Keywords
Code of ethics - Plastic surgery - Professional role
INTRODUCTION
Doctors in Western society have formed their identify by establishing standards of
professionalism. These regulations on appropriate conduct and ethical values and norms
have been the basis for researchers to qualitatively differentiate medical professionals
as a group [[1]
[2]]. As a result, those in medicine have been granted privileges such as autonomy and
social prestige. However, in return, expectations of altruistic service to society
have developed [[3]]. In the case of the American Society of Plastic Surgeons (ASPS), the Code of Ethics
of the ASPS was formed, to guide the conduct of its members to act in accordance with
the general and specific principles of the ASPS code of ethics, which pertains to
contact with patients, peers, and the general public [[4]]. However, in the beginning of the 1960s, skepticism and criticism increased toward
the conduct of physicians. Many held views that some doctors were using their autonomy
only to advance their own interests and wrongly covering-up the unethical behavior
of colleagues, putting collegiality before the interests of society [[5]]. This era was deemed a "crisis of professionalism," prompting self-reflection in
the field of medicine.
The introduction of a licensing system for physicians in Korea was the result of the
modernization of the health care system. The social status of doctors in Korea was
not acquired through their own competition and quality management, but through the
Korean government's unilateral introduction of a licensing system [[6]
[7]]. Historically, doctors in Korea did not have autonomy in establishing their role
as health care professionals [[8]]. This phenomenon was also true among plastic surgeons. In 1973, the Korean government
promulgated revised "Enforcement Regulations for Medical Law" due to the increasing
number of plastic surgery patients. As a result, plastic and reconstructive surgery
was recognized as a separate medical department, and residency programs were established.
Since 1975, the Korean Society of Plastic and Reconstructive Surgeons [[9]] independently began working on residency training and the qualifications of specialists.
As Korea became wealthier, those who could financially afford plastic surgery and
had the leisure time started to pay more attention to their physical appearance [[10]]. In considering the growing influence of plastic surgery on society, it is urgent
to establish standards of professionalism for health care experts. Moreover, it is
necessary to establish a proper professional code of ethics. Therefore, the purpose
of this research is to identify plastic surgeons' perception of professionalism, core
values, and types of professionalism. Such information would provide the basis to
build a model of professionalism to fulfill the duties of a plastic surgeon as a professional.
METHODS
This study targeted the 325 plastic surgery specialists and residents registered in
the Korean Society of Plastic and Reconstructive Surgeons in 2012. Of these, 256 (78.8%)
were specialists, and 69 (21.2%) were residents. Total respondents numbered 106 (32.6%).
Face-to-face and postal surveys were conducted with one respondent excluded from the
final subjects due to an incomplete questionnaire.
The survey questions were designed by modifying a survey by the Royal Physician Society,
2007 [[1]]. The contents of our survey included four questions ([11]]. They are autonomy, altruism, interpersonal competence, personal morality, professional
dominance, technical competence, social contract, social justice, lifestyle, and commercialism
and are evaluated on a 5-point scale. The survey of the core values is described in
the following figure ([Fig. 1B]). The Cronbach's alpha value based on the collected surveys was 0.825. The average
of the ten category values was calculated, and the high values were set as the priority.
Fig. 1 Survey
(A) Questions on the perception of professionalism. (B) Vocational assessment of the
core values.
The type of professionalism was compared using the seven types of medical professionalism
presented by Castellani and Hafferty [[11]]. Castellani classified these types according to the ten category values. In particular,
the professionalism of specialists practicing at university hospitals and clinics,
and then residents were compared. The collected values through the survey are listed
in the order of the highest value. The most important rank and the least important
rank category were evaluated by comparing them with the items in Castellani's seven
categories. The subjects were divided into two groups of specialists and residents,
and the differences between them were compared. The criteria for the specialist group
was at least 10 years of experience as a specialist. For the resident group, they
were divided into two groups as follows: low year for 1st and 2nd year, high year
for 3rd and 4th year. The proportions of each possible response to an item were obtained
through frequency analysis. Using a Mann-Whitney U test method, the difference in
the response of the resident group and the specialist group was compared. The SPSS
ver. 17.0K (SPSS Inc., Chicago, IL, USA) of the program was used.
