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The Top 10 Reasons Why General Surgery Is a Great Career

The Top 10 Reasons Why General Surgery Is a Great Career Abstract It is an honor to stand before yoeu with the opportunity to deliver the Presidential Address for the annual meeting of the Western Surgical Association (WSA). I have gained more from the WSA than I could ever return. To serve as the secretary for 5 years and the president this year represents the peak of my professional life. It is an honor that I will always cherish, and for which I will be forever grateful. My first task today is to thank several people who are responsible for my position at the podium. Anyone in the audience who knows me well realizes that I will be unable to accomplish that goal in the manner it deserves without completely dissolving into tears. Regrettably, by necessity, I must limit my remarks simply to saying “Thank you” to my family—Pat, Margie, and David. I would also like to introduce and thank the person who has run my surgical practice during my tenure at Virginia Mason, Sandhya Mishra. Finally, I would like to dedicate this talk to my father, Dr Richard Leeson Thirlby. It goes without saying that I have been contemplating the topic and content of my presidential address for 364 days. I reread many of the previous addresses of the presidents of the WSA. It became evident immediately that I could not match the eloquence or insight of my predecessors. I was left to abide by the sage credo that guides much of what I do: “Play to your strengths.” I am a very positive person. I believe much of my success results from an ability to ignore frustration and to act on the positives; hence, my topic. All too frequently, I hear tirades of surgical colleagues that could provide the content for another talk entitled “Top 10 Reasons Why I Hate My Job.” I will leave that talk for another individual. My objective today is to remind you or convince you that you practice the greatest profession on earth. View LargeDownload Richard C. Thirlby, MD Another guiding principle of any good address is to “know your audience.” From this principle emerges a potential problem with today's address. My audience today is dominated by several hundred successful, experienced general surgeons. Without sounding pretentious, my hope is that this address will be published, and so one day be read by young individuals contemplating a career in medicine and, eventually, surgery. This assumption affected my choice of topics you are about to hear. What could I say to convince a high school student, a college student, or a medical student that surgery is a great career? I suspect that some elements that you think unimportant may be very important to a college undergraduate. Thus, a potential problem with this talk is the inevitable “constructive feedback” I will receive from my colleagues about my Top 10 choices. They will point out things I forgot! Without doubt, I have omitted things and/or incorrectly ordered or ranked my reasons. I encourage you to let me know the errors of my ways. If I foster an enthusiastic discussion between you and your colleagues, challenging my thoughts with better ideas, I will have accomplished my goal today. So without further ado, with apologies to David Letterman, here we go. The “Top 10 Reasons Why General Surgery Is a Great Career.” 10. training is fun (you'll never forget it) and training never stops Surgical residency might be considered by some to be a deterrent to making general surgery a great career. I disagree. Is it arduous? Yes. Is it fun? Absolutely. The excitement starts on the first day of internship. Stephen Evans put it nicely in a recently published editorial: “No other profession comes close in terms of duplicating the level of intensity, fear, or anxiety that comes with the first day of internship.”1 This intensity continues for the duration of the training. It provides young people with great life experiences and memories. Let me illustrate the latter claim with an observation. If 2 or more surgeons who trained together are placed in a room together for more than 5 minutes, the conversation inevitably turns to recollection of experiences of residency. As any spouse of a surgeon can attest, stories of residency dominate conversation during alumni receptions at the American College of Surgeons Clinical Congress. Although the events may have occurred decades ago, they are recalled vividly, as if they occurred just yesterday. When one spends 80 to 100 hours per week with people in high-stress circumstances, personalities emerge. The experiences are remarkable and life-changing, and the friendships are enduring. They cannot be matched by any other career. The training never stops. Surgical or medical training does not stop with the end of residency. I can think of few, if any, careers in which the necessity of “continuing education” is so relevant. The judicial system has not changed appreciably since 1776; medicine and surgery change weekly. I asked our medical librarian to tally the English-speaking journals relating to general surgery. Her count totaled 75. Assuming the majority of these journals publish 12 issues annually, there are about 900 issues per year, probably in excess of 9000 manuscripts per year. What other career provides so much opportunity for mental advancement? There will be thousands of articles published this year that will be available to stimulate us to improve. Surgery is not unique among medical careers in this regard; however, I cannot think of another career that provides such stimulation, advancement, and change for an entire career. 