Surgical professionalism in the 21st century.

During the past 50 years, techniques and results in surgery have advanced enormously. Heart and lung surgery is now routine and is becoming steadily less invasive. Stapling devices have improved the speed and reliability of gastrointestinal surgery, and minimally invasive techniques are routinely used in procedures ranging from adrenalectomy, through gastric bypass for obesity, to difficult hernia repairs. Glimpses of the future have included demonstrations of robotic surgery, 1 telesurgery, 2 and surgery augmented by simultaneous optical and MRI examination of the tissues. 3 Parallel advances in supportive and anaesthetic care are allowing more ambitious procedures to be done in high-risk patients. Despite these advances, concern and pessimism are prevalent in the surgical community. Many senior surgeons are preoccupied with future threats to the role and professional ethos of the surgeon. Increasingly complex medicine has driven rises in both technical specialisation and the costs of health care, while changes in social and political attitudes have heightened expectations of success among the recipients of surgery and have forced reductions in working hours and training years for surgical trainees. The old system, under which the consultant and his team took on total responsibility for all aspects of management, is clearly incompatible with the changes of recent years. Many surgeons now look at the proposed huge reduction in overall training time and wonder how current levels of surgical expertise can be maintained, let alone increased. They worry that diffusion of responsibility for the overall care of the surgical patient through shift systems will increase the risks of harm inherent in high-intensity, high-tech hospital care. Consultants trained in the old system foresee a loss of professional values leading to a diminished role for the surgeon as a kind of clinical lathe operator, without any continuing responsibility for his patient—deskilled, disempowered, and easily manipulated by financial decision makers in charge of hospitals. This gloomy vision of the future is understandable, but it is not inevitable. Surgeons are pragmatists, well used to making the best of difficult situations. We can and should use the opportunities afforded by new technology and organisational changes to develop a new set of professional values appropriate for the challenges of the modern clinical environment. Surgery will need to adapt to strengthen the defining features of its professionalism—control over setting standards and responsibility for organising, appraising, and maintaining the quality of work. In at least five areas (training, specialisation, knowledge management, theatre …