Study approach and typology

This is an exploratory study with a qualitative approach. The qualitative approach is justified because it is the most adequate for describing, categorizing, interpreting, and understanding the facts that deal with meanings, purposes, aspirations, beliefs, values, perceptions and attitudes, determinants of social relationships, processes, and phenomena⁶.

Research setting and sample

The sample was obtained by convenience, by inviting all 95 residents who participated in the MR programs in GO in the city of Fortaleza in 2019. The researcher made the invitations through electronic communications (WhatsApp and e-mail) and telephone calls. Of these, 21 agreed to participate in the study and signed the Free and Informed Consent Form (FICF) when attending the Focal Group.

There are four MR programs in GO in the city of Fortaleza, comprising a total of 95 residents, the target audience of this study. Inclusion criteria: all residents from the first to the fourth year of MR. Residents who were on sick leave were excluded.

Data collection instruments and techniques

Data collection took place through focal groups (FG), which allowed apprehending the reality from the group interaction and a broad problematization of the phenomenon under study^7),(8. This technique is based on the human tendency to form opinions and act in society, exploring the participants’ conceptions and experiences.

Two FG were held in September 2019, with an average duration of one hour, conducted by two researchers, the authors of the study and preceptors of one of the MR programs, two speakers and two observers, divided into two rooms of the Ceará Society of Gynecology and Obstetrics (SOCEGO), in Fortaleza, Ceará, Brazil. To reduce the response bias, one of the preceptors led the group with the largest number of residents from other programs and the other facilitated the organization of the group of residents from the same program who had still had little contact. The focal groups included 21 residents from the four GO MR programs in that municipality, with ten participants in FG1 and eleven in FG2.

Initially, the researchers gave the participants the FICF and a form to fill in the sociodemographic data (gender, age, origin and time in the MR Program). Then, the debate was guided by the following guiding questions:

In this article we will address the meanings of professionalism.

The participants’ speeches were recorded and additional details were registered in writing by the speakers and observers. The criterion of saturation of responses was adopted throughout the interview.

Data analysis method

After the collection, the data were transcribed in full and the analysis was carried out based on the content analysis in the thematic modality⁹, for the identification of the topics and the understanding of the study object¹⁰. For this purpose, the following steps were taken: pre-analysis, exploration of the material and treatment of the results. After the speech transcriptions, the pre-analysis was carried out, when the collected material was read in depth, seeking a greater familiarization of the researchers with the participants’ ideas and perceptions. The exploration of the material was the next step, leading to the identification of the sense nuclei (SN), which occurred from the association of ideas that emerged from the participants’ oral reports and body expressions. Finally, the treatment of the results and the interpretation, using symbolic interactionism¹¹, led to the synthesis of these findings, maintaining a dialogue between the four identified topics, the objective, the study assumptions and the alignment with the literature.

The interpretation of the findings that address the meanings and senses attributed to medical professionalism by GO residents is based on symbolic interactionism¹¹, a sociological theory that deals with human relationships and considers the influence of meanings and senses constructed by individuals in social interaction to be fundamental. For Blumer^11),(12, the meanings attributed by individuals to social phenomena derive great relevance from this interaction.

To facilitate the understanding of the interpretative magnifying glass used in this study, it is important to mention the considerations involving the words “sense” and “meaning”, from the perspective of Symbolic Interactionism¹.

According to George Mead, one of the precursors of symbolic interactionism¹¹, a person’s relationship with a given situation occurs through a diversity of symbols. Thus, an individual’s gestures are imbued with ideas that lead others to react. This consists in a significant symbol. When this gesture causes a reaction in the other, corresponding to the intention of the first one, this symbol incorporates a meaning, showing that it has been understood. Therefore, the meaning is based on social interaction and its articulations, giving rise to significant symbols. Meanings are only made aware of from the moment the person is able to identify such symbols^13),(14.

The “sense” of things is verified from the perspective of the “value” that people attribute to a certain fact or situation. In turn, the “meaning” is related to the representations attributed by the subject to their reality and also to the corresponding value¹⁵.

