Presidential address: Professionalism and surgery–kindness and putting patients first

Volume 136 Number 2

SURGERY AUGUST 2004

Society of University Surgeons Presidential address: Professionalism and surgery–kindness and putting patients first Brad W. Warner, MD, Cincinnati, Ohio

From the Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio

IT HAS BEEN A DISTINCT HONOR and privilege for me to serve as president of this important society. The Society of University Surgeons (SUS) is the foremost academic society for accomplished surgeons in the country. I am in constant awe of the talent and quality of the many individuals that comprise the SUS. It is truly a sense of assurance that the future of academic surgery is alive and well. It is important for me to acknowledge several individuals who have contributed greatly to my professional career. First, I need to thank my parents. As a nurse, my mother instilled my initial interest in medicine. There were plenty of stimulating descriptions of hospital events during dinner. Her nursing books supplied countless unforgettable images of clinical medicine. She also provided a foundation for my understanding of the virtues of hard work and family. My father was a high school band director for most of my childhood. From him, I learned the value of education and what it meant to be a role model for innumerable Presented at the 65th Annual Meeting of the Society of University Surgeons, St. Louis, Missouri, February 11-14, 2004. Reprint requests: Brad W. Warner, MD, Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229-3039. Surgery 2004;136:105-15. 0039-6060/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.surg.2004.04.013

students. I saw how he interacted with them through private music lesions, during band parties at our house, and during concerts or rehearsals. I was always impressed with the significant impact that he made on them during a very influential time of their lives. I also learned about the power of music and how necessary it is to provide a balance in my life. I graduated from a new medical school that was not well known among other surgery programs throughout the country. As such, I felt somewhat disadvantaged when applying for surgical residencies. Dr Josef E. Fischer at the University of Cincinnati gave me the chance (Figure). As the chairman during my residency and as a junior attending, he set an incredible standard for excellence. For me, he was a phenomenal chairman. He truly created an atmosphere of academic distinction within our department. I am forever grateful to him for taking a chance with me and for instilling the values of scholarship and optimal patient care. Without any prior research experience, I was provided the opportunity to work in the laboratory during my surgical residency under the direct supervision of Dr Per Olof Hasselgren. It was Dr Hasselgren who inspired me with his excitement for discovery. He was the ideal laboratory mentor. He was patient and driven, and had an uncanny ability to identify the significance of data that I always felt were negative or unimportant. I was truly SURGERY 105

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Figure. Dr Brad W. Warner (left) and Dr Josef E. Fischer in the Chairman’s office at the Department of Surgery, University of Cincinnati College of Medicine.

blessed with having him provide me with my first exposure to research. Finally, I must mention the most important person in my life—my wife Barbara. She has been a role model for me in so many respects. In her role as a neonatologist, I am in constant amazement of her professionalism and maturity. She is the anchor of our wonderful family, my constant source of love and encouragement, and my best friend. I cannot imagine being more lucky than to share my life with her. PROFESSIONALISM DEFINED Today, I feel it is relevant to address the topic of professionalism in surgery. This is a critical component of our professional and personal lives, and has broad implications with regard to the standard triangle of academic surgery—patient care, education, and research. In many respects, professionalism defines the vast majority of us as university surgeons. Deficient or complete lack of professionalism in the minority of surgeons casts a broad and dark shadow on our field.

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Thirty years ago, ethical and appropriate physician behavior was assumed, and the teaching of profession and professionalism was absent in medical education.1 Today, professionalism has been characterized by the Accreditation Council for Graduate Medical Education as one of the 6 fundamental core competencies that must be cultivated and taught among all medical school graduates during their residency training.2 Professionalism in medicine has emerged to be such an important issue today as a result of innumerable factors. Some of the most frequently cited reasons include the explosion of technology, corporate/physician relations, for-profit managed care, more sophisticated and educated patients with higher expectations/demands, the constant and looming threat of legal recourse, and the imposition of corporations, government, and other bureaucratic agencies with regard to allocation of medical resources. These pressures are ubiquitous and seem to be increasing at an alarming rate. While many of these factors are external to the field of medicine and are not insignificant, I would argue that the emergence of professionalism as a targeted core competency has occurred in large part as a result of our own doing. As such, I feel that it is timely and beneficial for us to revisit our roots. Reminding ourselves as to why we chose medicine, in general, and surgery, in particular, will help to increase our insight into where we are currently and the realities of where we are headed. Before embarking on a discourse of professionalism in academic surgery, it is important to begin with a working definition. This is a very difficult subject to define as the context and implications for it are broad. In general, professions have the following characteristics: possession of a body of special knowledge, practice within some ethical framework, fulfillment of some broad societal need, and a social mandate that permits significant discretionary latitude in setting standards for education and performance of its members.3 Further, by virtue of educational breadth and importance in satisfying some fundamental human need, some professions, including law, ministry, and medicine are anointed with the term ‘‘learned professions.’’4 The special claim of these learned professions is not so much in their level of expertise, but in their dedication to something other than self-interest during the provision of their services. This concept of altruism has been somewhat of an epiphany to me with regard to understanding professionalism. I had always assumed that professionalism largely referred to behavior patterns and encompassed such issues as