RESULTS
Of the respondents, 69.5% were in their 40s (37.1%) and 30s (32.4%). The gender of
the subjects was mostly male, consisting of 98 subjects (93.3%), and 7 female subjects
(6.7%). Clinics (61.0%) and university hospitals (28.3%) were the most common workplaces.
In the case of the specialists except for the residents, aesthetic surgery was the
major task performed in the workplace indicated by 72 respondents, with 19 for craniofacial
reconstruction, 6 for microsurgery, 4 for hand surgery and 4 for other. The number
of specialists with experience of less than 10 years was 31 (40.3%), and those with
experience of more than 11 years was 46 (59.7%). The respondents to the survey were
77 specialists (73.3%) and 28 residents (26.7%) ([Fig. 2]).
Fig. 2 General characteristics of the subjects
(A) Age. (B) Gender. (C) Workplace. (D) Main expertise. (E) Resident grade. (F) Specialist
career.
A total of 90.5% of the respondents saw their future as a plastic surgeon as positive,
which was higher than the negative response of 9.5%. There was no difference between
the responses of the residents and the specialists. The proportion of respondents
considering the future of a plastic surgery specialist as being threatened was 77.1%,
and those who did not was 22.9%. The proportion of negative responses for the leadership
of the plastic surgery specialist in the medical field in the past 10 years was 28.6%,
and there was no difference between the group of residents and the specialists. The
proportion of responses who viewed the reliability of plastic surgery specialists
as declining was 48.6%, and those who did not was 53.4%. There was no statistically
significant difference ([Fig. 3]).
Fig. 3 Perception of professionalism among specialists and residents
(A) Survey question 1. (B) Survey question 2. (C) Survey question 3. (D) Survey question
4.
According to the ten value items of medical professionalism presented by Castellani
and Hafferty [[11]], the respondents indicated that "professional dominance" (4.58 pts) was the most
important value item of the professionalism of plastic surgeons. The others were "autonomy"
(4.45 pts), "life style" (4.34 pts), "commercialism" (4.31 pts), "technical competence"
(4.25 pts), "personal morality" (4.21 pts), "social contract" (3.94 pts), "altruism"
(3.84 pts), "interpersonal competence" (3.79 pts), and "social justice" (3.61 pts),
respectively ([Table 1]). To summarize the importance of the value items of medical professionalism, there
was no significant difference in the comparison of the two groups, one with 10 and
the other with less than 10 years of experience. They evaluated "autonomy," "professional
dominance," and "commercialism" as important. In the resident group comparing the
low and high years, the low year group considered "professional dominance," "autonomy,"
and "life style" to be more important. The high-year group considered "professional
dominance," "life style", and "technical competence" to be more important. There was
no statistically significant difference between the groups ([Table 1]).
Table 1 Mean score of the ten virtues of medical professionalism of plastic and reconstructive
surgeons between specialists and residents
Values are presented as the mean score of a 5-scale score.
a)Wilcoxon rank-sum test.
Although the plastic surgeon cannot be exactly matched with the type of medical professionalism
suggested by Castellani and Hafferty [[11]], it was most similar to the entrepreneurial type that views medicine as an enterprise.
In the case of the residents, it was similar to the entrepreneurial type in that they
regarded "professional dominance," "life style," and "technical competence" as important
and evaluated "altruism" and "social justice" poorly ([Table 2]). In addition, university specialists at hospitals and clinics indicated academic
and entrepreneurial types, respectively ([Table 3]).
