Senses and meanings of medical professionalism for gynecology and obstetrics residents

Introduction: Professionalism is an essential condition for the doctor’s performance. The specialty of Gynecology and Obstetrics (GO) has been marked by a growing demand for disciplinary proceedings. Faced with this reality, the American College of Gynecology and Obstetrics (ACOG) recommended recording destructive or hostile behaviors that affect patient safety and the quality of care, remediate them and educate the clinical staff of institutions about it. Despite its importance for the training of future professionals, the lack of consensus about its definition and measurement methods make it difficult to implement targeted actions aimed at this purpose. Objective: This study´s objective was to know the senses and meanings attributed by Gynecology and Obstetrics (GO) residents to medical professionalism. Method: An exploratory, qualitative study was carried out through focal groups with 21 GO residents from Fortaleza, Ceará, Brazil. The analysis of content in the thematic modality supported the data analysis and the interpretation was supported by Symbolic Interactionism. Results: The senses and meanings attributed to professionalism by the residents were expressed in four topics: set of conducts for the benefit of the patient; doctor-patient relationship and relationship with the work team; set of professional attributes; and moral and ethical exercise of the profession. Conclusion: Professionalism is understood as a set of characteristics that include the comprehensive training of the physician, based on skills, scientific knowledge, values, technical skills, clinical reasoning, enabling the exercise of Medicine with respect, morals and ethics.


INTRODUCTION
The specialty of gynecology and obstetrics (GO) has been marked by a growing demand for disciplinary proceedings 1 .
Faced with this reality, the American College of Gynecology and Obstetrics (ACOG) recommended recording destructive or hostile behaviors that affect patient safety and the quality of care, remediate them and educate the clinical staff of institutions about it 2 . It is, therefore, imperative to reflect on the meanings and teaching of professionalism in medical residency programs (MR), including GO programs.
Professionalism is a multidimensional construct 3 , whose understanding is not limited to technical issues, nor is it limited to the Code of Ethics. Its teaching in professional training during MR programs contributes to the development of the medical identity of resident physicians 4 . These actions, however, require time and planning. In this field of interest, the question goes beyond the values, rules and norms of the medical profession for the 21 st century, involving, above all, the residents' perception of the meanings in their daily practice 3 .
Despite its importance for the training of future professionals, the lack of consensus on its definition and measurement methods make it difficult to implement targeted actions aimed at this purpose 5 . From this perspective, it becomes relevant to understand the perception that GO residents have about professionalism. More specifically if they apprehend its meaning in the multiple dimensions and reflections on academic training. This reinforces the need to characterize medical professionalism, identify the causes of problems in this scenario, in addition to proposing interventions and teaching strategies on the subject that qualify the specialists and favor health promotion.
It is believed that research on professionalism and its relationship with medical training, as it is based on the investigated subject's point of view, promotes a meaning of its value and the acknowledgement of this concept as a goal to be pursued to meet the needs and demands of health system users.
The objective was, therefore, to know the senses and meanings attributed by GO residents to medical professionalism.

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 phenomena 6 .

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: • What does professionalism mean to you?
• According to your view, how does the teaching of professionalism occur in the training of residents?
• How does the professional training process take place at your residency?
• How do you seek improvement regarding professionalism?
• How are the teaching strategies of professionalism included in the competency matrix?
• How do you perceive the contributions of professionalism teaching in the change of professional attitude?
• What can be done to improve professionalism teaching in the gynecology and obstetrics residency?
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 modality 9 , for the identification of the topics and the understanding of the study object 10 . 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 interactionism 11 , 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 interactionism 11 , 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 Interactionism 1 .
According to George Mead, one of the precursors of symbolic interactionism 11 , 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 value 15 .
According to Blumer 11  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

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: 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 sense 18 .
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: 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: 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

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, 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 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 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 Law 35 . 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. Monte 36 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 performance 37 . 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 habit 38 . According to Nalini 39 , 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 Salloch 40 , 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 aging 41 . Therefore, it is essential that the training of the specialist includes knowledge and respect for bioethical principles, namely: autonomy, beneficence, non-maleficence and justice 42 .
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 own 43 .

FINAL CONSIDERATIONS
From the perspective of GO residents, it was observed that medical professionalism has a multiplicity of meanings and senses directly related to social interactions, values, worldviews, conceptions and experiences of the participants. Medical professionalism is understood by GO residents as a broad set of characteristics that comprise a complete professional, associating competencies, scientific knowledge, values, technical skills and clinical reasoning for the ethical and moral exercise of Medicine. Therefore, the residents' perception evidenced in this study contributes to the improvement of teaching strategies regarding this topic in residency programs, improving the "being" and "doing" of these professionals.