In the recent article, On the Road to Professionalism, “humility, servant leadership, self-awareness, attention to personal well-being, responsibility, lifelong learning, self-regulation, and honesty and integrity” were highlighted as key elements of professionalism in the practice of anesthesiology.1 It was further stated that “Professionalism is both a commitment and a skill—a competency—that we practice over a lifetime.”1 Indeed, professionalism in anesthesia has been recognized as a multifaceted topic that requires not just individual but also system-wide strategies to foster it.2

Professionalism and advocacy

Medicine is a profession where there is “a mastery of a complex body of knowledge and skills”, and a vocation where that knowledge is used to serve others.3 The concept of professionalism is a reflection of a group’s collective identity, standards, and ideology.4 The Royal College of Physicians and Surgeons of Canada states that as professionals, “physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health”.5

The national landscape of medicine is evolving rapidly, with limited resources, consumerism, and managed healthcare all necessitating greater advocacy by physicians.6,7 Anesthesiologists, as professionals, are well positioned to advocate for patients, colleagues, and our healthcare system, and in doing so, address this ever-changing medical landscape. Through interactions with other medical and surgical specialities, allied health practitioners, and health administrators, anesthesiologists can influence system-level changes not only within healthcare institutions, but also at both provincial and national levels. For example, regional anesthesiology groups and national societies have been instrumental in the rapid collective response to the coronavirus disease (COVID-19) pandemic, including the Canadian Anesthesiologists’ Society (CAS)-led educational seminars, online resources, and funding of pandemic-related research.

Avenues for advocacy and professional citizenship

There are numerous avenues for professional involvement and advocacy within the specialty of anesthesia. Patient safety is a fundamental tenet of this advocacy. Nevertheless, it also is accomplished through advocacy for quality care, health system efficiency in a resource-limited system, appropriate human resource allocation for anesthesiologist shortages, and the need for physician wellness, particularly in the current climate of increased awareness for physician burnout.8 Importantly, it can also extend to marginalized and indigenous populations where advocacy for social policy change to facilitate public health gains can address upstream social determinates of health.

Anesthesiologists can become professionally engaged in local departments, hospitals, and universities, as well as provincial and national physician associations (e.g., Canadian Medical Association). They can also contribute through professional administrative bodies such as provincial regulatory Colleges of Medicine or the national Canadian Medical Protective Association.

A less discussed, albeit equally important aspect of physician professionalism, is professional citizenship—accepting of personal responsibility for the current and future state of the profession.9,10 Anesthesia as a profession is at a crossroads. We must lead and represent the profession of anesthesiology collectively at economic and political tables to guide the discussion on important matters to the specialty including anesthesia patient safety, perioperative quality improvement, human resource allocation, funding for residency training positions, and research infrastructure. Importantly, public and global health anesthesia outreach activities11 such as educating the public about the national opioid crisis through media, or supporting anesthesia training in developing countries through the Canadian Anesthesiologists’ Society International Education Fund (https://casief.ca) are also examples of professional citizenship. We argue that this responsibility to the profession begins from the first day of residency training, when one chooses to embark on the journey to become an anesthesiologist.

At a national level, anesthesiologists can have collective professional impact, through the professional member organization of the CAS. Established in 1943, this national specialty Society is a voluntary, not-for-profit organization that represents Canada’s anesthesia providers including specialty-trained anesthesiologists, family practice anesthetists, anesthesia assistants, and anesthesia postgraduate trainees. It is dedicated to promoting excellence in patient care through research, education, and advocacy.12

A plethora of opportunities exist within the CAS for professional engagement and demonstration of professional citizenship. Subspecialty sections, division or regional representation, special interest committees and annual meeting/scientific planning committee, and contributions to the Canadian Journal of Anesthesia are just a small sampling. The organization provides professional direction for the Canadian anesthesiology community through the development of practice guidelines; networking and continuing educational opportunities such as the national annual meeting and continuing professional development modules. It recognizes its members’ excellence across clinical care, research, and education, and advocates this through national awards, as well as research funding through its partnership with the Canadian Anesthesia Research Foundation (CARF) (https://www.mycarf.ca).