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anger management or sexual harassment. While these factors are certainly under its umbrella, the scope of professionalism is much more. It is this overriding principle of unselfish regard for and devotion to the welfare of others that is woven throughout our professional lives and should be a central dogma among academic surgeons. The need for a renewed sense of professionalism in medicine has culminated in a charter for physicians. This charter was a joint project developed by the European Federation of Internal Medicine, the American College of Physicians–American Society of Internal Medicine, and the American Board of Internal Medicine, and has been published in several journals.5-8 In its preamble, the charter states that professionalism is the basis of medicine’s contract with society and that it requires placing the interests of the patient above those of the physician, setting and maintaining standards of competency and integrity, and providing expert advice to society on matters of health. The 3 fundamental principles and set of 10 professional responsibilities are cited in the Table. For most of us, these principles and responsibilities merely state the obvious and dictate what most of us already do. However, I believe that we can do better. Specifically, as university surgeons, we must absolutely embrace and fully understand professionalism. I believe that within all the above-mentioned definitions of professionalism, two common themes persist. They are both so simple as to be missed. The first is kindness. Kindness encompasses several themes, but in general, to me, it refers to empathy, respect, compassion, and honesty. I’m referring not only to the empathy, respect, compassion, and honesty that we extend to our patients, but also to our physician and nonphysician colleagues. The second is altruism—the unselfish regard for, or devotion to the welfare of others. I will discuss several examples of these key themes in the context of patient care, research, and education. I will end with the special role of the SUS as a critical catalyst for the promotion of professionalism in surgery. PATIENT CARE Surgery is undeniably one of the most fantastic, emotional, awe-inspiring, and gratifying disciplines of medicine. The concept that a patient and their family place complete trust in our judgment and technical abilities to perform a safe anatomic dissection on a part of the patient’s body should be viewed as the ultimate privilege. We cannot ever view this definitive trust in us as our right—simply

Table. Medical professionalism: The physicians’ charter* Fundamental principles Primacy of patients’ welfare Patient autonomy Social justice A set of professional responsibilities Commitment to: professional competence honesty with patients patients’ confidentiality maintaining appropriate relationships with patients improving quality of care improving access to care just distribution of finite resources scientific knowledge maintaining trust by managing conflicts of interest professional responsibilities *From references 5 and 6.

because we are able to complete medical school and a surgery residency. It is a tremendous responsibility. I believe we fall short of the major thrust of professionalism when we start considering patients as ‘‘customers’’ rather than as someone in need. The business of medicine—even though I appreciate that it cannot be ignored—should always remain secondary. It should never become the primary focal point for what we do in surgery. It should never take the place of doing what is right for the patient. Along these lines, I feel proud to represent university-based surgeons who have always carried a large amount of responsibility for the surgical care of the needy. University hospitals are usually the only source of health care for medically indigent patients. Providing the absolute finest, cutting-edge surgical care without regard for socioeconomic or insurance status is what we ought to continue striving for. This unselfish concern for mankind and contribution to society epitomize professionalism. Many of the fundamental principles and professional responsibilities outlined in the physicians’ charter are upheld extremely well by the vast majority of the academic surgeons. I will therefore not review them further. On the other hand, I do feel that certain areas under the heading of patient care warrant special mention. These involve our handling of emerging technology, peer review, maintenance of competence, and our own attitudes and conduct. Revolutionary advances in technology are evolving at warp speed and are especially germane to university surgeons. It is not uncommon for