9. job security Job security is a good thing. For decades, there has been debate regarding the supply and demand of physicians and surgeons. I have neither the time nor the desire to bore you with the details of the 1910 Flexner report, nor the multiple iterations of the Graduate Medical Education National Advisory Committee (or GMENAC) reports. Suffice it to say, these folks were not good at predicting things. This committee predicted that in 1990 there would be about 35 000 general surgeons in a country that needed about 23 000 surgeons, a surplus of about 12 000 surgeons.2 What happened? In 1990, there were about 29 000 surgeons in a country that needed about 28 000 surgeons.2 If I do the math correctly, that is about a 12-fold error. If any of us missed our targets by 12-fold on a consistent basis, we would be out of a job. The complexity of the variables involved exceeds the ability of most to make valid predictions. The current consensus is that there will not be enough general surgeons for the foreseeable future. There are several reasons. First, America is aging and general surgeons treat aged patients. At present, there are about 35 million Americans over the age of 65 years.3 By 2020, there will be about 53 million persons over the age of 65 years. The aged population, therefore, will increase by about 50%. This aging population will result in huge growth in demand for surgical services. It has been projected that the US population will increase by about 18% in the next 20 years.4 However, because of the aging population, it has been projected that the workload of general surgeons will increase by about 30%.3,4 How many general surgeons will there be? A recent publication by Stitzenberg and Sheldon5 suggests that progressive specialization within general surgery likely is going to decrease the numbers of general surgeons being produced and add to the complexity of workforce planning. Although about 1000 persons graduate from residencies in the United States annually, about 750 are currently entering fellowship training. Thus, the number of persons graduating and entering traditional general surgery practice in 2004 is only about 250 per year. Furthermore, surgeons are retiring earlier.6 The bottom line is that in the next few years, there will be a significant shortage of general surgeons, roughly 5000 or a 15% deficit. The Association of American Medical Colleges (AAMC) recently published a consensus statement on the physician workforce.7 They conclude that there will be a severe shortage of physicians in the next few decades. They suggest, therefore, that entry-level positions be increased in both medical schools and residency programs. They calculate that medical school enrollment should be increased by 30%.7 Similarly, the positions in graduate medical education programs, or residencies, should be increased by the same fraction. In a moment of remarkable insight, they go on further to recommend that “the AAMC should provide students, physicians, programs and hospitals with the best available and timely data on physician workforce needs in order to support informed decisions.”7 That is, the AAMC will give students information suggesting that we need general surgeons. However, I have a high level of cynicism toward those who try to predict the future. If given the opportunity to counsel young people, I would rather choose to state facts of the present and/or relate empirical observations to illustrate the point. As a program director in general surgery for 14 years, I have never had any trouble getting one of our graduates a good job; most have many great job offers. As a practicing surgeon, I can think of only 1 or 2 examples of good surgeons who left a community or a practice because of politics or lack of income or success of their practices. The bottom line is that a good general surgeon will be successful and have total job security for the next several decades. Name another desirable profession that can make that claim. You have total job security, and job security is a good thing. 8. the pay is not bad I live in Seattle, Wash. Not a week passes that does not provide me the opportunity to meet a “Microsoft millionaire.” A Microsoft millionaire is usually between the ages of 40 and 50 years, is worth millions, and has not worked for about 5 years. They do serve a purpose. They have the time to coach our children's Little League teams, which, regrettably, busy general surgeons do not. Yet, it does not seem fair. I work harder, am better educated and more skillfully trained, and deal with significantly more stress than they do. The surgical locker rooms of America are filled with surgeons complaining about inequities of financial compensation. I could relate to you countless examples of corporate greed, of insurance executives collecting obscene compensation packages, but I will not do that. Rather, let us look at the facts. The facts are that the average general surgeon in the United States has an annual salary of $280 000 per year.8 Pay increases progressively for the first 17 years of practice, peaking at about $300 000 per year. This pay scale puts him or her in the top 99.9% of income of employed Americans. The median household income in the United States is $44 000 per year.9 The average annual salaries of lawyers, computer/information systems, engineers, financial managers, financial advisors, and architects are $110 000, $102 000, $66 000 to $97 000, $96 000, $82 000, and $68 000, respectively.10 The Bureau of Labor Statistics calculates the average hourly wage for all professions in the United States.11 They provide data for 427 possible jobs in 2002. The highest hourly wage in the US is airline pilots, $95 per hour. The catch here is that pilots only work an average of 23 hours per week. The lowest salary, the 427th in the list, is that of waiters and waitresses, $4 per hour. The second highest hourly wage in the United States is that of physicians, $61 per hour. Physicians average 41 hours per week.11 The data are not broken down into physician specialty groups, but general surgeons are among the highest-compensated physicians. Lawyers and financial managers are ranked 14th and 34th in hourly wage, respectively. Are there inequities when it comes to compensation of general surgeons? Of course there are. If you are a general surgeon, 17 years into your career you likely have annual earnings ($300 000) that are substantially less than those of the radiologists or radiation oncologists in your institution ($450 000)—certainly not a fact that is based on common sense or justice. Even the anesthesiologist ($340 000) drinking coffee in the lounge while you are performing a Whipple resection is making more than you are. That is not fair or appropriate. However, the fact remains that general surgeons are paid very, very well. Our salaries afford us a lifestyle that is better than 99.9% of people in Western civilization. We should be embarrassed if we complain in public about our pay. 7. your mother will be proud of you The prestige of physicians and surgeons in the eyes of the American public has declined over the last 4 to 5 decades. The reasons for this