According to Blumer¹¹, social relations play a leading role in the creation of concepts and in the modeling of attitudes, based on the senses and meanings deriving from these connections, which can be verified in the premises of symbolic interactionism.

The human being acts in relation to things, based on the senses they have for them. The meaning of these things is derived, or arises, from social interaction. These meanings are manipulated and modified through an interpretative process used by the person when dealing with the things they encounter in social interrelationships. (p.2)¹².

Therefore, it is observed that life in society, groups and organizations presuppose continuous social interactions and whose actions result from responses of one in relation to the other. The attributed senses, the definitions and interpretations of objects and facts are products of social relations. This interpretative perspective supported, in this study, the understanding of the senses and meanings attributed by GO residents to medical professionalism, also taking into account that the learning environment influences how people think and act.

To preserve the anonymity of the participants, the letter “R” was used, which means “resident”, followed by cardinal numbers. Thus, R1 means “resident 1” and so forth.

Ethical principles

The study was submitted to the Ethics Committee for Research with Human Beings (COÉTICA) of Universidade de Fortaleza (UNIFOR) and was approved under number 2,038,755, in compliance with ethical principles, in accordance with the determinations of 510/16, of the National Health Council, which regulates the evaluation of ethics in research in human and social sciences.

Set of conducts for the benefit of the patient

When considering professionalism as a set of conducts that help to treat the patient, the senses attributed by the residents refer to “standardization of conducts”. It seems that the participants attribute to professionalism a meaning of its own and a sense based on what they think, based on their beliefs, values, perceptions, worldviews and theoretical knowledge. All of these are mediated by social interactions^11),(16.

Therefore, professionalism is described as follows:

[...] having a set of standardized conducts that help collaborate to treat the patient in the best and most professional way possible. (R1)

[...] attitudes that must be considered correct, both on the part of the relationship and on the part of the conduct you will take. (R14)

Based on the testimonies, the need for a more comprehensive, conscious and explicit understanding of medical professionalism is observed. From this perspective, the concept of evidence-based medicine (EBM) expands this view and offers subsidies for the understanding of medical professionalism in its entirety.

According to Lopes¹⁷, EBM consists of implementing the best scientific evidence, considering the clinical experience and the patient’s individual desires, based on three premises: “evidence”, “clinical experience”, and “patient desires”, including the understanding and recognition of the individuality of the human being, understanding the unique preferences and expectations that the individual brings to the medical consultation and that must be integrated to and respected in the clinical decision¹⁷.

From this perspective, the gynecologist acts at the gateway to women’s health care. To be a good professional, it is necessary to have the vision of the whole, in an integrated and conscious way, using personal experience and the best scientific, theoretical and methodological evidence available, without losing humanization and common sense¹⁸.

In other words, none of these premises work alone or are sufficient; they have to work as a system, in an articulated way, considering that the patients bring their biopsychic and social demands with them.

According to this assertion, the meanings of professionalism for residents are supported by a standardized set of conducts that favor better patient care.

Doctor-patient relationship and relationship with the work team

When translating professionalism as an element of the doctor-patient relationship and relationship with the work team, the participants point out the senses and meanings of this concept, based on their daily experiences. For the participants, these elements reflect on the social interactions, on the thoughts and actions of the residents, interns, preceptors and other members of the health team. From this perspective, the importance of establishing an “interpersonal relationship supported by professional knowledge” emerges, as the following speeches show:

[...] no one works alone, one depends on the other. (R2)

[...] I think professionalism depends on the relationship between the doctors and also between the team in general. (R3)

[...] you are a professional and you have to have a good relationship with everyone in the team, everyone you have contact with, with the patient and with the entire team. (R14)

[...] A good professional is one who aligns technical knowledge with a good relationship with the patient. (R17)

[...] Professionalism is also related to our relationship not only with the patient, but also with the team. (R18)

The residents disclose their understanding of the importance of cultivating a good doctor-patient relationship, being notorious the support given to the importance of the relationship established by the work team.