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patients to request that we perform operations using a specific technology or skill in which we have no expertise, or have never even heard of. It is critical that we offer the patient every opportunity to participate in decision making regarding their care. Patient autonomy is one of the fundamental principles outlined in the physicians’ charter. In these situations, we have to be honest with our patients and ourselves. Admitting that we have no experience with a particular technology or method defines professionalism. Even more importantly, if what the patient is requesting has been established to be the best, ignorance about it or not being able to offer it is simply unprofessional. This is an example of failure in our responsibility to stay upto-date with the field, thus not doing the best for our patients. The practice of medicine should be considered a lifelong residency in terms of learning something new and striving to do it better every single day. Setting that tone is what we, as university surgeons, should continue to strive for. Those sometimes painful review articles, commentaries, and book chapters that fall on the shoulders of most academic surgeons really do serve a purpose. They teach us about ourselves. They force us to step back and take a broad look at what we have written and, occasionally, what myths we have been propagating. As academic surgeons in the limelight of major medical centers, we have to be cautious about the endorsement of emerging technology. Evidencebased practice is a professional responsibility. Promoting to the general public technology that is desperately seeking a medical indication or that is not current standard of care is irresponsible and not in the best interest of our patients. We are all aware of instances whereby a new technology or approach is published in the lay press before it has been subjected to careful peer review. In these situations, I submit that we are only serving ourselves by providing a marketing ploy to enhance profit and attract paying patients to our institutions. This is the antithesis of professionalism. The wired world of information technology presents many new challenges to professionalism.9 Online, patients communicate with other patients, physicians communicate with other physicians, patients communicate with physicians, and so on. While many Web sites provide an important service for the provision of medical information to the public, we have to be very careful what information is promulgated. Fully 80% of adult Internet users, or about 93 million Americans, have searched for at least one of 16 major health topics online. This makes the act of looking for health or medical

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information one of the most popular activities online, after sending e-mail (93%) and researching a product or service before buying it (83%).10 This unprecedented availability of medical information to millions is extremely powerful. Unfortunately, most of the content is without rigorous peer review. In one report regarding the quality of information about laparoscopic bariatric surgery on the Internet, only 89 of 602 original ‘‘hits’’ led to Web sites that accurately discussed the details of the procedure and its complications in an unbiased manner.11 In another report evaluating online plastic surgery information using the keywords ‘‘breast augmentation,’’ 24 of 215 sites were found to be completely irrelevant and an additional 41 contained no medical information.12 The remaining 34% of Web sites contained false or misleading information. These examples underscore the great responsibility we must have to our patients for the objective content of the Web sites we are involved with. We have to always remember our primary goal is to place the interests of our patients above our own. Our relationships with the biotechnology, medical supply, and pharmaceutical industries must remain altruistic—consummated for the main purpose of doing what is best for our patients. That’s not to say we shouldn’t be entitled to profit from our time spent; however, the primary motive for initiating the relationship is to develop and/or test something new that benefits the patient. There are countless examples of successful relationships with industry, which have resulted in significant advances to our field. One of the more obvious examples of an outstanding relationship is the one between the SUS and Ethicon, who has continuously supported research fellowship awards for our junior members. We must remain at the forefront of cultivating these important relationships. On the other hand, with regard to how we practice, it is important to be sensitive to the influence of vested interest on objectivity. Peer review and self-regulation are critical components of professionalism. While outside agencies are perpetually attempting to intervene, we are the ones ultimately responsible for our own professional competence. The morbidity and mortality conference that is a requirement of every academic surgical program is a very important vehicle by which we can learn constructively from each other. It is the consummate professional who participates in these conferences, learns, displays empathy, and contributes honest and constructive criticism. I doubt anyone in this room has not learned profound lessons from publicly presenting

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to our peers what we were thinking and why we did what we did that resulted in an adverse event. Every doctor will allow a colleague to decimate a whole countryside sooner than violate the bond of professional etiquette by giving him away. —George Bernard Shaw

As part of this noble profession, it is critical that we regulate ourselves. This is done in our evaluations of students, residents, and fellows. It should also be done among ourselves. Turning our backs when colleagues from other disciplines or competing practices are having trouble in the operating room, with perioperative decision making, or in interpersonal relationships with patients or colleagues is an example of behavior that serves our own interests and is not in the best interest of the patient. Such behavior is not professional. Identification or recognition of incompetence mandates swift remediation and/or disciplinary action. Along these lines, I believe it is in our own and ultimately our patients’ best interests to work proactively with lawyers in legal cases involving medical malpractice and neglect. Being a fair and objective expert witness, whether it is for the plaintiff or the defendant, is an important responsibility to our profession and our patients. I think we all agree that the expert witness with questionable expertise working as a ‘‘hired gun’’ is highly unprofessional. I submit that it should be considered equally unprofessional to recognize medical malpractice, neglect, or incompetence and choose not to do something about it. Surgeon personality traits and behavior are quite diverse, but tend to reside somewhere between strong and brash. ‘‘Not always right, but never in doubt’’ or ‘‘ready, fire, aim’’ are phrases not infrequently applied to surgeons. Many of these personality traits are necessary for optimal performance during such surgical situations as managing an unstable trauma patient, controlling a hemorrhage, or reconstructing a liver or kidney ex vivo, to name but a few. On the other hand, I think we get carried away at times in our behavior and take some of these traits a little too far. As a result, we tarnish our relationships with our colleagues, sometimes permanently. Despite what we may think, such behavior does not result in improved patient care. It actually makes it worse. I believe that central to this behavior is the pervasive attitude of many surgeons that what we do is somehow more important or has a more profound impact on patients than what nonsurgeons do. That is simply wrong. One of the many blessings I have in being