Table 2 Ranking by priority of the ten virtues of medical professionalism of plastic
and reconstructive surgeons
Table 3 Comparison of professionalism type among the three groups
DISCUSSION
The fierce competition, commercialization, and industrialization of medicine within
the medical field has increased the pursuit of individual interests over of the needs
of patients. Also, the entrepreneurial approach of some medical professionals has
been highlighted as undermining basic values such as honesty and morality. Therefore,
the establishment of role models that may function harmoniously in a society is very
important as it may appropriately counteract conflict [[12]
[13]
[14]]. As all of the subjects evaluated "professional dominance," "autonomy," "life style,"
and "commercialism" highly as value items, while the traditionally important value
items for professionalism, "altruism" was poorly assessed implies that a plastic surgeon's
lifestyle is generally regarded as a higher priority than altruism. A comparison of
the priorities of residents and specialists showed similarities. However, the result
of "altruism" yielded a significant difference between the two groups. In the group
of residents, "lifestyle" (4.41 pts) was the second priority, reflecting the values
of a younger generation who are more likely to place a priority on their and their
family's lifestyle. The specialist group showed that there was no significant difference,
while a comparison of residents by year did not show a statistically significant difference.
The low year group assessed "professional dominance," "autonomy," and "lifestyle"
to be important. The high year group put greater importance on "professional dominance,"
"lifestyle", and "technical competence" ([Tables 1], [2]).
The plastic surgeons did not match any category of professionalism presented by Castellani
and Hafferty [[11]]. Although it can be interpreted as a result of differences between Western culture
and the diversity of physicians in different countries, the uniqueness of the plastic
surgeon's field played a role as well. Although there were similarities with entrepreneurial
or empirical types, it did not match completely. Specialists of university hospitals
and clinics showed that their type is close to "academic" and "entrepreneurial," respectively
([Table 3]). The plastic surgery residents group considered "professional dominance," "life
style," and "technical competence" to be important and evaluated "altruism" and "social
justice" poorly. This indicated that they have similar characteristics as the "entrepreneurial
type" ([Tables 2], [3]). The academic type is usually found in physicians working in academic medical centers,
medical schools, and related medical organizations. While they rank altruism high
and commercialism low, they do not place much stock in issues of autonomy or professional
dominance. The entrepreneurial type tends to regard medicine as a business and shows
interest in yielding a high profit. This group is characteristic of the type of doctor
who sells beauty products or engages in cosmetic surgery [[11]].
The professionalism crisis in the field of plastic surgery in Korea is intensifying
due to growing awareness of patient's rights as well as unreasonable regulations and
policies that infringe and restrict the autonomy of doctors. The commercialization
caused by the increase in the number of doctors leading to overcompetition in the
medical society is also to blame [[15]]. Also, poorly defined roles of specialists due to the short history of the specialist
system is presumed to be one of the main factors that have led to this crisis. In
order to overcome the crisis of professionalism in plastic surgery, excellence, humanism,
accountability, and altruism should be pursued. Independence from the domination of
the market as well as the state must also be obtained [[15]]. In addition, the Korean Society of Plastic and Reconstructive Surgeons should
develop a code of ethics for the professionalism of plastic surgeons. Also, they should
endeavor to produce plastic surgery specialists with a higher level of knowledge and
morality. Efforts must also be made to prevent their unique professional area from
encroachment by the developing cosmetic and reconstructive fields.
In general, altruism is considered important as a necessary core value to maintain
professionalism, but it is underrated by the participants in this study. This may
be attributed to the high emphasis on the excellence, professional knowledge, and
skills in the field of plastic surgery during the process of putting effort into differentiatiating
roles, task performance, and establishing identity. However, the tendency to underestimate
the core value of altruism cannot be ignored, and therefore further study should be
conducted. Moreover, the Korean society of Plastic and Reconstructive Surgeons should
provide opportunities to expand the competencies of professionals by carrying out
appropriate professionalism training programs for plastic surgeons [[16]]. In particular, training programs to enhance skills and competencies in accordance
with the principles of professionalism should be introduced [[17]].
The limitations of this study may have been the relatively high percentage of specialist
opinions. Second, the number of subjects working in private clinics was higher, which
may have affected the interpretation of the results. Third, further review is necessary
as to the adoptability of Castellani's core values and types to explain the current
environment for plastic surgery in Korea. However, the significance of this study
is that this is the first research to be conducted targeting the registered specialists
and residents since the founding of the Korean Society for Plastic and Reconstructive
Surgeons in 1966. This work serves as a primary work to increase our understanding
of the role of plastic surgeons by identifying the types of professionalism and determining
the appropriate code of ethics.