The American Board of Internal Medicine (ABIM), in the definition of medical professionalism, considers a good relationship with the patient, family and professional team as elements of the construct¹⁹. Similarly, Bandini et al.²⁰ emphasize the importance of interpersonal relationships in student learning. The daily observation of behaviors, known as hidden curriculum, has great relevance in medical education, contributing to professional performance. Moreover, it is worth noting that teamwork between the involved professionals contributes to the quality of health care for users and the population and promotes greater satisfaction at work²¹.

What is preponderant in the essence of meanings for residents is teamwork and interpersonal relationships, considered essential in daily work. The participants in this study perceive the importance of maintaining a good relationship with the multidisciplinary team and recognize this condition as basic and challenging in medical practice, as shown:

[...] what I find the most difficult, especially in my service, is the difficulty with relationships. Very often, because, as everyone here said, professionalism is also linked to our relationship not only with the patient, but also with the team... [...] Very often, what we see is that there is a certain dispute over who is in charge, who is in control. So, I think this is an important part that we have to try to change, that needs to be improved. (R18)

[...] in theory, multidisciplinarity is very beautiful; but, in practice, it is difficult to happen. (R16)

The testimonies of R18 and R16 bring an important discussion for a broader understanding of medical professionalism, which refers to the interaction with other residents, health professionals, interns and preceptors. While Functionalist theories conceive social relationships and actions as derived from social rules and norms pre-established by others; in contrast, symbolic interactionism defends social relationships and actions as derived from socially established norms²².

Confirming the emphasis given by residents, it is understood that social interactions in the work environment, with different actors, constitute processes that demand a discussion and critical reflection about their meaning. The perspective is to understand that interpersonal interactions are processes that are socially constructed from the relationships established with other people, combining visions, values, interests, cultures, practices, feelings, experiences and points of view¹³.

Based on theoretical-methodological assumptions, MR is a qualification course whose teaching-learning process aims to provide medical residents with the opportunity to deepen their theoretical-methodological knowledge and experiences in specific specialties, aiming to provide training with excellence according to the demands of the world of work in the health area. For Velho et al.²³, MR is qualified as a process of learning and training based on theories and practical skills in health, fundamental for medical education.

Based on these considerations, it is verified, from the premises of symbolic interactionism, that the actions of subjects are derived from meanings, which originate from social interactions and, finally, meanings are employed by social actors in group interactions, which, in turn, modify their own meanings¹¹. Based on this context and the analysis performed, medical professionalism is described as a complex, dynamic and multidimensional construct, comprising individual factors, learning behaviors and sociocultural norms, showing interpersonal and contextual dimensions, which manifest through behaviors within the scope of interpersonal relationships²⁴.

Set of professional attributes

The sense of professionalism as a physician’s expanded training is associated with “know to do it”, which refers to skills, competencies and commitment, as expressed by R4 “[...] I think professionalism ranges from the doctor’s skills, goes through the competencies and comes to the commitment to what they do.”

The testimony shows that professionalism is a set of characteristics that involves skills and commitment to what one does. This means that it is not enough to be a physician, one expects them to be competent. From this perspective, although the subjects get close to apprehending the concept, the construct includes other aspects that give it greater significance.

Professionalism is, therefore, understood in this study as a set of characteristics that constitute a professional, comprising their skills, responsibilities, ethics, knowledge, values, technical skills, clinical reasoning, which govern their field of work, converging with the concept of Zink et al.²⁵ who make professionalism the basis of the physician’s contract with society²⁶. Moreover, the Accreditation Council on Graduate Medical Education (ACGME)²⁷ emphasizes the attributes of compassion, sensibility, honesty and commitment to the patient for the good performance of the resident physician.“I think professionalism ranges from the doctor’s skills, from competencies to commitment to what they do.” (R4).

Thus, the concept of competency and its evolution throughout the history of the practice of Medicine encompasses the need for “clinical updating” and the construction of knowledge based on good “scientific bases”, as the testimonies illustrate:

[...] I believe that the search for learning, for knowledge, for novelties is also part of the professionalism to update oneself. (R4).

[...] professionalism lies mainly in following the scientific bases (R16).

