Andrea Herzka, MD, Discusses Importance of Demonstrating Professionalism in Orthopaedic Training

AAOS Now Editor-in-Chief Robert M. Orfaly, MD, MBA, FAAOS, sat down with Andrea Herzka, MD, FAAOS, professor of orthopaedic surgery at Oregon Health and Science University and chair of the AAOS Board of Councilors/Board of Specialty Societies Professionalism Committee, to discuss professionalism as both an area of work within AAOS governance and an important pillar of clinical practice.

Dr. Orfaly: What work has the Professionalism Committee done recently, and what are the priorities for the next year or two?
Dr. Herzka: Current things underway [from the committee] are the Standards of Professionalism (SOPs). The committee is charged to review the SOPs annually and [regularly reflect] on whether our standards are up to date, whether we are evolving with societal norms, and how we can improve or optimize those standards to reflect putting our best level of professionalism as an expectation for all of our AAOS members.

How do you see things evolving or maturing, if you will, in terms of how we think about professionalism in everyday practice?
There has been a tremendous evolution within the field of orthopaedics, when we look back to things that were maybe not completely acceptable but very much tolerated … [behaviors such as] screaming in the operating room, throwing things, … arguments in the hallways where patients could overhear, things like that, where maybe people would look the other way, historically. There is now much more awareness about professionalism.

Members of AAOS want to have the best level of professionalism. There is an emerging willingness and motivation to understand how we can improve our performance, [and] professionalism is part of that process. … Part of [improving professionalism] is being honest, not being fraudulent, respecting boundaries, and [clarifying] relationships with industry. All those things are just ethical, honest behavior. Beyond that, on an interpersonal communication level, showing respect at all times and promoting an inclusive environment are really important traits. We want to be able to model those characteristics for our residents.

Conflict resolution and being able to deescalate situations are also important. As part of our professionalism, we need to train ourselves in how to stay calm in the face of conflict and how to best manage it.

In the operating room, when things are really suboptimal, how do we demonstrate to our residents how to perform in that [high-pressure] environment, to our best abilities, to maintain an environment that allows the procedure to move forward in the way that is in the patient’s best interest? When do we point out somebody else’s unprofessional behavior? As a bystander, how can we participate or intervene in a situation? … How can we subtly educate somebody about a comment that was inappropriate? Is that done later in private, or is it done in the [moment] because somebody else is immediately affected?

At our university, we did bystander intervention, and I trained to be an instructor for our department and for internal medicine as well. A lot of these training modules, like unconscious bias and bystander intervention, … are values that are very important to AAOS and show our residents that these are standards that needs to be maintained.

Tell me more about your journey as an educator for medical students and residents. You obviously teach them the technical aspects of orthopaedic surgery, but how has it been received when you try to either mentor them or lecture to them about professionalism?
I think the way that we [teach professionalism to residents] is by behavioral modeling. … Professionalism is a nuanced skill that the residents are learning by observing in clinic. It is how we communicate and interact with our patients and … our staff, especially in a stressful environment. Residents can learn a lot of the tools and language we use and pick up on those nuances.

I think back many years ago to when we really started to focus on communication skills and had classes and workshops on doctor-patient communication. In many senses, I perceive that AAOS’ work on professionalism is an extension of that, where if we make the patient the center, this is not something different. Part of improving professionalism is effectively communicating with our patients.
Absolutely. When an interaction with a patient wasn’t optimal, I’ll come out of the room with a resident and ask, “What did you think?” You get their perception of what happened. I may also ask them, “Do you think that could have gone better? What do you think could have been done differently?”

Have them reflect and think about if there was something that could have been said earlier. Could we have made this situation better? Were we inadequately validating [the patient’s] beliefs? … Everyone does their best, but, of course, not every single interaction can be perfect.

It is an imperfect art to pursue. Ultimately, would you agree that everyday practice is really central to maintaining professionalism, more so than any regulatory issues or having your institution monitor interactions? It is, again, about that physician and patient interaction that you are always trying to self-critique and improve.
Conflict management is also a huge part of it as well. Of course, there will always be conflicts in a group of surgeons, whether it is administrative or about resource allocation. … But finding ways to communicate effectively in the face of conflict is a really important skill.

An important part of professionalism in how we can work more effectively together, collaborate, work out differences of opinion, work better with our patients, provide better care, become better educators, [and] make a better environment in the operating room where everyone is happy and having fun. When you are respectful of your staff, [as well as] the patient in the room, everybody is going to be much more at ease and your team is going to perform at its best. It is really important to create that environment where everyone can do their best for the patient.

Ultimately, what you are describing gets down to culture, which I think we recognize even from the business world. Culture is so critically important to creating a safe environment for the team, which actually is the only way to get effective treatment done.
We want the culture to be a safe and inviting place, where residents and students feel like they can ask questions and learn. And we can be better educators and provide more opportunities for learning as well.

Robert M. Orfaly, MD, MBA, FAAOS, is a professor in the Department of Orthopaedics and Rehabilitation at Oregon Health and Science University. He is also the editor-in-chief of AAOS Now and chair of the AAOS Now Editorial Board.