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married to the woman that I am is the fact that she is a gifted and hard-working neonatologist. When she is called emergently into a delivery room in the wee hours to stand over a 450-g infant and, within a matter of seconds, make a decision about life or death in the high-intensity, emotion-laden theater of the delivery room is just as important as anything we do. The same can be said for a medical oncologist who completely ablates the bone marrow cells of a cancer patient as part of therapy and then rescues the patient with a stem cell transplant. There are countless examples of interventions, recommendations, and therapies performed by nonsurgeons, which have enormous impact on patient lives. Showing kindness toward nonsurgeons, inviting and respecting their opinions, and working cooperatively with them is what is best for the patient and is an essential tenet of professionalism. During my residency, I had the benefit of working with Dr Richard H. Bell. He exemplified professionalism in his interaction with his patients and referring physicians. He was one of many great role models for me during my training—not only from the standpoint of defining evidence-based practice, but also in terms of how he worked with others. He commanded the ultimate respect from his colleagues on the medicine service. Dr Bell reciprocated this attitude. I never heard him say a negative thing about a referring physician, even in clear situations whereby a surgical consultation should have been considered sooner. This behavior set an important new tone in our department and greatly reduced the barriers to consultation by nonsurgeons, thereby improving patient care. As medicine transitions from a discipline-based toward a disease-based focus, it is even more important that we show respect to our nonsurgeon colleagues at all levels. We will increasingly have to learn to play on a team that has great diversity in terms of background, education, and specific training. Working together as clinical teams concentrating on specific diseases will result in much greater advances than any individual discipline working alone. I had the great personal fortune to be raised by a mother who was also a nurse. From her, I learned firsthand the true virtues of a good doctor from a very different perspective. The best doctors in her eyes (and I know she has worked with many) were those who were able to get along with everyone around them. They were kind and showed respect. They didn’t yell and scream to get things done. They were team players who were not in it for themselves as much as for the patient. When they were unsure, they asked for help. They solicited

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opinions from the experienced nurses. I believe that the patients of these doctors actually received better care because the nurses, respiratory therapists, radiology technicians, and so forth were all more fully invested. Their opinions were respected and sought out. How many of us during our training have been placed into a situation whereby the nurse has completely bailed us out? I recall my first several days as an intern rotating through the Surgical Intensive Care Unit. The presence of experienced nurses and the fact that I listened to their suggestions made a rotation that could have been a disaster for me and the patients a great experience with many triumphs. On the other hand, I know of several instances whereby the opinions of the nurses were never taken into account. Predictably, this adversely influenced patient care. Demonstrating kindness and showing respect to nurses and other nonphysician professionals is a critical aspect of professionalism and results in better patient care. In light of the ongoing and worsening shortage of qualified nurses, we have to work harder to demonstrate professionalism toward them. It just might make surgical nursing a much more attractive vocation. In light of resident work hour restrictions, we have to rely increasingly on nurses for many aspects of care and communication of important patient information. Working with a professional behavior and attitude will greatly facilitate this transition.

promotion, peer recognition, financial gain, or other self-serving needs. While these aspects of doing quality research are linked, they should never replace the basic premise: we do it for the benefit of our patients. In doing research with the ultimate goal of benefiting our patients, there are several principles to which we must adhere. First and foremost, the overriding goal of research should be to seek the truth. Honesty is integral to professionalism. As such, we should always tell the truth. The worse thing we can do for our field, our patients, and ultimately ourselves is to build a story based upon fiction, not fact. This is where the elements of peer review in research link to professionalism. This is why research that doesn’t fall under the scrutiny of peer review doesn’t carry as much weight—and it shouldn’t. Surgeons as members of grant study sections must therefore be stringent and score highly for the grants that contain the best science. We have to resist the urge to fight for a grant simply because it was written by a surgeon. In the former instance, we are putting the interests of our patients above ourselves. In the latter situation, we are putting the interests of ourselves first. Objective and careful peer review with high standards is critical not only with regard to grant applications, but also in the publishing of scientific data.

