MUCH is now made about appropriate behaviours and being professional.
The health industry has seen the development of many codes of conduct, standards and ethical briefs. The vast majority of the health, medical and surgical workforce adhere closely to these and recognise they have a responsibility not just to the individual patient, but also to serve the broader community as a whole.
Sociologists and experts in behaviour have described the development of the social contract that underpins the obligations that are placed by society on the professions in exchange for many privileges, but particularly for their ability to enjoy autonomy and self-regulate.
Rules or standards are but empty ideals without sanctions. It is easier to spell out the rules by which people should abide but far more difficult and painful for professional organisations to make sure that they are adhered to.
The Royal Australasian College of Surgeons (RACS) has a Code of Conduct that highlights the Pledge that all Fellows make on joining. RACS has done the “nice and easy” bit in writing this Code and updating it. We are now being confronted by the few who breach our code.
RACS has been particularly involved in two parts of our pledge over the past 5 years.
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The first relates to “I will be respectful of my colleagues”. During 2015 RACS has been very involved in a detailed assessment of discrimination, bullying and sexual harassment. An Expert Advisory Group found the problems are substantial and serious. We accepted their recommendations and published an action plan: Building Respect, Improving Patient Safety.
This multi-year initiative will require leadership and cultural change, comprehensive education around discrimination, bullying and sexual harassment, and an approach to complaints management that is transparent and trustworthy. The medical workplace must become a safe workplace for all health workers.
The RACS Council is committed to change and the way forward involves the participation of all Fellows of the College, but also implies that future breaches of the Code of Conduct will be dealt with seriously, in a graded manner to the point of losing the Fellowship.
The other part of the pledge is “I will never allow considerations of financial reward, career advancement or reputation to compromise my judgement or the care I provide”.
Traditionally, RACS has found discussion of fees “too hard” and outside our remit. However, inevitably the charging of inappropriate fees – which has variably been called extortionate, excessive, gouging or rorting the system – is clearly a professional issue. A body such as RACS that aspires to champion standards cannot ignore it, for no doctor should take advantage of the vulnerability of their patients, be they rich or poor.
RACS cannot stand by if members are charging fees that cannot be justified as reasonable, when considered in terms of expertise, resources or time. In a market that is clearly not properly informed or transparent, despite informed financial consent, there is a moral dimension. Professional reputation and surgical standards are at stake. No one should have to seek financial advice, access their superannuation, remortgage their home or resort to crowd funding for a clinically indicated procedure. There is no correlation between the size of fee charged and the quality of the surgery. Most excellent and busy surgeons charge reasonably.
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RACS is also working with a number of insurers and funding bodies to better understand their administrative data sets to enable the provision of clinically relevant feedback to all surgeons.
Reports of high-volume procedures will provide a global view of outcomes such as length of stay, complications and use of intensive care units, but will also show variations in total fees charged or out-of-pocket costs. This will enable individual surgeons to understand their outcomes and fees and to reflect on their own practice.
The greatest change in building respect and being reasonable may be accepting responsibility. Professional bodies need to take the collective responsibility for the behaviour of their members and do this for the benefit of patients and the community.
Professor David Watters, OBE, is President of the RACS. Associate Professor David Hillis is Chief Executive Officer of the RACS.