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ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net

Professionalism and the role of medical colleges David J. Hillis a,b,*, Michael J. Grigg a,c a

Royal Australasian College of Surgeons, 250 e 290 Spring St, East Melbourne, VIC 3002, Australia Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC 3010, Australia c Monash University, Clayton, VIC 3800, Australia b

article info

abstract

Article history:

Background: There has been substantial interest and emphasis on medical professionalism

Received 1 March 2015

over the past twenty years. This speaks to the history of the medical profession, but

Received in revised form

increasingly to a broader understanding of the importance of socialisation and professional

31 March 2015

identity formation.

Accepted 1 April 2015

Method: A literature review was undertaken of professionalism and the role of professions

Available online xxx

and medical professional organisations. Results: A key outcome has been the recognition that medical professionalism must be

Keywords:

actively taught and assessed. Substantial effort is required to improve the educational

Professionalism

environment, so that it nurtures the development of professionalism within the work-

Professional identity

place.

Standards

Although medical colleges have been prominent in identifying and progressing the

Education

recent developments within professionalism there is still much to be done to deliver fully

Medical colleges

on the societal contract between the public and the profession. There are key gaps to address, particularly with regards to self-regulation, civil behaviour and effective leadership and advocacy. Conclusion: Medical colleges need to take direct responsibility for the professionalism of their members. The expectations of the community are increasingly clear in this regard. © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction Medical colleges are the professional organisations for medical practitioners. They have formed and evolved at the interface between the profession, the public and the government over many years. The interfaces provide the dynamic that go to form the ‘societal contract’ that is reflected in how we view and express professionalism.

In very basic terms, the societal contract allows medical professionals the autonomy to act in the best interests of their patient, conferring benefits such as being a monopoly and remuneration, in return for self-regulation by the profession effectively guaranteeing to society professional competence as well as character traits such as integrity and the provision of altruistic services.1 Medical colleges need to ensure the implicit and explicit requirements of the societal contract, particularly self-regulation are achieved.

* Corresponding author. Royal Australasian College of Surgeons, 250 e 290 Spring St, East Melbourne, VIC 3002, Australia. E-mail addresses: [email protected] (D.J. Hillis), [email protected] (M.J. Grigg). http://dx.doi.org/10.1016/j.surge.2015.04.001 1479-666X/© 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

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In all countries, the explicit parts include legislation outlining the structure of the healthcare system and laws establishing the regulatory framework such as licencing and certification. The Hippocratic Oath and codes of ethics also constitute explicit parts of the contract. However, there are also the unwritten components including the moral commitments that are fundamental to the societal contract.2 These particularly come from within individual clinicians and collectively from their professional organisations.3

Definitions of professionalism Definitions of professionalism are abundant, contested, complex and reflect educational, socio-cultural and historical contexts.4 Analysis is now beyond ethics, values and beliefs and includes behaviours and attributes. Common elements include mastery of a complex body of knowledge and skills, service to others, commitment to competence, integrity, altruism and promotion of public good, autonomy, selfregulation and accountability to society.1,5 It is important to understand that many in the medical profession may still use the term ‘professionalism’ in a fairly narrow sense and some may use the term from habit without fully contemplating the inherent significance. Understanding professionalism requires analysis of its attributes. Writers such as Steinert et al. have provided a grouping of core attributes to the role of healer, to the role of professional and to attributes that are shared.6 Some medical practitioners perhaps see themselves as simply a ‘healer’ believing that fulfilling this role alone is sufficient. The complexity emerges in that society requires the healer, but there must be organisational and regulatory frameworks and a healthcare environment, within which the services of the healer are dispensed and requires the skills and commitment of a ‘professional’. Hippocrates (460e370 BC), and subsequently Aristotle (384e322 BC) clarified the differences between healer and professional, and this continues to be highly relevant today. The Hippocratic Oath still remains the seminal document on the ethics of medical practice. It has been confirmed and restated on numerous occasions by leaders of the profession including Guy de Chauliac (died 1368), often thought as the Father of Surgery, Thomas Percival (1740e1804) who wrote the first modern code of medical ethics,7 and William Osler (1849e1919), the ‘Father of Modern Medicine’. The work in professionalism has been even more intense as well as reflective over the past century following the Flexnerian educational reforms and the growing understanding of the role of socialisation. What is clear, is that there are both written and unwritten expectations entailing moral commitments, fundamental to both the societal contract and the details of professionalism. They are required for the intimate work of ‘healing’ done by a ‘professional’.8