RESEARCH Professionalism is a critical component of how and why we do research. Research, as well as education of residents, has typically distinguished academic physicians from all others. As such, the SUS, as a prestigious organization that is dedicated to the promotion and presentation of cutting-edge research, epitomizes professionalism. As active members of this elite group, we should all be proud. The issue of why we do research should be easy. We do it to provide new knowledge that can be applied to improve the care of our patients. This altruistic rationale reflects the ultimate in professionalism and is typified by Dr Elias Zerhouni, the current director of the National Institutes of Health, who stated that it is ‘‘. . . the profound commitment of NIH and its stakeholders to do whatever is necessary to rapidly exploit the revolutionary advances of the past few years for the benefit of the people.’’13 It is as simple as that. I believe this concept sometimes gets lost in the shuffle. Research is sometimes used as a vehicle for

Second, our science must be of the highest quality and reproducible. How many of us do experiments until we obtain the outcome we desire—that which fits with our hypothesis? Then we go on. When the experimental outcomes don’t fit with our hypothesis, our natural instinct is to blame some poor laboratory technician or surgical resident, or even search for a new technique or assay. To me, this speaks most directly to the wonder and mystery of science, which I find so aweinspiring. Having the humility to accept that our original hypothesis may in fact be wrong and to proceed from there constitutes responsible research and defines professionalism. Evidence-based practice is fundamental to doing what’s best for the patient. The best evidence is published in high-quality, peer-reviewed journals. It is absolutely essential that we maintain high standards for what we publish. For example, a recent review of all literature regarding the utilization of minimally invasive surgery in children failed to identify a single paper that was rated as

The great tragedy of science—the slaying of a beautiful hypothesis by an ugly fact. —Thomas H. Huxley

Surgery Volume 136, Number 2 either good or excellent.14 All published manuscripts on this topic were judged by rigorous criteria as being fair to poor in overall quality. We have published such a flurry of case reports, short series, and historical reviews of our experience that it has become nearly impossible to perform the type of rigorous clinical studies necessary to determine what is the best practice, and why. This is one example of how we must bear the burden of responsibility to do better for our patients. Third, we have to accept and cultivate new paradigms to succeed in bringing our research ideas to fruition. Gone are the days of ‘‘let’s cut it out and see what happens’’ as the basis for successful grant applications. These descriptive projects have certainly had their place and contributed much important information, but now they are anachronistic. Furthermore, the ability of the independent investigator who also has clinical responsibilities to direct a successful and sustainable research program is increasingly more difficult. For grants to succeed in the present day, they must be mechanistic, hypothesis driven, focused, employ the most cutting-edge techniques, and have more direct translational impact in terms of bringing information from the bench to the bedside. The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don’t play together, the club won’t be worth a dime. —Babe Ruth

How, therefore, can a university surgeon keep up and remain competitive? The manner in which this question is phrased would appear to be selfserving and suggests that we are placing the interests of our field and ourselves first. A more appropriately phrased question in the context of professionalism is how could we as surgeons contribute toward successful research programs that will ultimately benefit our patients? One answer is the development and/or participation within interdisciplinary research teams. This is exactly what the NIH is looking for as a major implementation group proposed under the theme of Research Teams of the Future and outlined in the recent NIH Roadmap.13 Our professional behavior and conduct are critical to aid in opening doors for both development of and participation within interdisciplinary research programs. Showing kindness and respect for nonsurgeon and nonphysician researchers is central to establishing important collaborations, facilitating the sharing of ideas, and pushing the envelope toward an improved

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understanding of disease. I cringe when I hear surgeons minimize the impact of nonsurgeondirected research as being somewhat less relevant or important to patient care. Such a shallow attitude is distinctly unprofessional. For over 9 years, I have had the unique privilege of working collaboratively with a PhD, Dr Christopher Erwin. He has contributed countless ideas, new technology, and interpretation of data to our laboratory from a unique perspective as a molecular geneticist. This has been invaluable for the success of our research program. I need to underscore the fact that it is our research program. The concept that we are working together in a culture of mutual respect and equality is fundamental. Being able to work collaboratively in research with PhDs and nonsurgeon physicians is a significant strength of any research endeavor. As surgeons trained to foster the ultimate in trust and respect from our patients, we should also work to cultivate the same from our colleagues. Countless examples exist in which surgeons are active and necessary participants within successful multidisciplinary, multicenter trials. As a pediatric surgeon, I have truly appreciated this concept as an early participant in the Children’s Cancer Study Group, which has now merged with the Pediatric Oncology Group, among others, to form the Children’s Oncology Group. There are few better examples of cooperation and teamwork across numerous disciplines to triumph in the treatment of many childhood cancers. One specific example is in the treatment of Wilms’ tumor. Decades ago, a child with this renal tumor had a dismal chance for survival. Nowadays, the overall survival is greater than 85%. Without surgeon cooperation and input, I would argue that these trials would have not been as successful. Kindness and compassion, critical elements of professionalism, should extend not only to how we treat each other, but also to how we deal with the animals we utilize for our research. Because of past behavior, legislation for animal rights and protection has necessarily evolved. While it can be viewed as potentially obstructive to our research projects, it is a critical aspect of professionalism that we cannot overlook. Strict adherence to Institutional Animal Care and Use Committee– approved protocols is extremely important. This is imperative not only from the standpoint of keeping the laboratory going, but also in demonstrating humane concern for the care and use of animals in the research setting. Paralytic agents should not replace pain medication. Indifference to animal pain and suffering as a result of our