are complex, and time does not permit me to discuss them at length. The condensed version or explanation of this decline in prestige is that we have “what we deserve.” My father practiced urology in northern Michigan for 40 years. One of his pet peeves was the phenomenon of physicians driving expensive cars with personalized license plates advertising the fact that they are physicians. I recently saw a Porsche with a license plate that said “skin doctor.” How can we, as a profession, complain that we have lost the respect of the American public when we do things like that? Thankfully, however, the fact remains that our patients, and the residents of the communities we serve, respect us a great deal. Surgery was ranked as the most prestigious occupation in a recent national survey, outranking the positions of college presidents, astronauts, big-city mayors, lawyers, and all other physicians. Recent data compiled by the National Opinion Research Center concluded that surgeons are the most respected professionals in the United States.12 We are highly respected for our technical skills, and the public values our ability to deal with very high on-the-job stress and appreciates our work ethic. Surgeons are respected in their communities. At work, surgeons are treated with respect and admiration by all levels of coworkers, from nurses to the hospital maintenance workers. Surgeons are revered by their patients. Your family is proud of you; even your mother-in-law is proud of you. Most important, however, your mother is proud of you. 6. surgeons have panache: the surgical personality and the culture of surgery As described before, surgeons are admired by the public. While you may argue that your life bears little resemblance to that portrayed by surgeons in Hollywood and modern television, there must be some justification for the dozens of movies or television shows depicting surgeons in action. The panache of the surgical personality is glorified by Hollywood. Surgeons on the movie screen are portrayed by people like Elliot Gould or Donald Sutherland, on television by the beautiful young men and women of Grey's Anatomy. Internists are portrayed by people like Robert Young in Marcus Welby, MD. The surgical personality is part of the culture of surgery. The recently published book, The Scalpel's Edge was written by a psychologist who had the opportunity to observe a team of academic surgeons.13 The author, Pearl Katz, very accurately describes the surgical personality and the culture of surgery. Like the writers of MASH, she observed that surgeons have a demeanor of confidence and apparent arrogance. She then attempts to explain why that might be the case. She suggests that: The kind of work that surgeons do influences their demeanor and behavior with others. What other profession makes decisions and takes risks that literally control patients' lives or deaths on a daily basis? Who but a surgeon routinely and boldly cuts into the most intimate depths of people's live bodies, penetrates their innermost body cavities? . . . Surgeons' detachment from their patients may be understood as necessary protections from these routine sights, smells, acts, and dramatic confrontations with mortality. Their demeanor of confidence and apparent arrogance may be partially explained by the almost superhuman requirements of their work.13(pviii) Katz observed that the surgical personality is characterized by a preference for acting over not acting. It has been part of the culture of surgery, since it was distinguished from medicine in the second century. “Surgeons' reluctance to admit doubt and uncertainty or error was likely to have permitted them to be sufficiently bold to carry out extremely difficult and risky procedures.”13(pviii) How is it that surgeons can deal with the stress of performing life-threatening operations on a daily basis? Katz's hypothesis is interesting. She was fascinated by the rituals of the glove and gown process, of the draping procedure that shielded the face and personality of the patient from the surgical team. She believes that: The rituals that are enacted in the operating room also shield surgeons from the emotions of other patients and from their own emotions. . . . In addition to separating the head of the patient from the rest of his body, operating room rituals facilitate a mind-set which focuses [on the technical aspects of the case, not the patient] . . . they facilitate surgeons' existing penchant for action and to avoid responding to distressing emotions.13(p110) The dominant themes of surgical culture—action, heroism, certainty, and optimism—are not compatible with identification with, or communication with, helpless, hopeless patients. . . . The process of repressing normal feelings of empathy is necessary during surgery. . . . Otherwise, they [the surgeons] would be forced to experience intolerable feelings of disgust, horror, fear, or excitement, and their own confrontations with death.13(p123) For decades, the culture of surgery was dominated by men. Is the traditional surgical personality by necessity masculine? The answer is no. Will the surgeons of the future have “panache”? The answer is yes. Katz accurately observed that “Surgical culture perpetuates itself by the recruitment and training of residents through a long apprenticeship process. Residents are often attracted to surgery by the image of the surgeon, with its prestige, power, and heroic mystique that is shared by most people in North American culture.”13 There is nothing related to gender in this attraction to surgery and the surgical personality. I would agree with Katz, who believes that women in surgery will make our profession better. The new surgical heroes may rather be those who can admit doubt and uncertainty when it exists, and can admit limits and be comfortable with palliation. They may communicate sensitively with patients. . . . The new surgical heroes may not be those men who make decisions and take risks for their patients, but rather those men and women who make decisions and take risks with their patients.13(p210) Women in surgery will enhance the prestige of our profession, while maintaining the culture and panache of surgery and, more important, improving the product. The culture of surgery is further illustrated by the WSA. Name another career that has resulted in organizations like the WSA, that drives busy professionals to spend thousands of dollars to spend time, learn, and socialize with colleagues from around the country. There is a bond, cemented by a profession that is greater than any other, that connects us all. In summary, if you choose surgery for a career, you will join a culture like no other. 