department of Surgery were successful in improving both self-perceived and objectively assessed mastery of the 6 ACGME domains of professionalism.6,7 Rowland et al demonstrated the utility of a focused professionalism course in preparing for the American Board of Surgery examination.32 Professionalism training has been incorporated into intern induction or so-called boot camp courses in certain general surgery and neurosurgery programs.33Y35 The importance of professionalism training has also been recognized in the cardiothoracic, pediatric, and orthopedic surgery literature.36Y38 Outside of the United States, the Canadian CanMEDS competencies and the UK’s Intercollegiate Surgical Curriculum Project also include professionalism as a crucial component of surgical practice.39,40 Similar themes have emerged to those seen in the US literature, with Dreyer et al debating the importance of a clear definition of professionalism as it relates to surgical practice.41 The same authors proposed multisource feedback as the most useful method of assessing professionalism. The need for further formalized professionalism training has also been highlighted.42 In Ireland, a human factors curriculum, which incorporates professionalism, has been established and is integrated into the surgical training program of all surgical subspecialties.43 The current study is limited by the small number of papers included in the final analysis. Broadening our search to include other surgical subspecialties would have yielded more papers, but we felt that the ethical and professionalism concerns in plastic surgery are unique and therefore chose to limit the selection in this way. Furthermore, as cited above, the literature regarding professionalism curricula in general surgery has recently been reviewed and an additional study is not warranted at this time.
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DISCUSSION In this systematic review, we sought to investigate the extent of formalized teaching in ethics and professionalism that exists in plastic surgery training programs. We found only 2 studies describing such educational interventions. In spite of the increased emphasis placed on ethics and professionalism both by the ABMS and the ACGME, it appears that plastic surgery as a specialty is falling short in terms of providing structured education in this core competency to its trainees. There has been no shortage of discussion of professionalism and ethics in the plastic surgery literature, however. A concise history of ethics in plastic surgery was provided by Sterodimas et al in their 2011 paper, which outlines the competing interests of personal finance, outside regulations and professional duty as factors which influence decision making in modern plastic surgery.13 A number of surgeons have contributed valuable opinion pieces to the literature.14Y20 Specific ethical issues, which have prompted such discussions, include flamboyant commercial advertising, raffling of cosmetic procedures, ‘‘out-of-field’’ cosmetic practice by unqualified practitioners, current procedural terminology coding aberrations, and billing malpractice.14,16,19 Cosmetic surgery in particular has been the subject of a number of thought-provoking commentaries.20Y22 Preminger et al have pointed out the inherent difficulty in defining professional standards that are based on objective norms when much of plastic surgery is governed by rather subjective norms.22 The bioethicist Franklin Miller has even gone so far as to argue that cosmetic surgery ‘‘lie(s) far outside the core domain of medicine as a profession dedicated to saving lives, healing and promoting health’’.23 Further controversy arises when it comes to teaching professionalism and the notion that this is a trait that is inherent to the individual and cannot be taught.15,24 Indeed several authors have stated that attempts should be made to psychologically evaluate applicants to plastic surgery programs to identify ‘‘unethical candidates’’.16,25 The importance of mentoring in teaching ethical practice has also been discussed.17 Aside from commentary articles, a number of authors have explored attitudes of plastic surgeons towards ethics and professionalism.26Y28 Kim et al found that a group of 300 plastic surgeons demonstrated more entrepreneurial than altruistic characteristics and concluded that vocational education in professionalism was therefore warranted.27 To date, efforts in this area have been limited. In the current study, we identified only 1 group that has developed a comprehensive professionalism curriculum specific to plastic surgery. Employing standardized techniques for curriculum design and evaluation, the model provided by Hultman et al is an excellent reference for units seeking guidance on how to go about establishing such a program.10 The second study we selected, by Davis et al, did not provide a set professionalism curriculum per se.9 We included this paper in our review nonetheless, as we felt that the inclusion of professionalism as a formally assessed competency in their OSCE examination met our inclusion criteria and was commendable. Together with the previous paper, these 2 studies comprise the only published reports of formalized assessment of professionalism in a plastic surgery training program. Both studies identified a satisfactory level of professionalism in the majority of candidates assessedVwith only the Hultman group having received formalized training. It is difficult to draw * 2014 Lippincott Williams & Wilkins