Socialisation e the professional identity as a key formation It can be contended that the role of medical colleges is to maintain and enhance professionalism of medical practitioners for the benefit of society. Professional identity and professional behaviour were significant foci of Flexnerian9

reforms and they ushered in a significant wave of medical professionalism and a requirement to educate young medical practitioners in these norms. This now includes the socialisation of learning to function within a particular society or group by internalizing its values and norms. The socialisation process has also been described as legitimate participation in a community of practice by writers such as Lave and Wenger.10,11 They highlight how the community of practice learns from and contributes to the community with their variety of experiences. Indeed it is often stated that the common aim of professional education is to ensure specialised knowledge and a developed professional identity with its own values and behaviours.12 Identity formation occurs at both the individual and collective level of the profession.13 Professional socialisation is an adult or secondary socialisation or more correctly resocialisation. Becoming a surgeon is set within complex hierarchical institutions and is intensely demanding both cognitively and emotionally, with the formation of surgeons being a particularly potent socialisation.12 Surgical training is a process that for better or worse, does change hearts and minds. Along the path from trainee to experienced surgeon, the individual is impacted by positive and negative experiences with mentors and role models as well as the formal curriculum and expectations of society itself. Socialisation is a negotiation. With increasing competence and confidence the process becomes cyclical and self-reinforcing. The individual moves from ‘doing’ to ‘being’ and becomes part of a ‘community of practice’. Socialisation and professionalism are linked indelibly to forms of social control.12 This is again at two levels, the individual's willingness to regulate their own behaviour in the public interest and also at the collective level of the profession policing itself. No matter how the process of socialisation occurs, professionalism is an attributed status that requires considerable and ongoing legitimisation from society. How medicine and the medical colleges make the ‘professional’ case to the public, then, is as important as the steps it takes to convince itself of individuals' good motives and intentions.14 Within a complex and changing world, the challenges confronting professional organisations and the professional are particularly important.

Challenges to professionalism Scanlon15 has highlighted two concepts posing a challenge to professionalism. The first of these is from multiculturalism, where social norms are no longer as strongly embedded in society. There is less direct support for, or experience in professionalism. Secondly, there is ‘deprofessionalism’ which occurs when professional occupations lose their influence and control over traditional knowledge and authority. This has been amplified from a global perspective by the growth and progressive fragmentation of knowledge e a super-specialised task approach rather than a holistic approach. Commercial market forces and increased access to knowledge and technology are transforming healthcare systems as well as the patient-doctor relationship. This provides the ongoing temptation for physicians and surgeons to ignore