5. you will have “heroes”; you will be a hero The Halstedian teaching model, the apprenticeship model, provides mentors. Mentors become role models and they become heroes. While many careers potentially foster a “hero-worship” relationship between the pupil and the teacher, I would contend that the relationship between surgeons and their mentors transcends that of all other careers. Claude Organ incorporated a feature called “Surgical Reminiscences” in the Archives of Surgery that illustrated the uniqueness of this bond. Each article describes what I call “hero-worship” between student and mentor. Western Surgical Association member Byron McGregor talked about his relationship with fellow WSA member and WSA president Chester McVay, who quoted the 12th-century chancellor Bernard in his classic anatomy text, saying that “we are like dwarfs seated on the shoulders of giants. If we see more and further than they, it not due to our own clear eyes or tall bodies, but because we are raised on high by their bigness.”14(p1) Byron astutely observed that McVay transformed himself from a humble dwarf into one of the very giants he so admired, “thereby making room up there for the rest of us . . . and, the view is fine!”14(p1) Doctor Organ wrote about his first interaction with Lester Dragstedt. Claude was a junior resident doing basic science research in a gastrointestinal physiology laboratory; the legendary Dr Dragstedt was a visiting professor. During the visit, a young Dr Organ had the opportunity to discuss his research with Dragstedt during a one-on-one meeting in his laboratory. Claude then transported Dragstedt to his hotel. As they departed, Dragstedt presented Claude with his card and offered to communicate with him about the research project. It was a moment, Claude observed, “in my surgical training and surgical experience I shall never forget.” He observed that “others might possess the card of legendary sports figures, but I had the card of Lester L.R. Dragstedt, MD, FACS, Professor of Surgery and Physiology.”15(p1) My mentors are heroes. I could list dozens of heroes . . . many are sitting in this room. I need to acknowledge two, both members of the WSA: Bill Fry and Robert McClelland or “Dr Mac.” It was my privilege to sit on Bill Fry's shoulders for 10 years in Dallas. He is the most talented surgeon I know. Dr Mac, the originator and editor of Selected Readings, has done more for surgical education than any surgeon ever. Dr Mac's knowledge of the surgical literature dwarfs that of any other individual on earth. A Dr Mac–trained surgeon knows that good surgical care can only be delivered by a surgeon who gets better every day. The best way to accomplish that goal is to read the surgical literature every day. I have photos of Drs Fry and McClelland in my office. I look at them daily for inspiration. To quote Dr McGregor, the view from their shoulders is “just fine.” Every surgeon in this room is somebody's hero. Whether you are in private practice in a small community hospital or a department chair at a major university, there are young surgeons, young medical students, or young people thinking of a career in surgery who had the privilege to work with you in a hospital and think of you often. You are somebody's hero. Of all the letters I have received from graduates of our program thanking me for being part of their training, perhaps the one that affected me most profoundly ended like this. “How does a student thank a mentor? . . . How do we thank you for those gifts? We emulate you.” What a great career. We have a profession and a culture that fosters heroes, we sit on the shoulders of giants, and we too can impact others' lives profoundly. 4. there's spirituality if you want it What do I mean by this? I can illustrate what I do not mean with a joke you have all heard. Although there are many variations on the joke, the short version goes something like this: “What is the difference between surgeons and God? God knows he is not a surgeon.” My circulating nurse of 17 years, Thea Nortness, told me that joke. I do not recall exactly the circumstances that prompted it, but I have encouraged her to retell the joke any time she feels it is appropriate. We would all probably benefit from having a hospital employee tell us this joke on a frequent basis. What I do mean is that, as surgeons, we are dealing with people on a daily basis who are using their spirituality to navigate through very stressful and/or life-threatening circumstances. A recent poll shows that 59% of the US population considers religion extremely, or very, important in daily life. However, being a surgical patient is not “daily life.”16 Nearly 100% of our patients use their spirituality during their surgical care.17 How is that relevant to the career of surgery? If spirituality is important in your life, if spiritual interactions give you strength, give you peace, surgery will make your life better every day. Surveys of hospital inpatients report that 77% of patients believed their physicians should consider their spiritual needs, 48% wanted their physicians to pray with them, but 68% said no physician had ever inquired about their spiritual or religious needs. . . . 