“What Not to Wear” and Other Aspects of Professionalism (2023)

In a recent editorial, I discussed medical professionalism in the context of patient-centered care, a well-recognized concept in today’s health care environment. But as I read the two excellent guest editorials on cosmetic surgery training in the United Kingdom and the United States appearing in this issue of Aesthetic Surgery Journal—authored, respectively, by medical students Mr. Joseph George¹ (with Dr. Beryl deSouza) and Mr. Kyle Edwards² (with Dr. Clyde Ishii)—I am reminded of the many facets of professionalism about which some trainees (not necessarily the above-mentioned authors) and young doctors remain as yet blissfully unaware.^1,2

Most medical students understandably are focused on the clinical aspects of their training. In fact, clinical knowledge and technical proficiency undoubtedly overshadow every other thought in a young doctor’s mind as he or she prepares to navigate the challenging terrain of medical/surgical practice. While a key issue such as patient-informed consent is presumably on the radar screen, issues such as professional courtesy, operating room (OR) behavior, and even “what not to wear” seldom make the top 10 list of “Things I Need to Remember When I Become a Doctor.” Yet these are in fact important aspects of professionalism that deserve more attention than they currently receive in the education of young surgeons.

Don’t Underestimate The Importance Of Professional Courtesy

As plastic surgeons, all of us have had the experience of working with a variety of medical colleagues in the course of providing patient care. Some of these experiences are highly positive, while others may fall short of expectations—either ours or theirs. There are countless examples of situations in which we have the opportunity to exhibit professionalism in our dealings with other medical personnel—whether doctors, nurses, technicians, or hospital administrators. How we handle these situations, both in and out of the OR, not only reflects our personal professionalism but also contributes to the general reputation of our specialty.

A published statement on interprofessional relations issued by the American College of Surgeons reminds us that “team medicine has become the norm.”³ In plastic surgery, nowhere is this more evident than in the burgeoning field of postbariatric body contouring. Plastic surgeons seeking to help patients complete their journey from obesity to normalcy often work with a team of professionals, including bariatric surgeons, internists, anesthesiologists, nutritionists, and even mental health professionals. To a great extent, the ultimate success of our surgical enterprise depends on the effective coordination of patient care among all these individuals.

Beyond basic cooperation, professionalism means being both respectful and responsive. I doubt that there is one among us who has not occasionally been frustrated by waiting for the electrocardiogram report that never arrives and having to deal with a personal physician who seems not in the least concerned that our mutual patient’s surgery is scheduled for tomorrow and medical clearance is still pending! Usually such unresponsiveness is due to office inefficiency of which the physician is not even aware, but repeated offenses can lead to a perception of unprofessionalism. Every physician and surgeon should instruct their office staff that communications between doctors have the highest priority—whether it’s the delivery of a requested report, a timely response to a personal phone call, or other matters involved in the delivery of quality patient care.

When a professional courtesy is extended, it should elicit a reciprocal response. In today’s Internet age, referrals from physicians may be a less important source of cosmetic surgery patients than in the past, but such referrals still require careful attention to professional etiquette. Whether it is by phone or a personal note, a physician deserves to know that his or her referral patient has been seen and evaluated. Yet it is surprising how often this simple act of professional courtesy is overlooked.

Sometimes a plastic surgeon’s patient may come to see me for an opinion on a problem perceived to be the result of an unsuccessful surgery. We have all been at both ends of this situation one time or another. In such cases, I always inform the original surgeon (unless the patient asks that I refrain from doing so). I consider this not only a matter of professional courtesy but also one of benefit to the patient, whose interests usually will be best served by returning to the operating surgeon for a resolution of the problem.

These are only a few examples of how professional courtesy plays an important role in our practices and in our relationships with colleagues, other specialists, and patients.

Tread Lightly in the OR

In the “old days,” despite the overriding atmosphere of seriousness in the OR, a relaxed moment might be an opportunity to try out your latest slightly-indelicate joke or at least kid around with the nurses and other attending staff in a casually familiar way. Today, while a sense of OR camaraderie still thrives, medical professionals have become increasingly sensitive to maintaining certain boundaries in their OR behavior.