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research is unacceptable. This abhorrent behavior is unethical and reflects a total lack of compassion and respect for life. A fourth principle for research with the ultimate goal of benefiting our patients is that university surgeons must have the responsibility to embrace and understand science—beyond merely the science of performing operations. In other words, I feel that the most significant advances will be made not in how we operate, but why. Several conditions encountered in pediatric surgery, such as congenital diaphragmatic hernia, neonatal necrotizing enterocolitis, or biliary atresia, remain enigmatic. Current surgical interventions for these conditions include repairing the hernia, resecting the necrotic bowel, or removing the scarred extrahepatic biliary tree. None of these surgical approaches is curative. None directly targets the underlying pathophysiology. I submit that, for these conditions, surgical treatment alone is going to provide little impact. Clutching to operative approaches alone is shortsighted and will have much less impact than rigorous and serious basic and clinical investigation. Finally, the potential for financial gain as a result of basic and/or clinical research is present now greater than ever. This is potentially a negative influence on the maintenance of professionalism. The Patent and Trademark Law and Amendments Act, also known as the Bayh-Doyle Act, was enacted in 1980 for the purpose of facilitating technology transfer from universities to industry. This act allows universities to patent their own inventions that were developed with federal support and to become directly involved in their commercialization.15 Intellectual property is therefore most appropriately maintained and fostered within the university setting. More than 2200 companies were formed on the basis of university-initiated licensing between 1980 and 1999, and resulted in over 1000 products being successfully brought to market.16 It is easy to appreciate that, from an initial incentive for benefiting society, the temptation for abuse and conflicts of interest is omnipresent. Maintaining the general themes of professionalism should remain as a strong bridle to these temptations. EDUCATION As academic surgeons, we bear a tremendous responsibility for education. We have to take this responsibility seriously. We must teach as if our life depends on it because someday it probably will. There is no question that the work hour restrictions imposed on residents has created an enormous strain on a system that we used to believe was ideal.

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On the other hand, the design of a curriculum for surgery training ensures that residents receive formal education in the entire spectrum of surgery. This is far better than relying on what patients walked through the door during their training. Ensuring time off for self-study is far better than spending time in noneducational activities such as transporting patients, drawing blood, or tracking down laboratory values. Documentation of such things as clinic attendance, quality and quantity of teaching, achievement of learning objectives, and evaluation of competence are all new concepts to us. Despite this increased complexity, I would argue that this evolution of change in surgical education is long overdue and much needed. It needs to be embraced as an opportunity to do a better job of teaching our residents. Despite that fact that most of us in academic surgery love to teach, fewer of us are actually good at it. We need guidance, training, and ongoing evaluation to be the best teachers. Providing the best quality of education to our trainees is fundamental for sustaining medicine’s contract with society and defines professionalism. As academic surgeons working within teaching institutions, we are in the unique, but critical, position of influencing virtually every medical student, regardless of the specialty that they eventually choose. Our influence can shape their choice of specialty as well as what they think of us when they leave the service. Think about it. They are exposed to us as academic surgery role models before many have decided on a specialty or even decided between private practice and academics. Therefore, acting as model professionals, we have one of the first opportunities to attract the very best. For the field of surgery, this will naturally lead to better patient care, more competitive and innovative research, and higher standards for education. Kindness is not usually the first word that comes to mind when medical students contemplate their first rotation in surgery. Why is that? I believe it should. Demonstrating kindness and being a role model for our profession makes an enormous impact. We must never underestimate the magnitude of this factor. Role models throughout my life remain one of the major reasons why I chose surgery as a career. While in junior high school, I had the opportunity to work as a volunteer in the surgery clinic at the Jewish Hospital of St Louis. During that time, one single random act of kindness transformed my life and solidified my desire to become a surgeon. As a young surgery intern, Dr Robert D. Fry invited me to observe in the operating room. I will never forget the profound effect that this singular experience

