The changing face of professionalism

Professionalism is a core facet of being a doctor but it remains enigmatic to define.¹ It is often easier to identify poor behaviours rather than acceptable behaviours expected of the medical profession.^2–4

However, authors agree that professionalism is a set of positive attitudes, values and behaviours,^5,6 with recurring themes being altruism and accountability.^7–11 Altruism is defined as a ‘willingness to do things that bring advantages to others, even if it results in disadvantage for yourself’.¹² Accountability in reference to an obligation to the general public is defined as ‘liability to account for and answer for one’s conduct, performance of duties’.¹³

The complexity in defining professionalism is compounded by its fluid nature changing with time, among nations and even within and between professions.^14,15 Furthermore, the doctor–patient relationship has dramatically altered in recent decades shifting from one of medical paternalism to patient autonomy.^16,17

It is understandable why doctors functioning in such an evolving working environment may have altered their understanding of professionalism and what it means to be a member of a profession. Indeed, there is increasing recognition of a generational shift from a sense of vocation, where an individual places the needs of those they serve above their own, to calls for a better work–life balance, where individuals consider their own needs equal to those they serve.^18,19

The literature concentrates on intergenerational differences in medical professionalism from an American perspective focusing on general surgery and orthopaedics with only one paper relating to plastic surgery.^20–22

More recently, one study looked at professionalism across three generations within plastic surgery: baby boomers, generation X and generation Y.¹⁷ Generations are groups of individuals tied together by year of birth who have been exposed to similar sociocultural and political events throughout their formative years. Such blocks of individuals are certainly not uniform in nature but share certain generalised behaviours that can help to explain current issues and predict the future.²³

Baby boomers (1946–1964) were raised in a period of increasing prosperity and cultural awakening seen as the increased request for civil and women’s rights. They were less encouraged by parents and grew up to become self-driven, possessing a sense of duty to country and employer, respecting hierarchies at a cost to themselves and judgemental of differing views. They were brought up before the age of computers resulting in struggles with the pace of technological development.^23,24

Generation X (1965–1980) faced increased parental divorce rates, single-parent families and/or both parents working, resulting in less parental instruction. They grew more independent and self-directed, being wary of authority with an increasing sense of work–life balance. Importantly, computers and the internet became readily available as they matured resulting in them being more technologically adept.^23,24

Generation Y (1981–1996) grew up in a world of increasing societal uncertainty following the events of 9/11, increasing societal violence, financial crises and globalisation. Their parents are said to be highly protective resulting in a generation with a greater sense of entitlement for whom self-esteem is key. This generation has grown up savvy in the use of computers, the internet and social media, leading to social connectedness and the wish to work in teams that exhibit meritocracy and free expression. This generation seeks equal fulfilment in both work and life.^23,24

Looking within plastic surgery, baby boomers and generation X were found to hold a nostalgic sense of professionalism where their work was regarded as a vocation that came at a personal cost, with the needs and expectations of patients taking priority over their own. Conversely, generation Y perceived themselves as employees, rather than professionals, expecting a better work–life balance than their predecessors. When considering altruism and accountability, generation Y were reluctant to allow careers to come at significant personal cost to them or their families, with flexible and part-time work being increasingly requested. In addition, accountability was of lower priority compared with doctors from the preceding generations.¹⁷

This emerging interpretation of professionalism has resulted in conflict between generations as previously noted.^17,24 Increasingly baby boomers and generation X are frustrated with their younger colleagues who they see as lacking commitment and having an employee-like attitude, whereas generation Y are simply not prepared to accept the sacrifices made by older colleagues for the sake of their careers.

This change in generation Y’s interpretation of professionalism reflects the society from which they come, but also changes within the structure of the United Kingdom’s National Health Service. Between 2003 and 2011 a compulsory reduction in junior doctors’ hours as a consequence of the European Working Time Directive resulted in a move away from an apprenticeship-style of training in teams towards a shift system.²⁵ Reducing contact hours between trainees and trainers has had unforeseen consequences. First, a reduced ability for the generations to experience and nurture shared learning and working environments. Second, it has significantly reduced the transference of professionalism through the hidden curriculum (the informal means by which professional behaviours are passed on to the next generation subliminally by the interaction of trainees with trainers).^26–28 This has left plastic surgery trainees feeling unsupported, isolated, demoralised and leaderless, and produced doctors who identify as employees rather than professionals.^17,24 Consequently, the generations blame each other when it is in fact the working environment that is the source of discord.

Many authors point out the advantage for all individuals within a team to work together to ensure goals are maximised in the most efficient manner.^29–32 Teamwork is vitally important within medicine as it is recognised that poorly performing teams can impact upon patient outcomes and safety.³³

The importance of teams was recognised by the Royal College of Surgeons of England, which has recommended not only a return to better-functioning teams but also a wish to improve relations between generations by the introduction of mentoring schemes.^34,35

Generation Y’s call for a better work–life balance, will likely put them into conflict with both government and the general public as predicted by social contract theory (SCT). This theory considers the tripartite relationship between government, society and medicine. When one group in the social contract senses a negative shift in their position within the tripartite relationship, that group will react to re-establish the equilibrium within the contract.^15,36,37

To accommodate flexible and/or part-time work requires increasing the number of undergraduate and postgraduate training places in order to maintain whole time workforce equivalence to provide the same level of service. This will come at a cost to the public purse and require cuts elsewhere in public services or increased taxation. Neither option would seem palatable in the United Kingdom, given the recent years of austerity and with taxation currently at its highest level since World War II.³⁸

Perhaps more worrying for society is the apparent reduction in altruism and accountability in generation Y trainees when patients continue to expect doctors to put the needs, wishes and expectations of those they serve above their own.^39–44 Patients will find it difficult to accept a lowering of their expectations of the medical profession; government will baulk at increasing taxes to pay for doctors to have a better work–life balance; and generation Y doctors will remain frustrated with their working environment as reflected by the current junior doctor strikes in the United Kingdom.

Generation Y’s new sense of professionalism has produced conflict between the generations in plastic surgery. One response is for all generations to step back and appreciate the views of other generations. The generations should work together to overcome these difficulties through enhanced teamwork, mentoring and flexible working.

Without compromise on all sides, this generational change in professionalism will continue to impact the provision of health services in the United Kingdom, which will remain in a precarious state for the foreseeable future.

Conflict of interest

The author has no conflicts of interest to disclose.

Funding declaration

The author received no financial support for the research, authorship, and/or publication of this article.