94% thought it appropriate for physicians to inquire about their spiritual beliefs if they became gravely ill.16-20 How should these data influence my surgical care? I am not sure. I do know that the bond that can form between surgeon and patient is profound. The act of making a skin incision may be a simple technical exercise, but as the tissues open, the patient and the surgeon are bonded. From the patient's perspective, undergoing general anesthesia, being put to sleep while lying prone, is cause for thought. Is that spirituality? It usually is. All of us acknowledge the value of the recent emphasis in medical care on “patient-centered care” and the paramount importance of health-related quality of life. As John and Maggie Tarpley21 observe, if the majority of our patients view spirituality to be important in their ability to deal with illness, and “if the patient-centered approach to medicine is the gold standard, then spiritual aspects of each person must be considered.” Spiritual well-being is a major component of health-related quality of life.22 However, despite increasing evidence that patients would like their physicians to do so, spiritual issues are rarely addressed by 21st-century Western physicians.21 Clinicians who ignore the spiritual concerns of patients are, in effect, asking many patients to alienate themselves from beliefs that deeply define them. Astute clinicians pick up clinical clues from patients.23 The Hindu amulet, a copy of the Qur’an, rosary beads, a Bible, or Shabbat candles on the nightstand next to the bed may be as much communication to the surgeon as they are spiritual aids to the patient. They are signs of what the patient holds most dear. All that may be needed is a simple, open-ended question to engage the patient on a spiritual level. Showing respect for such defining features of a patient's life may constitute a healing act and can be integral to the care of the “whole patient.”23 How many careers can document that 90% of their customers use prayer or spirituality to help them through their relationship with the provider of the service? I can only think of a couple: airline pilots and casino dealers. In the case of commercial airlines, there are few atheists in the passenger section. However, the pilot has no personal or emotional contact or spiritual bond with the client. In the case of casinos, the dealer is the devil. The problem for me is that none of my training taught me to address the spiritual needs of my patients. How should physicians examine and engage religion in the lives of their patients? As a program director in general surgery for the last 14 years, I have supervised the curriculum of about 2100 didactic conferences. Ninety percent of my patients want me to address spirituality, yet I have never put the topic “on the table” for my residents. I have no great expertise or insight into this dilemma; I just know it is important. Jerome Groopman recently addressed this dilemma in an editorial entitled “God at the Bedside.”24 One of his dying patients told him she was frightened and said “Doctor, I want you to pray for me.” Groopman, however, had no training for dealing with this request. He eloquently describes the uncertainty of the boundary between professional and personal relationships. Finally, he drew on the customary practice of his teachers and answered a question with a question. He asked his patient: “What is the prayer you want?” “Pray for God to give my doctors wisdom,” the patient said. To that, he silently echoed, “Amen.” I will summarize with a statement that I will boldly call “Thirlby's dictum”: There are no atheists lying on operating room tables. Virtually all of your patients who are about to undergo major surgical procedures are having conversations with a being that is bigger than you or me. If you wish to do so, you can acknowledge this. You can do it with words, most patients welcome it, or you can do it with a smile, a gentle touch, and a few seconds of eye-to-eye contact that communicates clearly the spirituality of the moment. Few careers involve daily situations in which this intense, yet peaceful, exchange can occur. Name another career that evokes such emotions from the recipient and provider of services. 3. you will change patients' lives On the advice of a colleague a few years ago, I started saving thank you letters I receive from patients. They are in a file in my office. All of you have received these. I suggest you save them as well. If you read them again, it will convince you that you are in a great career. It will keep you going. You truly do change patients' lives. Here is a sampling from my file: “Thank you for successful efforts. It's great to have my life back.” “He was sick for a long time, but thanks to all of you, he has been given a chance to live a normal life again.” “Thank you all in helping rid me of a condition which gave me no peace. . . . Love you all for who [you are] and what you’ve done.” “Thanks so very much . . . you have freed me from an outer shell of anguish. God bless you.” “I intended to write this note a while ago to thank you for the wonderful care all of you provided during my recent surgical experience. You made such an impact on my life and I feel as if I have been given a second chance after having gone through this ‘miracle surgery.’ I am so thankful you have dedicated your lives to help improve the lives of others. I will never forget the incredible impressions all of you have made on my life and in my heart.” “I am doing wonderful! I can't even thank you enough. My appetite is crazy . . . too good! My system is finally feeling and doing its own natural things once again.” “Thank you so very much for all your kindness and care. I feel better than I have in years.” “I don't know how to begin to express my thanks and the thanks of my family.” “It is truly life changing. It's awesome.” “After living with UC [ulcerative colitis] for 25 years, for the first time in my memory, I know what ‘health’ feels like.” From another patient with UC, “I count my blessings every day to have had you as my surgeon. I think of my scars as beauty marks that remind me of how much I have to be thankful for. I wear them proudly.” And another patient with UC. “You have totally changed my life. . . . I had an absolute blast at the ninth-grade dance. My friends . . . said I looked gorgeous. And I owe it all to you . . . I will be eternally grateful, you erased the disease that had ravaged my body for 3 years.” “I am so thankful you have dedicated your lives to help improve the lives of others.” Many letters will draw on the importance of spirituality that I discussed above. “I know it was God who placed you in that ER room that Monday.” “God has given you the best gift of all . . . the ability to save lives. Thank you for everything.” “We have faith in you and a deep faith in God and He’ll watch over both of you.” “I thank God every day. . . . May you continue to be blessed with His healing gift.” “I don't know if you are a spiritual person, but I believe you are an angel.” While reading these may seem a bit self-promoting, that is certainly not my intent. All of you have received letters nearly identical to this; all surgeons have. I read these to remind all of you that you are truly changing patients' lives. Save the letters and reread them when you are down on your luck. It will remind you that you have a great career. 