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their traditional commitment to the primacy of patients’ interests. The dynamics of the societal contract have changed. Commodification, commercialisation, cost constraints, and corporatisation are now constants. It is little wonder that there are concerns for a decrease in trust, accountability and the perceived authority of the professions. The need for medical colleges to maintain standards of professional behaviour and competence, irrespective of these challenges is greater than ever. More significantly, a perception of failure of self-regulation by the profession risks loss of trust by society.16 Unfortunately in the past, a misplaced sense of collegiality and professional autonomy has allowed poor practice to be tolerated.17 In today's society, if the profession is not strongly proactive in ensuring that the practice of all doctors licenced to practice can be regarded as ‘good’, then it will not enjoy full public trust and consequences will ensue, including the possibility of a significant change and rebalancing in the societal contract.18 As highlighted by Davies19 this is already happening with the control by the profession over the conduct and competence of its members being eroded by government action. Recognising and confronting unprofessional behaviour is challenging. Kanat and Epstein20 interestingly used the Nicomachean Ethics21 where Aristotle presented a catalogue of virtues, to then highlight a ‘catalogue of vices’. These speak to the everyday concerns of clinical practice and include abuse of power, arrogance, greed, misrepresentation, the impaired professional, lack of conscientiousness, conflicts of interest and acceptance of gifts. Unfortunately when confronted by unprofessional behaviour there is still a poor response by those in positions of authority (such as a supervisor), even when it involves issues like showing disrespect for patients, cutting corners and outright hostility or rudeness. If there is a response, passive nonverbal gestures are often favoured rather than explicitly discussing attitudes, referring to moral or professional norms, and giving behaviour-specific feedback. There is a tendency to avoid, rationalise or medicalise these behaviours and avoid moral language.22 For medical colleges the situation can also be difficult. If a medical college sanctions an individual member for reasons that benefit Society, it is predictable that the individual will turn to the legal system for protection e a legal system that is primarily interested in protecting the rights of the individual rather than protecting Society. The difficulties required to achieve the appropriate balance, can be a deterrent in addressing unprofessional behaviour and action. At an individual level positive role modelling is powerful but in these more complex situations of handling unprofessional behaviour, both theory23 and empirical evidence24 support role modelling being more effective when attention is also drawn to what should be modelled. Combined with directional documents like Codes of Conduct, it structures experiences, so that better professional formation can occur. However, it is also important to recognise the broader range of individual skills required in handling everyday challenges to professionalism. Professional action in these circumstances does not necessarily require rule-based action but, instead, thoughtful analysis and judgement.25 This supports Leach's construct26 that professional behaviour is a

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teachable skill set that follows a universal developmental curve.8 Addressing challenges to medical professionalism require an educational community, a structured curriculum, programs for role modelling and mentoring, and attention to the assessment of professional conduct.27 Writers such as Wynia further emphasise an ethical obligation towards engagement with professional associations.28 It is vital that medical colleges as professional organisations can support and nurture professionalism but also overtly correct unprofessional behaviour.

Development of professional organisations The primary relationship of the individual physician in both moral and fiduciary terms is with the individual patient. However, this relationship cannot be isolated from the system within which it operates, nor from the wishes of society as a whole. It is truly the balancing of the ‘healer’ and the ‘professional’. Tensions are unavoidable.28 In particular there is interaction with the government through the loosely coupled networks of health care. Professionalism needs to serve as the basis of these interactions, essentially establishing the rules of the game. It then impacts issues of funding and the structure of the health care system itself. It is stated that the core function of the professional medical organisation is writing the societal contract and ensuring that all medical practitioners are living up to it.28 However, the number and types of organisations involved in educating, licensing, regulating and representing medical practitioners vary significantly depending on the individual country or geographic region.29 The societal contract does vary in different countries because of differences in the regulatory framework. Indeed, the ongoing standard and the way in which it is enforced may also vary significantly. The AngloSaxon traditions place more emphasis on the autonomy and independence of the profession.30 Professional groups consequently differ in the way they are perceived from being the defender of professional standards to ‘unnecessary and unwarranted service monopolies’.31 Professional communities remain critical for reflective practice and improving standards but must continue to earn the privilege of selfregulation in an open and transparent manner. Collegiate organisations also have specific tensions. Professional leaders need to establish and maintain a shared and cohesive understanding of the societal contract as well as orientation to professional instruction and practice. This is not easy. Explaining the opportunities and challenges in the larger environment requires cognition of occupational, political, social and cultural concerns that will have multiple views. It is recognising these concerns that give the emphasis to nurturing and developing professionalism, as well as identifying and remediating individual lapses in a collegiate and open manner. When effective, collegial organisations can institutionalise professional behaviour and mediate professionally on multiple issues both within and across dispersed venues. Medical colleges need to deeply appreciate the trust within the societal contract. The trust that the public puts in doctors rests on the practical realisation of medical professionalism, being the doctor's duty to the patient comes before all other

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interests. Indeed, at its best, professionalism is deeply and constructively challenging to those who wield political power.