The residents considered the search for learning, for knowledge and reasoning, based on accredited scientific bases, as fundamental components of professionalism. These elements are so relevant to the physician’s clinical update that they even get mistaken by the very concept of professionalism. For Silva²⁸, professionalism and professional competence demand the acquisition of scientific knowledge and its correct application in medical practice, based on scientific foundations. This definition is supported by Resolution CNE/CP N. 3, of December 18, 2002, which defines professional competency as the “capacity to mobilize, articulate and put into action the knowledge, skills, attitudes and values necessary for the efficient and effective performance of activities required by the nature of the work and by the technological development”²⁹.

The importance of scientific knowledge for professional updating is one of the ten commitments of the “Charter of Medical Professionalism” published in 2002, having been written under the aegis of the following institutions: American Board of Internal Medicine Foundation, American College of Doctors Foundation and European Federation of Internal Medicine³⁰.

Corroborating this perspective, a study carried out by Jauregui et al.³¹ with Emergency Medicine residents showed that they considered professionalism as a dynamic, cultural and specific construct, whose conception occurs in the teaching-learning process, as well as other attributes, valuing scientific knowledge as a key element for the competent exercise of the profession.

In the context of professionalism, understanding the concept of professional competency deals with the criteria expected from health professionals to meet the requirements for the exercise of the function. From this perspective, it is a widely discussed concept and applied to a huge variety of scientific disciplines as a new perspective for the training of professionals in different areas, including health, aiming to encourage critical reflection and meet the demands imposed by the current social, political and citizenship development scenario, considering health as a right for all.

Moral and ethical exercise of the profession

Submission to the professional code of ethics, obeying the rules of the service and respecting the moral and ethical principles also emerged as meanings attributed by residents to medical professionalism.

From the perspective of medical professionalism, respect for the laws and norms that govern professional practice provided subsidies for the reflections of this study. It is worth noting that in addition to values, the rules of the profession and submission to the code of professional ethics are meanings that are interconnected and articulated, coexisting in symbiosis in the residents’ perceptions.

It is important to treat the professional practice of physicians and their self-regulation in accordance with the Constitution and the laws that govern their performance in a hierarchical manner. Initially, it is important to mention the law that validates the professional practice according to the dictates of the Federal Constitution, which establishes in its article 5, item XIII, that the exercise of any work, trade or profession is free, provided that the professional qualifications established by law are met³². In this conception, the guarantee of professional practice can be understood through the prerogative of professional qualification. In the training of the specialist, however, there is a gap in the clarifications regarding the legal support for the exercise of the profession, which results in the lack of knowledge about this issue.

As for the exercise of medical practice, Law N. 12,842, of July 10, 2013, deals with professionalism³³, in its 2^nd article, according to the following terms: “The object of the physician’s work is the health of the human being and of human collectivities, for the benefit of which they must act with the utmost zeal, to the best of their professional capacity and without discrimination of any kind”.

The Medical Ethics Code approved through Federal Council of Medicine (CFM) Resolution n. 2,217, of November 1^st, 2018, contemplates a set of principles and norms aligned with the Federal Constitution, which must be followed by physicians in their professional practice³⁴.

This Code of Ethics reiterates medical professionalism as a fundamental principle, in Chapter I, item II, in the following terms: “The aim of all the physician’s attention is the health of the human being, for the benefit of which they must act with the utmost zeal and to the best of their professional capacity”³⁴. In this aspect, the residents demonstrate the need to submit to the Code of Medical Ethics and the set of laws that govern professional practice. For this to fully happen, it is necessary to have a formative process that leads to the signification of these concepts and processes.

The analysis of the meanings attributed by the residents reflects an understanding of professionalism that goes beyond the exercise of the profession. For them, it is necessary to comply with requirements that govern the doctor’s performance in the professional environment, including laws, norms, service rules and medical ethics. Moreover, they draw attention to good coexistence, interpersonal relationships with the patient and the work team, as R15 and R12 report:

[...] [professionalism involves] an adequate conduct considering the rules of good coexistence, social relationships and medical ethics to which we are submitted, as well as the laws and norms. (R15)

[...] I think professionalism involves not only the Laws, but legislation, but also the rules of the service itself, with which we have to comply. (R12)

It is observed, in this context, that the subjects are slightly confused regarding the understanding of what laws, norms, rules and ethics are. At a certain point in the Focal Group, some residents expressed doubts, even about important aspects for their professional performance.