2. patients will change your life A patient, J.S., developed testicular cancer when he was a young man. His treatment included high-dose, external-beam radiotherapy to the pelvis. He presented to the Virginia Mason Medical Center a few years ago in his early 40s with a destructive, high-grade sarcoma of the left pubic ramus. The only effective treatment was radical excision. Our orthopedic oncologist, our vascular surgeon, and I performed a radical en bloc excision of the pubis and the hip joint. I reflected structures such as the colon and ureter out of harm's way; the femoral vessels were divided and reconstructed. The pubis and part of the acetabulum were resected en bloc. My orthopedic colleague assured me that ambulation would be possible despite the loss of the essential bony structures of the left hip, but that it would “hurt a little bit.” During J.S.'s preoperative evaluation, he was always remarkably upbeat. He never expressed any blame on the medical community for this “radiation-induced” tumor. He never seemed the least bit scared, bitter, or sad. He never intimated that he had been dealt an unfair circumstance; he only asked what we, and he, needed to do to get on with treatment and healing. He did not change after his operation. His pain management used the typical patient-controlled, narcotic analgesic techniques. On his second postoperative evening, his care team decided that he needed to mobilize to a bedside chair the next day. I entered J.S.'s room that morning on rounds. He was in the middle of his chair transfer. A nurse was in attendance. Every vein in J.S.'s forehead was popping out, sweat was beading on his brow, he was clearly in great pain, but was determined to transfer to the chair as he had been told to do. As I sized up the situation with my residents, I told J.S. to “hold on,” we could lift him to the chair. J.S. stopped his agonizing transfer, somehow managed to smile at me, and said “Don't worry Doc, I don't need any help.” That moment is etched in my brain. I shall never forget it. With tears in my eyes, I thanked him for changing my life. How many times have you treated a patient with a disabling or lethal disease? Despite pain, despite the prospect of mortality or severe disability, despite potential financial ruin, our patients routinely smile; they routinely exhibit a strength of spirit, mind, and body that transcends normal human behavior. Many times we see the anger. Many times we see the fear. Many times we see difficulty dealing with pain. However, when it is all said and done, what we are privileged to see on a daily basis is a strength of spirit that trivializes our daily worries. How can we, in good conscience, complain about anything in our daily life on the same day that a patient with a lethal cancer who is in extraordinary pain says “he doesn't need any help”? When our patients thank us for all our work on their behalf, our response should be “No, J.S., thank you. You did all the work. I did the easy part. Thanks for the privilege of getting to know you.” 1. i love to cut Rolling the right colon in a thin young patient with ulcerative colitis, putting a suture in the stomach, putting a stitch in Cooper's ligament: I could go on and on. A tough operation is completed with intuitive and clear anatomic dissection, minimal blood loss, a perfect anastomosis. You know the patient is going to do well. My vascular surgical colleagues tell me it is completing the perfect carotid endarterectomy in the perfect plane with a perfect feather. The patch looks like it was placed with a precise sewing machine. At the completion of a complex operation, you take your gloves off, take a cleansing breath, thank the operating room staff (and, in ingenuous fashion, the anesthesiologist), and find the family to relay the good news: you tell the family that “all is well, your loved one is going to be just fine.” What satisfaction! What other career provides both the rush of operating and the satisfaction of guiding a smooth perioperative course? I love to cut. Many a resident has heard me say, while rolling the right colon during an ileoanal pouch, “I can't believe somebody is paying me to do this.” With the exception of professional baseball, I cannot think of another job where the pay is so good to do something so fun. The cynics in the audience might respond, “Yes, but what about all of the baggage outside of the operating room?” My response to that is that the prize makes the other stuff worth it. We have a career that affords us the opportunity to be paid to do something that is truly fun. It is why we are all in surgery. Cherish it. In conclusion, members and guests of the WSA, you are all very fortunate indeed (Table). You were born with the mental and physical attributes necessary to excel as high school, college, and medical students. You were blessed to be provided with the opportunity to utilize your talents. At some time in your education, you were injected with the addicting drug called “surgery.” You had and/or developed panache. You have become a very successful surgeon, which affords you job security, financial comfort, great respect in your community, and daily personal interactions that are profound and fulfilling. Best of all, when you go to work, you get to cut. Don't ever complain; you have the greatest job in the world. Table. View LargeDownload Top 10 Reasons Why General Surgery Is a Great Career Back to top Article Information Correspondence: Richard C. Thirlby, MD, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, PO Box 900 (C6-SUR), Seattle, WA 98111-0900 (gtsrct@vmmc.org). Accepted for Publication: December 5, 2006. Financial Disclosure: None reported. Previous Presentation: This paper was presented as the Presidential Address at the meeting of the Western Surgical Association; November 13, 2006; Los Cabos, Mexico; and is published after peer review and revision. Acknowledgment: The author gratefully acknowledges Cynthia Kirtland, chaplain at the Virginia Mason Medical Center; Susan Long, MLS, at the Virginia Mason Medical Center Medical Library; and Elisabeth Davis, MA, of the American College of Surgeons for invaluable support with literature search and review. References 1. Evans SRT A year like no other [editorial]. Arch Surg 2005;140592Google ScholarCrossref 2. Powell