Educational requirements The challenge for professional education in general is how to teach the complex ensemble of analytic knowledge, skilful practice and wise judgement upon which each profession rests.32 This practical wisdom of the mature professional is ‘phronesis’ as proposed by Aristotle, clearly involving judgement and decision making. The progression from novice to expert requires the development of a sophisticated set of skills, developed through experiential learning, structured reflection and coaching across the breadth of the speciality. Importantly it includes strategies to help surgeons build a repertoire of responses to deal with the predictable challenges of professionalism.8 These need to be contextualised not only for training, but also ongoing professional development.33 In the past, almost the sole educational focus of professional organisations was on the pre-qualification trainee but of recent times the community of practising surgeons is increasingly recognising a responsibility for supporting, reinforcing, and guiding surgeons to remain professional throughout their careers. Throughout their careers, surgeons are expected to continue to learn, mature and gain experience. This further learning spans cognitive, affective, active and reflective dimensions.34 As highlighted by Gruen et al.,35 wisdom is not just the accretion of layers of experience upon a core of taught competencies. It is an emergent property of highly integrated brain functions, developed through upbringing and habit, and, as shown above, embedded within the sociality of practices. Educational strategies to enhance professionalism, start by defining professionalism, improving selection of students, improving instruction in professionalism, maintaining learning environments that promote and recognise professionalism, and assessing professionalism through a variety of tools.36,37 There are at least three interrelated spheres of influence in medicine's educational milieu and these are differentiated as the formal, informal and hidden curriculum.38 The formal curriculum speaks to the explicit curriculum found in courses and classrooms. The informal curriculum is the unscripted, reflective and highly interpersonal form of learning. This socialisation profoundly influences students' values and professional identities.39 The hidden curriculum is the set of influences that function at the level of organisational structure and peer-related culture. The hidden curriculum includes the rules and routines needed to survive through the educational and health organisations.40 Educating surgeons, like all teaching, is an intensely personal41,42 and complex craft, needing its own training and education to inform a broad range of skills and values.43 These skills need to be effective over the three domains of the formal, informal and hidden curricula. Professionalism is taught and learned from a wide range of sources, including didactic sessions offered from the formal curriculum, the reflection within the informal curriculum and from role models within the hidden curriculum. Fostering professionalism at all levels is essential. It is important that

the educational body create an empathic supervisory milieu, with supervisors able to assist with uncertainty and lack of knowledge. Prideaux44 confirms that the important thing for Trainees is that their clinical teachers act professionally, are seen to act professionally and ensure that their educational charges follow their good example. He states boldly that this ultimately is the single most important contribution that a clinical teacher can make as the healthcare environment around them changes and the nature of their work intensifies. At the same time, the personal commitment needs to be matched by strong institutional leadership to change the institutional culture for the better.45,46 Within institutions, educators of all types need to make behaviours more intentional and role modelled by demonstrating professional attitudes and skills during the course of day-to-day practice, and explicitly explain to students what is being done and why it is being done.22 Quality clinical standards are not aspirational but something that need to be actively pursued and audited across professional activities.16 There are many such opportunities that occur on ward rounds, in unit meetings or morbidity and mortality meetings. However, it is critical the educational and institutional approach supports and reaffirms professionalism as identify formation occurs.12

What should medical colleges do? It is not difficult to contend that the next phase of evolution of medical colleges is to increasingly focus on the promotion, teaching and defence of professionalism. The challenge is in the breadth of required activities. It is not only in defining and nurturing the individual aspects of professionalism, but the collective responsibilities as well as addressing pervasive issues in the health sector, of addressing uncivil behaviours, but also developing the qualities of leadership. Stern and Papadakis36 have divided the structured learning of professionalism into three key blocks: the setting of expectations, providing experiences and evaluating outcomes. The Royal Australasian College of Surgeons (RACS) has instituted a number of initiatives in setting expectations, including Codes of Conduct and the College pledge. Courses have also been developed as examples of the formal curriculum. The Training in Professional Skills (TIPS) course has particular emphasis on patient centred communication and situation awareness. The Non-Technical Skills for Surgeons course (NOTSS) provides ratings and feedback over the four domains of situation awareness, decision-making, communication and teamwork, and leadership.47 A national approach to audit of all surgical deaths is now well established.48 Assessment, using multiple tools needs to be more fully incorporated and undertaken within a supportive environment. This should be both within training and within ongoing practice.49 Lapses in professionalism need to be seen as opportunities for targeted coaching. Sanctions should be reserved for those who have failed to respond to the appropriate pedagogical approach. Sanctions, although required, are a manifestation of failure e the educational process has failed to produce and support a competent professional. Providing feedback and encouraging reflection are areas frequently highlighted as needing development.50,51 Feedback