CONCLUSION Having applied the strict inclusion and exclusion criteria of a systematic review, an area of deficiency in the plastic surgery literature has been identified. We suggest that further research is warranted and that curricula should be in place to provide formalized training in professionalism and ethics to all plastic surgery residents. Guidance from the papers identified in this review, as well as the experience of other surgical specialties both nationally and internationally, could be used to inform such initiatives. REFERENCES 1. Maintenance of Certification Competencies and Criteria. 2012. (Accessed 13 August, 2013, at http://www.abms.org/Maintenance_of_Certification/MOC_ competencies.aspx.) 2. Chung KC, Clapham PJ, Lalonde DH. Maintenance of certification, maintenance of public trust. Plast Reconstr Surg. 2011;127:967Y973. 3. Ludwig S, Day S. New standards for resident professionalism. In: Philibert I, Amis S, eds. The ACGME 2011 Duty Hour Standards: Enhancing Quality of Care, Supervision, and Resident Professional Development. Chicago: ACGME Press; 2011:47Y51. 4. Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach. 2007;29:648Y654. 5. Copeland EM 3rd. Professionalism and ethics in the current resident training paradigm. Bull Am Coll Surg. 2008;93:8Y12. 6. Hochberg MS, Berman RS, Kalet AL, et al. The professionalism curriculum as a cultural change agent in surgical residency education. Am J Surg. 2012; 203:14Y20.
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7. Hochberg MS, Kalet A, Zabar S, et al. Can professionalism be taught? Encouraging evidence. Am J Surg. 2010;199:86Y93. 8. Margaliot Z, Chung KC. Systematic reviews: a primer for plastic surgery research. Plast Reconstr Surg. 2007;120:1834Y1841. 9. Davis D, Lee G. The use of standardized patients in the plastic surgery residency curriculum: teaching core competencies with objective structured clinical examinations. Plast Reconstr Surg. 2011;128:291Y298. 10. Hultman CS, Halvorson EG, Kaye D, et al. Sometimes you can’t make it on your own: the impact of a professionalism curriculum on the attitudes, knowledge, and behaviors of an academic plastic surgery practice. J Surg Res. 2013;180:8Y14. 11. ADDIE Model. 2013. (Accessed 13 August, 2013, at http://en.wikipedia.org/ wiki/ADDIE_Model.) 12. The Kirkpatrick Model. 2013. (Accessed 13 August, 2013, at http://www.kirkpatrick partners.com/OurPhilosophy/TheKirkpatrickModel/tabid/302/Default.aspx.) 13. Sterodimas A, Radwanski HN, Pitanguy I. Ethical issues in plastic and reconstructive surgery. Aesthetic Plast Surg. 2011;35:262Y267. 14. Wray RC Jr. On morality, ethics, and the American Board of Plastic Surgery. Plast Reconstr Surg. 1994;93:1506Y1507. 15. Rohrich RJ. Professionalism: the end product of the medical profession. Plast Reconstr Surg. 2006;118:1487Y1488. 16. Puckett CL. An ethical dilemma: some will get through. Plast Reconstr Surg. 1994;93:852Y853. 17. Holt GR. Idealized mentoring and role modeling in facial plastic and reconstructive surgery training. Arch Facial Plast Surg. 2008;10:421Y426. 18. Rohrich RJ. The sandbox rules for plastic surgery. Plast Reconstr Surg. 2008; 122:303Y305. 19. Gatti JE. My modest proposal. Plast Reconstr Surg. 1999;104:1553Y1554. 20. Murray JE. On ethics and the training of the plastic surgeon. Plast Reconstr Surg. 1978;61:270Y271. 21. Spear M. The ethical dilemmas of aesthetic medicine: what every provider should consider. Plast Surg Nurs. 2010;30:152Y155; quiz 6. 22. Preminger BA, Fins JJ. Plastic surgery, aesthetics, and medical professionalism: beauty and the eye of the beholder. Ann Plast Surg. 2009;62:340Y343. 23. Miller FG, Brody H, Chung KC. Cosmetic surgery and the internal morality of medicine. Camb Q Healthc Ethics. 2000;9:353Y364. 24. Lineaweaver WC. Professionalism: the end product of the medical profession. Plast Reconstr Surg. 2007;120:1440; author reply 1. 25. May JW Jr. The honor and responsibility of teaching in plastic surgery. Plast Reconstr Surg. 1991;88:869Y873. 26. Hayran O, Gursoy A, Akcay F, et al. Turkish physicians’ attitudes to ethical issues. Bull Med Ethics. 1994;No. 102:16Y21. 27. Kim JY, Kang SJ, Kim JW, et al. Survey of attitudes on professionalism in plastic and reconstructive surgery. Arch Plast Surg. 2013;40:134Y140. 28. Wagner IJ, Hultman CS. Elevation: developing a mentorship model to raise the next generation of plastic surgery professionals. Ann Plast Surg. 2013;70:606Y612.