ACMcAneny DHirsch EF Trends in general surgery workforce data. Am J Surg 2004;1881- 8PubMedGoogle ScholarCrossref 3. Etzioni DALiu JHMaggard MAKo CY The aging population and its impact on the surgery workforce. Ann Surg 2003;238170- 177PubMedGoogle Scholar 4. Liu JHEtzioni DAO’Connell JBMaggard MAKo CY The increasing workload of general surgery. Arch Surg 2004;139423- 428PubMedGoogle ScholarCrossref 5. Stitzenberg KBSheldon GF Progressive specialization within general surgery: adding to the complexity of workforce planning. J Am Coll Surg 2005;201925- 932PubMedGoogle ScholarCrossref 6. Jonasson OKwakwa F Retirement age and the work force in general surgery. Ann Surg 1996;224574- 582PubMedGoogle ScholarCrossref 7. AAMC Statement on the Physician Workforce, June 2006. Association of American Medical Colleges Web site. http://www.aamc.org/workforce/workforceposition.pdf. Accessed October 2, 2006Google Scholar 8. US Department of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook: Physicians and Surgeons. 2006;http://www.bls.gov/oco/ocos074.htm. Accessed August 2, 2006 9. Fronczek P American Community Survey Reports: Income Earnings, and Poverty From the 2004 American Community Survey. Washington, DC Housing and Household Economic Statistics (HHES) Division, US Census Bureau2005;1- 20 10. US Department of Labor, Bureau of Labor Statistics, Occupational employment and wages: 29-1067 surgeons. May2005;http://stats.bls.gov/oes/current/oes291067.htm. Accessed August 2, 2006 11. Buckley JE Research summary: rankings of full-time occupations by earnings, 2000. Mon Labor Rev 2002;12546- 57Google Scholar 12. National Opinion Research Center, General Social Survey. Chicago, Ill National Opinion Research Center1991; 13. Katz P The Scalpel's Edge: The Culture of Surgeons. Needham Heights, Mass Allyn & Bacon1999; 14. McGregor DB Chester Bidwell McVay, MD: the practicing anatomist. Arch Surg 2002;137226PubMedGoogle ScholarCrossref 15. Organ CH Jr Lester is coming [Surgical Reminiscence]. Arch Surg 2001;1361087PubMedGoogle ScholarCrossref 16. Maugans TAWadland WC Religion and family medicine: a survey of physicians and patients. J Fam Pract 1991;32210- 213PubMedGoogle Scholar 17. Hinshaw DB Spiritual issues in surgical palliative care. Surg Clin North Am 2005;85257- 272PubMedGoogle ScholarCrossref 18. Koenig HG Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J 2004;971194- 1200PubMedGoogle ScholarCrossref 19. King DEBushwick B Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 1994;39349- 352PubMedGoogle Scholar 20. Ehman JWOtt BBShort THCiampa RCHansen-Flaschen J Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;1591803- 1806PubMedGoogle ScholarCrossref 21. Tarpley JLTarpley MJ Spirituality in surgical practice. J Am Coll Surg 2002;194642- 647PubMedGoogle ScholarCrossref 22. Sulmasy DP Spiritual issues in the care of dying patients: “ . . . it's okay between me and God.” JAMA 2006;2961385- 1392PubMedGoogle ScholarCrossref 23. Puchalski C Spirituality in health: the role of spirituality in critical care. Crit Care Clin 2004;20487- 504, xPubMedGoogle ScholarCrossref 24. Groopman J God at the bedside. N Engl J Med 2004;3501176- 1178PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

The Top 10 Reasons Why General Surgery Is a Great Career

Archives of Surgery , Volume 142 (5) – May 1, 2007

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References (28)

Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0004-0010
DOI
10.1001/archsurg.142.5.423
pmid
17515483
Publisher site
See Article on Publisher Site

Abstract

Abstract It is an honor to stand before yoeu with the opportunity to deliver the Presidential Address for the annual meeting of the Western Surgical Association (WSA). I have gained more from the WSA than I could ever return. To serve as the secretary for 5 years and the president this year represents the peak of my professional life. It is an honor that I will always cherish, and for which I will be forever grateful. My first task today is to thank several people who are responsible for my position at the podium. Anyone in the audience who knows me well realizes that I will be unable to accomplish that goal in the manner it deserves without completely dissolving into tears. Regrettably, by necessity, I must limit my remarks simply to saying “Thank you” to my family—Pat, Margie, and David. I would also like to introduce and thank the person who has run my surgical practice during my tenure at Virginia Mason, Sandhya Mishra. Finally, I would like to dedicate this talk to my father, Dr Richard Leeson Thirlby. It goes without saying that I have been contemplating the topic and content of my presidential address for 364 days. I reread many of the previous addresses of the presidents of the WSA. It became evident immediately that I could not match the eloquence or insight of my predecessors. I was left to abide by the sage credo that guides much of what I do: “Play to your strengths.” I am a very positive person. I believe much of my success results from an ability to ignore frustration and to act on the positives; hence, my topic. All too frequently, I hear tirades of surgical colleagues that could provide the content for another talk entitled “Top 10 Reasons Why I Hate My Job.” I will leave that talk for another individual. My objective today is to remind you or convince you that you practice the greatest profession on earth. View LargeDownload Richard C. Thirlby, MD Another guiding principle of any good address is to “know your audience.” From this principle emerges a potential problem with today's address. My audience today is dominated by several hundred successful, experienced general surgeons. Without sounding pretentious, my hope is that this address will be published, and so one day be read by young individuals contemplating a career in medicine and, eventually, surgery. This assumption affected my choice of topics you are about to hear. What could I say to convince a high school student, a college student, or a medical student that surgery is a great career? I suspect that some elements that you think unimportant may be very important to a college undergraduate. Thus, a potential problem with this talk is the inevitable “constructive feedback” I will receive from my colleagues about my Top 10 choices. They will point out things I forgot! Without doubt, I have omitted things and/or incorrectly ordered or ranked my reasons. I encourage you to let me know the errors of my ways. If I foster an enthusiastic discussion between you and your colleagues, challenging my thoughts with better ideas, I will have accomplished my goal today. So without further ado, with apologies to David Letterman, here we go. The “Top 10 Reasons Why General Surgery Is a Great Career.” 