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and reflection can occur together but as highlighted by Branch, reflection requires consideration of the larger context and integrates a concept or combination of skills, knowledge, values and attitudes.52 Medical practitioners undervalue the role of feedback as a fundamental clinical teaching tool, and do not recognise the many opportunities that exist.52 Reflection is probably employed even less commonly than feedback in clinical teaching. Understanding the motives and justification of behaviour is important. Reflection leads to more growth of the individualdmorally, personally, psychologically, and emotionally, as well as cognitivelydwhereas feedback tends to promote technical proficiency. Both feedback and reflection are essential to educating the surgeon.52,53 Enhancing the ability to provide effective feedback and encourage reflection is increasingly important for the development of our faculty and mentors. Any faculty development aimed at changing the current surgical culture of teaching and evaluating professionalism will need to promote greater identification, discussion, and remediation of surgeons, their colleagues' and trainees’ minor to moderate lapses in professionalism. Such interventions will require a collegial, supportive and open environment that promotes both self- and group-reflection on these complex and difficult matters. These interventions will require greater prominence at the surgical educator and institutional level.

Behaviours Uncivil behaviour is so present in society at large that it is not surprising it is found among healthcare workers and in hospitals54,55 This disrespect itself is also acknowledged as a threat to patient safety.56,57 When uncivil behaviour is reflected as a lack of teamwork it becomes a risk factor for complications, particularly in the complex workplace of the hospital. It is now well documented that medical errors are grounded in non-technical issues such as miscommunication.58 Most lapses represent deficiencies in judgement and skill, particularly in times of stress. They reflect a lack of resilience.8 When uncivil behaviour occurs within the educational environment, the impact educationally is significant and at times profoundly negative. Belittlement and harassment are unfortunately well-established in medical schools.59 This appears worse with Surgery where even higher levels of mistreatment and violence occur.60 Educational programs and faculty development needs to emphasise interactions with learners in an appropriately respectful manner and addresses how to provide feedback and evaluation constructively as well as additional training in stress management and communication skills. The environment of crisis control and unprofessional behaviour needs to change so educators can effectively role model.56,61 In dealing with unprofessional behaviour there is increasing evidence that an institution wide commitment to professionalism substantially enhances patient care.49 Importantly organisations are now starting to address individuals with unprofessional behaviour.51,62,63 It is important that medical practitioners are provided with the skills and training to influence organisations.

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Management leadership and advocacy skills Sir Donald Irvine64 has highlighted the importance of medical leadership from the power of role modelling to challenging the status quo to creating a more holistic culture of the profession. Doctors need to go further in engaging with health management to influence the health sector environment and deliver on the commitments that professionalism implies for patients, fellow professionals, the institutions and system. Beyond this, it is important that clinical leaders are identified and developed. This is a broad responsibility but medical colleges need to more fully grasp this role. Clearly, a purely individualistic approach to professionalism does not resonate with contemporary, team based healthcare. Work-based groups need to be supported and nurtured by senior clinicians and leaders.65 There is an increasing expectation that trained professionals demonstrate the ability to be proactive, to lead and facilitate the dynamics of a diverse team. At the same time, as one moves through the various levels of the health system, different skills are required. Core values such as compassion, integrity, accountability, excellence, stewardship and professionalism are expressed differently. This is a vital area for medical colleges to understand and provide development for their future leaders. Medical colleges confront the issue of broader advocacy and this reflects that the contemporary societal contract continues to change and evolve. A contemporary societal contract focuses far more attention on matters of sustainability of health care, excessive fees,66 quality measurement and the interactions of the various players in the health-care system.28 Gruen et al.67,68 have defined advocacy and public action roles into two categories, the first being domains of professional obligation including individual patient care, access to care, direct socioeconomic influences, and the second being domains of professional aspiration being broad socioeconomic influences and global health influences. They suggest that many physicians believe they have professional responsibilities to health-related issues outside their direct clinical practice. The professions need to engage more fully in advocacy, to reinvent their civic dimensions by identifying and promoting policies that clearly benefit the common welfare and properly align with the mission of the medical college.