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had on me. A doctor had actually paid attention to me! He taught. He joked. He made me feel like I was part of some wonderful team. I guess my enthusiasm was fairly obvious from the start. This led to more invitations to the operating room, to the emergency room to see trauma patients, and to the wards to see interesting physical findings or procedures. I was hooked. The simple things we do can be easily taken for granted. They have a profound effect. As surgeons, we touch many more lives than we realize and in ways that we never fully comprehend. As role models in surgery, it is critical that we project professionalism to our students. It is easy to see why surgery might be an undesirable field to anyone who is exposed to surgeons who scream profanities, are confrontational, callous, arrogant, or show minimal respect for colleagues. Further, complaining about such things as compensation, how hard we have to work, and how impossible our jobs are reflects negatively upon the field of surgery and ourselves. We have been too successful in terms of promulgating this dissatisfaction. In the face of increased numbers of unfilled slots in general surgery training programs from 1997 through 2001, the percentage of senior medical students who perceived that general surgeons have ‘‘inadequate control over their time’’ increased from 67% to 92%.17 We certainly should not sugarcoat what we do. In the spirit of recruiting the brightest and the best, it is dishonest to suggest that being a surgeon is easy, doesn’t require much time or energy, and personal sacrifices aren’t necessary. They are. It is hard to be a surgeon. It does require energy, hard work, and commitment. It is our ultimate responsibility to be honest with our students about this. At times, we need to step back and remind ourselves about why we went into medicine in the first place. Why we chose surgery in particular. I suspect that for most of us, it was for the altruistic privilege of helping others. In essence, we actually understood professionalism before we ever became physicians! For others, it was the intellectual stimulation, the curiosity of disease. For a few, I suppose it was the drama of dealing with life and death—being able to make an impact. It might have even been an exposure to a person whom they try to emulate. These are the things that need to be conveyed to our students—the excitement and love for what we do. The rewards should always be the gratitude of our patients, our discoveries, our contributions to making life better for mankind. For the students that respond to this charge, we have truly won, for we have communicated the best that is in us – our

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passion for surgery – to students who share it and so will join us in its pursuit. And for the students who do not respond, we must not say that we have truly lost; those who do not share our passion for surgery will surely find their own passions, their own paths, somewhere else in medicine. A master in the art of living draws no sharp distinction between his work and his play, his labor and his leisure, his mind and his body, his education and his recreation. He hardly knows which is which. He simply pursues his vision of excellence through whatever he is doing and leaves others to determine whether he is working or playing. To himself he always seems to be doing both. —Anonymous

The path of academic surgery is certainly not easy. This was recently reaffirmed to me during a phone conversation with a former trainee who proudly announced that he was performing the same number of operations as I, making twice my salary, taking three times as much vacation, and not having to be burdened with research or teaching. My knee-jerk response was one of envy. I actually began to feel sorry for myself for choosing the path of academic surgery. But then I began to realize what the world would be like if everyone’s priorities in surgery were compensation, time off, and no concern for research or teaching. With these priorities, it is appalling to think where we would be with regard to helping mankind. I feel proud as a representative of the SUS—a body of true leaders and scholars—that taking a more difficult road and making sacrifices defines professionalism and has a much greater impact toward the betterment of mankind. Taking the harder road, however, doesn’t really have to be more difficult. We have to continue to create new paradigms that will allow for important contributions of individuals who either choose, or are unable, to carry out all the responsibilities of academics in terms of full-time patient care, research, and education. As a member of a team, it is just as important to make contributions in any of these components individually and in the capacity of working either full or part time. As a field, we need to develop much more flexibility with regard to time off for family or other personal reasons. For all of the mentorship we provide to students, residents, and colleagues, no mentorship is ever more important than what we provide our own children. Maintaining balance in our lives is crucial. Individually, we should be valued and accepted in surgery by our altruistic contributions, regardless of who spends the most time at it.

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MEDICAL SOCIETIES We are working toward a joint meeting termed the Academic Surgical Congress to be held in 2006 with our sister organization the Association for Academic Surgery (AAS). As such, it is timely and important to address the significance of professionalism within medical societies. The purpose of the SUS, or any surgical organization for that matter, should be to improve the welfare of the patients that we care for. It is that simple. It is an honor to be a member of this great organization. It is recognition of significant achievement in academic surgery. It represents professionalism from the standpoint that membership is granted after careful peer review and that the basic tenants of our society are altruistic. It is important that we preserve this identity. On the other hand, in order to remain a significant influence in American surgery and continue to grow, we need to de-emphasize the guildlike, exclusionary attitudes associated with being a member of an honor society. I know of many great surgeons who are tremendous role models who do not wish to be involved with the SUS. For a few, it is because they might have been turned down for membership previously. For many, I suspect it is the notion that we value doing basic research and being the principal investigator on an NIH grant above all other factors. This is a notion we are working to dispel. The SUS membership committee and executive council have placed a high priority on enumerating basic criteria for SUS membership. These criteria represent much more than being actively involved in basic research and seek to recognize important contributions to education, clinical care, and innovation. Developing new clinical programs, directing a training program or medical student clerkship, holding a leadership position within an education society, publishing innovative education or clinical papers, inventing and patenting medical devices all represent novel and appropriate avenues for membership in the SUS. One of the most important aspects of professionalism in our society is the collegiality and kindness that occur among our members. I have been so impressed with the willingness on the part of SUS members to help each other and to serve as role models. Several years ago, one former president of this society, Dr Mark Evers, spent an incredible amount of time helping me with my first NIH proposal. At that time, he was merely an acquaintance. But without knowing me well at all,