The CAS provides a nationwide platform to address a variety of issues. For example, it addresses patient safety and quality improvement through the development of the Canadian Anesthesia Incident Reporting System, and committee liaisons with Canadian Patient Safety Institute, Health Canada, and the Canadian Standards Association.13 The growing anesthesiologist health human resource shortage can, in part, be addressed by working with the Association of Canadian University Departments of Anesthesia. The maintenance of clinical practice and safety can be addressed through the continued development of clinical practice guidelines for anesthesiologists, family practice anesthesia, and anesthesia assistants14 through the CAS’ standards committee. Navigating medical assistance in dying issues has been facilitated through the CAS’ ethics subcommittee. In the past year, CAS members are advocating for physician wellness and focusing much needed attention on diversity, equity, and inclusion for both CAS members and the patients we serve. In recent months, the CAS has been an important source of information through webinars and clinical care guidance for anesthesiologists regarding COVID-19.15

Resident engagement in the CAS and professional citizenship

The Royal College of Physicians and Surgeons of Canada identified professionalism as a core competency integrated into Competency By Design (CBD). CanMEDS 2015 Physician Competency Framework has professional as one of seven roles for which physicians are expected to be accountable.5 Three key competencies include commitment to their patients, profession, and society through ethical practice; commitment to their patients, profession, and society through participation in profession-led regulation; and a commitment to physician health and sustainable practice. Attaining these competencies and the formation of a professional identity begins in medical school, solidifies in residency and postgraduate medical training, and continues throughout one’s career.1

Residents have personal, academic, and clinical priorities competing for their time, yet postgraduate training may be the best time to engage residents and introduce them to professional citizenship. The need for system-wide strategies for professionalism development mentioned earlier2 may be particularly important during residency training. At the resident level, involvement in professional citizenship goes beyond personal responsibility; it requires collaboration from stakeholders at departmental program, provincial, and national levels. Protected educational program time, funding for travel, and even requirements to attend local departmental, university, and national professional committees and meetings as part of a formal CBD curricula would support a trainee’s engagement and ability to participate.

Early participation in professional societies, including committees and meetings, can provide residents with unique and valuable in-person networking opportunities to share their scholarship, engage with opinion leaders, build new social networks, and advocate for change. It provides exposure to mentoring role models that may facilitate a culture of professional citizenship, advocacy and leadership, potentially serving an important role in shaping the future of the specialty of anesthesiology.

Despite the multiple opportunities for physician engagement, over the past decade or so, membership in the CAS has seen a decreasing trend, especially among graduating residents. According to CAS registration data from 2012 to 2017, only 261 of 768 (34%) residents continued their membership upon completion of their postgraduate training programs.16 Even after accounting for emigration of Canadian-trained anesthesiologists, the number of new CAS members is actually quite low. If this alarming trend continues, anesthesiology as a specialty may be at risk of losing its representative voice in the medical profession and the Canadian healthcare system. Thus, to promote early career engagement, the CAS has a Residents’ Section, and also waives the annual CAS membership fee for residents.

The CAS, through its Residents’ Section, has carried out several initiatives to understand how to better serve, engage, and retain its resident and new graduate members. These include bursaries to attend the annual meeting, with improved resident sessions and social gatherings, funding for the “Simulation Olympics”, a communications and social media strategy, and a formal staff-resident mentorship matching program. Other projects underway include national awards to recognize resident accomplishments and more local CAS-affiliated events for residents. Through the CARF Research Awards program there is a designated resident research award.

In this issue of the Journal, Ke et al. in collaboration with the CAS, report the results of a national resident needs assessment survey16 including the identification of various communication, career, and educational resources, financial supports, and social engagement targeting areas for ongoing improvement of resident engagement.

Conclusion

Professionalism, including advocacy and professional citizenship, is a competency critical to the future of anesthesiology. It is a competency that begins in residency and requires formal development and support. The impact of professionalism goes beyond clinical care, research, and education, and includes involvement in leadership and healthcare policy. These various aspects can occur in many settings including local departments, hospitals, and national professional organizations such as the CAS.