The legal definition of harassment can conceivably include a range of behaviors that some might regard as innocuous but that nevertheless are inappropriate in a professional setting. Creating an uncomfortable working environment on the basis of personal attributes (sex, race, religion, etc) is obviously reprehensible, but one must be aware that the threshold for discomfort varies considerably among individuals. What seems like a harmless quip to one person may be deeply insulting to another. Needless to say, acts of aggression or intimidation, whether overt or subtle, have no place in the patient care environment. While sometimes it is necessary to be firm in commandeering the OR team, especially in response to a crisis situation or to the failure of a team member to fulfill his or her responsibilities, there is never an excuse for “losing it” (using abusive language, throwing instruments, etc) in the heat of the moment.

Perhaps the most important aspect of OR behavior is consideration for the patient. With a patient under anesthesia, medical professionals in the OR should never engage in conversation that could not take place if the patient were conscious. Comments concerning the patient’s body shape or weight, deformities or conditions, or personality or behaviors for the sake of banter or ridicule are offensive and unacceptable. Exposure of the patient’s body should be limited to the parts needed and to the required personnel only. In every way possible, the patient’s right to privacy should be respected.

Patients should be informed if the primary surgeon plans to allow another surgeon to perform a significant part of the operation. Patients also have the right to know if their operation will be observed by trainees or anyone other than the operating team; they should be given the opportunity to provide or withhold their consent. The merits of teaching do not lessen the surgeon’s responsibility to respect the privacy and rights of patients.⁴

Observe the Unspoken Rules of What Not to Wear

It may seem like a physician’s attire is among the least important aspects of professionalism. However, several studies have suggested that what a physician wears may affect patients’ perceptions of competence, even if patients are not consciously aware of their preferences. One study found that patients had a higher opinion of competence when residents wore a white coat compared to more casual dress.⁵ A similar study in Hawaii revealed that patients were more accepting of informal attire, but extremes such as shorts and flip-flops still were not approved by the majority of them.⁶

On a personal note, I recall a couple of incidents with medical students and residents who appeared for rounds dressed in a manner that I considered unprofessional. In one instance, the young man thought I was joking when I told him I would be unable to take him on rounds with me. In the other case, a medical student was actually offended and took the matter up with his surgical tutor! Though both these examples involved young men, inappropriate dress can be a problem for women professionals as well. An article appeared a few years ago in The New York Times entitled “When Young Doctors Strut Too Much of Their Stuff.”⁷ While it focused, perhaps unfairly, on female physicians who wear provocative clothing on the job, the point that patient confidence can be negatively affected by an unprofessional appearance is applicable across the board. I feel as strongly today as I did 20 years ago when I asked a resident wearing no tie and a dirty white coat and a medical student wearing sneakers to wait in the hallway during rounds—that neat, clean, and appropriate attire is essential for any medical professional.

There’s Always Something to Learn

While young doctors perhaps have the most to learn about professionalism, that doesn’t mean that older physicians (and I include myself in this category!) don’t need a refresher course. As many of us seek to fulfill Maintenance of Certification requirements, not only our continued competence but our professionalism will be under scrutiny. In fact, a letter attesting to our professionalism (or lack thereof) from our hospital chief of staff goes directly to the American Board of Plastic Surgery as part of the certification process.

Even more important, we have a responsibility to our patients and our colleagues to exemplify the highest standards of professionalism. I believe that the majority of plastic surgeons fulfill this lofty goal on a daily basis and in every aspect of their work, but it never hurts to reexamine old habits—just to make sure that we are taking every precaution against even the suggestion of unprofessional conduct.

It is my observation that, for the experienced surgeon, arrogance and impatience are perhaps the two most insidious enemies of professionalism. Arrogance is an affectation that can arise from a misplaced sense of confidence or, in some instances, from a lack of genuine confidence. Impatience is often habitual, and we may not even realize that we are exhibiting such behavior with staff and even with patients. There are, of course, situations in which our impatience is entirely justified. Nevertheless, cultivating an attitude of calm in dealing with the inevitable irritations, errors, and delays involved in our day-to-day dealings with colleagues and staff not only helps keep our blood pressure down but also creates a work environment based on mutual respect. By nurturing such an environment based first on our observance of professional behavior, we help to ensure the optimal environment for quality patient care. That, ultimately, is the overriding goal of medical professionalism—to serve the best interests of our patients.