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he offered to help. It was never a question to him. He always responded to e-mails. He wrote careful reviews of my original proposals with many thoughtful suggestions. This is the type of Society that we should constantly strive to be. In the context of professionalism and doing everything we can to improve the care of our patients, it seems obvious to me that a joint meeting with AAS is crucial. There are several obvious advantages beyond the simplistic view that bigger is better. These include greater numbers of papers and posters leading to more information exchange, more opportunities for corporate support and improved funding for fellowships, and the development of a larger voice for academic surgery. The cultural differences between the two organizations are the very reasons why such a joint meeting is so important. The AAS generally comprises younger surgeons in the development phase of their academic career. The SUS membership tends to be a bit older, more established, and with a proven track record of academic success. The AAS has an open membership, while the SUS does not. As a commitment to our profession and society, it therefore is an absolute responsibility for the established and successful members of the SUS to be mentors and role models for the younger surgeons of the AAS. We are responsible for the academic success of our more junior colleagues. The visibility of our members at their meeting goes a long way toward facilitating that success. Discovery consists of seeing what everyone else has seen and thinking what no one else has thought. —Albert Szent-Gyorgi, 1937 Nobel Laureate in Physiology and Medicine

Beyond our visibility as role models to the younger members of the AAS, we have to appreciate the value in what we learn from our more junior colleagues. I have had the great fortune of working with intelligent, hard-working surgical residents in my laboratory over the past 10 years. As the senior investigator and mentor, I have always felt as if it was my ultimate responsibility to maintain focus and identify new directions and questions. In light of this, I have noted that virtually every resident has made important observations, asked great questions, and frequently opened my eyes to new and important directions. Similarly, the participation and input from the AAS membership should be viewed as critical for providing important insight into the research, education, and clinical components of our organization.

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The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient. —Francis W. Peabody, Lecture to Harvard Medical Students18

In closing, I would like to express my heartfelt gratitude for the honor of serving as your president. Reach out. Help one another. Show kindness. Through continued demonstration of these virtues, we will always remain at the forefront of what others will be inspired to do. Putting patients above ourselves and striving to do everything possible to make things better for them is what professionalism in surgery is all about.

REFERENCES 1. Arnold L. Assessing professional behavior: yesterday, today, and tomorrow. Acad Med 2002;77:502-15. 2. Accreditation Council for Graduate Medical Education Web Site. Available at:http://www.acgme.org. Accessed November 4, 2003. 3. Freidson E. Profession of medicine: a study of the sociology of applied knowledge. Chicago: Chicago University Press; 1998. 4. Pellegrino ED. Professionalism, profession and the virtues of the good physician. Mt Sinai J Med 2002;69:378-84.

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5. Medical professionalism in the new millennium: a physicians’ charter. Lancet 2002;359:520-2. 6. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-6. 7. Medical professionalism in the new millenium: a physician charter. J Am Coll Surg 2003;196:115-8. 8. Medical professionalism in the new millennium: a physicians’ charter. Clin Med 2002;2:116-8. 9. Blumenthal D. Doctors in a wired world: can professionalism survive connectivity? Milbank Q 2002;80:525-46. 10. Internet health resources. Available at http://www.pewtrusts. org. Accessed November 4, 2003. 11. Madan AK, Frantzides CT, Pesce CE. The quality of information about laparoscopic bariatric surgery on the Internet. Surg Endosc 2003;17:685-7. 12. Jejurikar SS, Rovak JM, Kuzon WM, Jr., Chung KC, Kotsis SV, Cederna PS. Evaluation of plastic surgery information on the Internet. Ann Plast Surg 2002;49:460-5. 13. Zerhouni E. Medicine. The NIH Roadmap. Science 2003; 302:63-72. 14. Rangel SJ, Henry MC, Brindle M, Moss RL. Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies. J Pediatr Surg 2003;38:1429-33. 15. Council on Governmental Relations. Available at http:// www.cogr.edu. Accessed November 4, 2003. 16. Eisen A, Berry RM. The absent professor: why we don’t teach research ethics and what to do about it. Am J Bioeth 2002;2:38-49. 17. Gelfand DV, Podnos YD, Wilson SE, Cooke J, Williams RA. Choosing general surgery: insights into career choices of current medical students. Arch Surg 2002;137: 941-5. 18. Peabody FW. The care of the patient. JAMA 1927;88: 877-82.