[...] Because sometimes, something that we think is correct is not, according to the Law, you know? Then, we fall into the question of, am I really being professional? [...] this thing I can do, do you understand? This is ethical, but according to the law I can and I cannot, and we sometimes fall into this doubt. But I think this is the adequate conduct in the face of the rules of good coexistence, the ethics we are subjected to, medical ethics, the Laws. (R15)

[...] I think not only the Laws, the legislation, but also the rule of the service itself. A legal conduct for the Law, but if the service does not allow [taking some action], then I must, inside my service, adapt, be professional by complying with their rules. I think it is also a bit of the reasoning. (R12)

The residents mention an incompatibility between the rules of the service and the dictates of the codes that govern professional performance in certain situations, with the “option” for the standardization of services as a way of adapting to the environment in which they are inserted.

The norms of the service where the doctor works are not of a higher hierarchy than that established in the Code of Medical Ethics and are not sufficient to revoke or contradict any of its provisions. Furthermore, both the service’s norms and the Code of Medical Ethics have an infra-legal nature and must be subordinated to the Constitution and the laws, which give validity to the aforementioned legislation. Moreover, considering that the legal system must be harmonious and not allow antinomies, any disagreement between the norms must be resolved by the rules prescribed in the Law of Introduction to the norms of Brazilian Law³⁵. In this aspect, the importance of discussing this issue in the residents’ training is verified, clarifying the differences in the hierarchy between the service norms governed by the Unified Health System and the Code of Medical Ethics, and there cannot be opposition between them.

It is appropriate to clarify that uncertainties were also observed in the residents’ statements about the concepts of ethics and morals, which are interrelated.

[...] Thus, professionalism permeates the concept of professional ethics. (R12).

[...] I think professionalism is interconnected with both the concept of ethics and the concept of morals. (R13).

Monte³⁶ reports that the theoretical-conceptual evolution of studies on medical ethics and professionalism led to a review of intersecting elements. In this process, ethics, Law and morals have their own paths. Despite emerging from the same source (morality), these concepts run in parallel and influence each other, being interdisciplinary.

The theoretical and practical understanding of medical ethics is not something restricted to conferences or seminars; on the contrary, it is a necessary, useful and productive grounded basis for professional activity and performance³⁷. This analysis, perhaps, explains the conceptual shortcomings of residents regarding the different categories of analysis in this study, which underlie medical professionalism.

The term ethics, in the etymology of the word, éthos (from the Greek, singular) translates the idea of habit, the result of repeated human action. Éthe (from the Greek, plural) means a set of behaviors or habits or customs. The Latin translation of “éthos” is ‘mos’ (moral), which means habit³⁸. According to Nalini³⁹, the ethical dimension is associated with professional action, influencing moral behavior. It can be perceived, in the testimonies, the residents’ concern of guiding their actions according to ethics, in the sense of acting according to an unspoken professional rule.

According to Salloch⁴⁰, professionalism is an ideology or system of beliefs that is used to defend the values inherent to the ethos of physicians (p.1). The author points out that the distinction between ethics and professionalism is not clear in medical education” and emphasizes that, in most cases, “the ethical basis is associated with the ‘internal morality’ of medical practice and the objectives inherent to Medicine, such as preventing and curing, alleviating pain and disability, or helping the patient to live with their illness” (p.1)⁴⁰.

Another dimension associated with the health professional’s performance that should guide the training of the specialist is the respect for bioethical principles. GO is a specialty that faces ethical dilemmas when providing obstetric care or in other situations of vulnerability for women, from birth to aging⁴¹. Therefore, it is essential that the training of the specialist includes knowledge and respect for bioethical principles, namely: autonomy, beneficence, non-maleficence and justice⁴².

In the same direction, and more specifically in relation to the action of the specialist in GO, the International Federation of Gynecology-Obstetrics (FIGO) recommended the practice of professionals in GO based on ethics, morals, integrity, compassion and respect for autonomy, placing the patients’ interests above their own⁴³.