The Association of Women Surgeon’s Code of Conduct

1. The Association of Women Surgeon’s Code of Conduct Conception, development, and theoretical due date Kim Ephgrave MD FACS, 2002

2. Genealogy • Leigh Neumayer, Monica Maillet, Peggy Kemeny, Beth Sutton, Yvette LaClaustra, Mary Rippon, Denise Johnson, Marilyn Borst, Myriam Curet, Susan Kaiser, ……. • So many AWS members (and staff) worked on the code for so long, it is impossible to list them all. It is a product of the Association of Women Surgeons.

3. Unexpected conception • AWS Council meeting, spring 2000. • Leigh Neumayer, MD, FACS shared a frustrating anecdote re unprofessional behavior in a faculty member. • Horror stories from the past popped up, along with stories of problematic surgeon behavior in recent months. • Eventually we planned to address surgical behavior formally at our next meeting.

4. “Surgical” Behavior topic took over the next meeting • Summer 2000: Beaver Creek, Colorado. • Leigh brought Monica Maillet, PhD., a biomedical ethicist who channeled our stories into several major themes. • High altitude and the input of members/meeting attendees as well as council members led to rapid progress.

5. Initial Impediments • Nobody wanted to sound whiny. • Nobody wanted to appear puritanical. • All of us had behaved at some point in at least some of the ways we decided should be avoided by Fellows of the American College of Surgeons.

6. Why should surgical ‘Conduct’-be addressed be AWS? • Precedents exist for predominantly female groups to positively impact society at large: Mothers Against Drunk Driving. League of Women Voters. • Women and minorities may be disproportionally affected by unprofessional behavior.

7. What had we heard from our male surgical colleagues? • “How come all of you haven’t fixed things by now? I was hoping the culture would improve after women had been in surgery for a while.” • “The female surgeons in our program have been trying to act more macho than the guys. It shouldn’t be necessary anymore.”

8. Early Development • Conception occurred at the AWS spring council meeting, development of specific principles was complete by summer. • We realized that all of us had acted unprofessionally at various times, but decided it was still desirable to set a high standard for Fellows of the ACS. • We deleted from early our versions any problematic behaviors already addressed by legal codes, or by the American College of Surgeons Statement of Principles.

9. The Current Form • Eventually, we decided to put forward all our points as a group. • From Utah, (Neumayer/Maillet), the nomenclature shifted from additional ‘principles of ethics’ to an AWS proposed “Code of Conduct”. • In the process, we familiarized ourselves with some of the admirable aspects of the existing ACS pledge and statements of principles.

10. American College of Surgeons Pledge: I I pledge myself to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else. I promise to deal with each patient as I would wish to be dealt with if I were in the patient's position.

11. Pledge: Part II • I will set my fees commensurate with the services rendered. I will take no part in any arrangement, such as fee splitting or itinerant surgery, which induces referral or treatment for reason other than the patient's best welfare.

12. Pledge: Part III Upon my honor, I declare that I will advance my knowledge and skills, will respect my colleagues, and will seek their counsel when in doubt about my own abilities. In turn, I will willingly help my colleagues when requested.

13. Pledge: Final Portion Finally, I solemnly pledge myself to cooperate in advancing and extending the art and science of surgery by my Fellowship in the American College of Surgeons.

14. What did we want to add to the ACS Pledge and Principles? Surgical conduct issues that perhaps seem self-evident, but where we could think of many current problematic examples.

15. Proposed Addition # One • Fellows of the American College of Surgeons who become temporarily impaired by illness, alcohol, fatigue, or other conditions that affect surgical judgment or performance will arrange for a qualified colleague to assume their clinical responsibilities until their condition is sufficiently improved.

16. This happens to all of us • Not the progressive impairment associated with Alzheimer’s. • Not the chronically relapsing ‘impaired surgeon’ with substance abuse. • Asking for help from peers or superiors runs counter to the surgical mystique-but we all get sick. • In the future, it will be helpful for resident compliance to have FACS level surgeons role-modeling helping each other routinely after 24 hours without sleep.

17. Proposed Addition # Two • Fellows of the American College of Surgeons will treat everyone in the health care setting with respect, avoiding displays of uncontrolled anger, abuse, intimidation, or ridicule.

18. This is the one that gives Surgery a bad reputation! • The profession can’t afford to tolerate abusive behavior or uncontrolled anger. • Top medical students currently favor dermatology over more demanding fields like surgery. • Our AWS mission is to enable female surgeons at all levels to reach their personal and professional goals. • Thus, intimidating behavior by surgeons of either gender directly interferes with the core mission of AWS.

19. Proposed Addition # Three Fellows of the American College of Surgeons should not have intimate personal relationships with individuals for whom they have supervisory responsibilities.

20. Difficult to discuss without squirming • University of Iowa (in response to problems) bans consensual relations between faculty and students or trainees. (Committees can make exceptions with ongoing monitoring.) • The Cinderella myth is a problem. • Deception of ‘significant others’ is a problem, partly because of role modeling unprofessional behavior. • Beware: philanderers tend to be repeat offenders.

21. Proposed Addition # Four Fellows of the American College of Surgeons will neither engage in nor condone any sexual harassment or other forms of harassment that contribute to an uncomfortable, ineffective, or hostile workplace.

22. Is Harassment part of Surgical Culture? • The Anita Hill case brought sexual harassment into our vocabulary. • Many > 40 y/o female surgeons recognized something they hadn’t been able to label. • ‘Quid pro quo’, as opposed to a hostile work environment, is vanishingly rare in 2002. • Unfortunately, more general harassment- ‘encouraging someone to move on’ -is not rare behavior, for surgeons of either gender.

23. Proposed Addition # Five • Fellows of the American College of Surgeons have an obligation to act if they notice ‘unethical conduct’ in another fellow. If directly approaching the fellow or following local institutional procedures is insufficient to resolve the problem, this obligation includes reporting to the college (see III:I in ACS principles).

24. The obligation to report may be the most difficult part of our current ACS principles • Nobody likes a squealer; “Goody-two shoes” is not a compliment. • AWS is proposing approaching the colleague and/or local procedures first (local alternatives to approaching a problematic supervisor usually exist), reporting to ACS only if necessary.

25. Why should we act when someone else is misbehaving? • Giving and receiving feedback is an essential professional skill. The public needs surgeons who help each other improve. • Noticing bad conduct and failing to act puts us at risk for legitimate guilt (and sometimes liability) if persistent bad behavior leads to bad outcomes.

26. Code of Conduct: Movement out from AWS • Lyn Hanlon, MD, FACS recommended forwarding the AWS Code to the ACS Ethics committee. • Ron Rosenthal, MD, FACS placed it on the Ethics Committee’s agenda. • Dissemination: AWS programming October 2002 at ACS meeting in San Francisco. • Upcoming Point/Counterpoint article(s) in American Journal of Surgery

27. Ideal Impact of Code of Conduct Dialogue on Surgical Culture: Fellows of the American College of Surgeons will be perceived as exemplars of professionalism in private and academic settings…and surgery will be flooded with talented applicants.