29. Deptula P, Chun MB. A literature review of professionalism in surgical education: suggested components for development of a curriculum. J Surg Educ. 2013;70:408Y422.
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30. Iramaneerat C. Instruction and assessment of professionalism for surgery residents. J Surg Educ. 2009;66:158Y162. 31. Helft PR, Eckles RE, Torbeck L. Ethics education in surgical residency programs: a review of the literature. J Surg Educ. 2009;66:35Y42. 32. Rowland PA, Trus TL, Lang NP, et al. The certifying examination of the American Board of Surgery: the effect of improving communication and professional competency: twenty-year results. J Surg Educ. 2012;69:118Y125. 33. Todd SR, Fahy BN, Paukert J, et al. Surgical intern survival skills curriculum as an intern: does it help? Am J Surg. 2011;202:713Y718; discussion 8Y9. 34. Selden NR, Origitano TC, Burchiel KJ, et al. A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses. Neurosurgery. 2012;70:971Y981; discussion 81. 35. Dehmer JJ, Stafford RE, Marshall HP, et al. Boot camp: a method of introducing the competency of professionalism to surgical residents. Am Surg. 2011;77:960Y961. 36. Wang TT, Ahmed K, Patel VM, et al. A competency framework in cardiothoracic surgery for training and revalidationVan international comparison. Eur J Cardiothorac Surg. 2011;40:816Y825. 37. Nwomeh BC, Caniano DA. Emerging ethical issues in pediatric surgery. Pediatr Surg Int. 2011;27:555Y562. 38. Patel P, Robinson BS, Novicoff WM, et al. The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability. J Bone Joint Surg Am. 2011;93:e1261Y6. 39. CanMEDS 2005 Framework. 2005. (Accessed 12 August, 2013, at http:// www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/the_7_canmeds_roles_e.pdf.) 40. ISCP Surgical Curriculum Version 9.6. 2013. (Accessed 13 August, 2013, at https://www.iscp.ac.uk/surgical/syllabus.aspx.) 41. Dreyer JS. Assessing professionalism in surgeons. Surgeon. 2010;8:20Y27. 42. Patel VM, Warren O, Humphris P, et al. What does leadership in surgery entail? ANZ J Surg. 2010;80:876Y883. 43. Doherty E, O’Keeffe D, Traynor O. Developing a human factors and patient safety programme at the Royal College of Surgeons in Ireland. Surgeon. 2011;9(suppl 1):S38YS39. 44. Walden JL, Phillips LG. Career development resource for plastic and reconstructive surgery. Am J Surg. 2010;199:271Y274. 45. Bancroft GN, Basu CB, Leong M, et al. Outcome-based residency education: teaching and evaluating the core competencies in plastic surgery. Plast Reconstr Surg. 2008;121:441eY448e 46. Spencer JM. Sharing knowledge. Cosmet Dermatol. 2005;18:266 47. Ward CM. On learning medical ethics. Brit J Plast Surg. 1994;47:507Y511.
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