Next steps for professionalism Despite the challenges the medical profession has not been idle. During a period of rapid social change and public reflection about the role of professions in society, medicine has invested considerable energy in looking at its own fundamental values. One example is the Medical Professionalism Project which resulted in a new charter on medical professionalism. This sets out three principles (on patient's welfare and autonomy, and on social justice), together with a set of professional responsibilities. These are expressed as ten commitments e to competence, honesty, confidentiality, maintaining appropriate relationships, improving quality of care, improving access to care, the just distribution of finite

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resources, scientific knowledge, maintaining trust and professional duties.69 Similar endeavours have seen many developments including the Physicians Charter,70 the Australian Medical Council Code of Conduct,71 and the Royal Australasian College of Surgeons Code of Conduct which details the code through an analysis of the Fellowship pledge.72 However as explained by Dahrendorf,73 professional rules of conduct are neither simple nor painless. It is nice, even easy, to spell out the rules by which people should ideally abide; it is difficult and painful for professional organisations to make sure that they do so. Rules are but empty ideals without sanctions. However, sanctions conflict with the natural solidarity of those who share a professional interest.73 Professional organisations need to guard the rules of conduct jealously, and be seen to do so. If the professions become slack in enforcing their code of conducts, they put the entire edifice of self-regulation and the trust of the societal contract in jeopardy. Doctors working together must take full responsibility for their clinical and professional standards, individually and collectively. They must show that they have the will and the means to discharge this responsibility and commitment consistently.74 The underperforming medical practitioner needs to be identified with remediation an essential step. Unfortunately at this point, Davies believes that colleges and speciality societies in Australia and New Zealand have failed miserably to date.19,74 His concern speaks to the perceived weakness in the structures of the profession and perhaps to the culture itself. This has enabled the current social and political tide to become more rule based and regulatory. Government is progressively imposing their standards by regulation. The future of professionalism in medicine then depends on creating an environment for professional values to flourish combined with the profession accepting the responsibility of enforcing its standards. At a minimum this needs to extend into areas of leadership, teams, education, appraisal, audit, careers and research. Professionalism is an important lever for improving the quality of services to patients. Significantly, the most important feature of the last twenty years’ discussion around professionalism is that the profession is now aware that it must lead this debate with policy makers, managers and regulators. The medical colleges have a vital role to play.

Conclusion Medical professionalism is not optional. It is vital. As stated by William Sullivan, a prominent medical sociologist: Neither economic incentives nor technology nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism.32 An important issue requiring recognition and action is that, although there are clearly core elements that are foundational and seem to be timeless, some aspects of the traditional professional identity must change. As medicine and

society evolve, the details of our societal contract have been rewritten and the nature of being a good physician or a good surgeon is continuously renegotiated. The nostalgic professionalism of the past that emphasized the role of the individual physician is no longer as valid. The future emphasises the team in health care, civility in behaviour, leadership and advocacy in our skills. The issue of professionalism has been reintroduced and highlighted over the past twenty years with urgency. It is critical for the medical colleges to engage meaningfully and comprehensively in the discussion. The colleges can bring all the pervasiveness of collegiality, culture and the hidden curriculum into the discussion and be demanding of the standards. The community now has clear expectations that professional accountabilities for practices, and malpractices, should be explicit. Many of these expectations are articulated through our societal contracts, covenants or competences. The best contribution that the medical colleges can make is to take direct responsibility for the goodness of the professionalism of their own members. Fine talk of professionalism and worthy codes of practice will all come to nothing unless the profession shows the will and determination and leadership needed to put principles into practice systematically, for the benefit of all patients.

references

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Please cite this article in press as: Hillis DJ, Grigg MJ, Professionalism and the role of medical colleges, The Surgeon (2015), http:// dx.doi.org/10.1016/j.surge.2015.04.001