10. training is fun (you'll never forget it) and training never stops Surgical residency might be considered by some to be a deterrent to making general surgery a great career. I disagree. Is it arduous? Yes. Is it fun? Absolutely. The excitement starts on the first day of internship. Stephen Evans put it nicely in a recently published editorial: “No other profession comes close in terms of duplicating the level of intensity, fear, or anxiety that comes with the first day of internship.”1 This intensity continues for the duration of the training. It provides young people with great life experiences and memories. Let me illustrate the latter claim with an observation. If 2 or more surgeons who trained together are placed in a room together for more than 5 minutes, the conversation inevitably turns to recollection of experiences of residency. As any spouse of a surgeon can attest, stories of residency dominate conversation during alumni receptions at the American College of Surgeons Clinical Congress. Although the events may have occurred decades ago, they are recalled vividly, as if they occurred just yesterday. When one spends 80 to 100 hours per week with people in high-stress circumstances, personalities emerge. The experiences are remarkable and life-changing, and the friendships are enduring. They cannot be matched by any other career. The training never stops. Surgical or medical training does not stop with the end of residency. I can think of few, if any, careers in which the necessity of “continuing education” is so relevant. The judicial system has not changed appreciably since 1776; medicine and surgery change weekly. I asked our medical librarian to tally the English-speaking journals relating to general surgery. Her count totaled 75. Assuming the majority of these journals publish 12 issues annually, there are about 900 issues per year, probably in excess of 9000 manuscripts per year. What other career provides so much opportunity for mental advancement? There will be thousands of articles published this year that will be available to stimulate us to improve. Surgery is not unique among medical careers in this regard; however, I cannot think of another career that provides such stimulation, advancement, and change for an entire career. 9. job security Job security is a good thing. For decades, there has been debate regarding the supply and demand of physicians and surgeons. I have neither the time nor the desire to bore you with the details of the 1910 Flexner report, nor the multiple iterations of the Graduate Medical Education National Advisory Committee (or GMENAC) reports. Suffice it to say, these folks were not good at predicting things. This committee predicted that in 1990 there would be about 35 000 general surgeons in a country that needed about 23 000 surgeons, a surplus of about 12 000 surgeons.2 What happened? In 1990, there were about 29 000 surgeons in a country that needed about 28 000 surgeons.2 If I do the math correctly, that is about a 12-fold error. If any of us missed our targets by 12-fold on a consistent basis, we would be out of a job. The complexity of the variables involved exceeds the ability of most to make valid predictions. The current consensus is that there will not be enough general surgeons for the foreseeable future. There are several reasons. First, America is aging and general surgeons treat aged patients. At present, there are about 35 million Americans over the age of 65 years.3 By 2020, there will be about 53 million persons over the age of 65 years. The aged population, therefore, will increase by about 50%. This aging population will result in huge growth in demand for surgical services. It has been projected that the US population will increase by about 18% in the next 20 years.4 However, because of the aging population, it has been projected that the workload of general surgeons will increase by about 30%.3,4 How many general surgeons will there be? A recent publication by Stitzenberg and Sheldon5 suggests that progressive specialization within general surgery likely is going to decrease the numbers of general surgeons being produced and add to the complexity of workforce planning. Although about 1000 persons graduate from residencies in the United States annually, about 750 are currently entering fellowship training. Thus, the number of persons graduating and entering traditional general surgery practice in 2004 is only about 250 per year. Furthermore, surgeons are retiring earlier.6 The bottom line is that in the next few years, there will be a significant shortage of general surgeons, roughly 5000 or a 15% deficit. The Association of American Medical Colleges (AAMC) recently published a consensus statement on the physician workforce.7 They conclude that there will be a severe shortage of physicians in the next few decades. They suggest, therefore, that entry-level positions be increased in both medical schools and residency programs. They calculate that medical school enrollment should be increased by 30%.7 Similarly, the positions in graduate medical education programs, or residencies, should be increased by the same fraction. In a moment of remarkable insight, they go on further to recommend that “the AAMC should provide students, physicians, programs and hospitals with the best available and timely data on physician workforce needs in order to support informed decisions.”7 That is, the AAMC will give students information suggesting that we need general surgeons. However, I have a high level of cynicism toward those who try to predict the future. If given the opportunity to counsel young people, I would rather choose to state facts of the present and/or relate empirical observations to illustrate the point. As a program director in general surgery for 14 years, I have never had any trouble getting one of our graduates a good job; most have many great job offers. As a practicing surgeon, I can think of only 1 or 2 examples of good surgeons who left a community or a practice because of politics or lack of income or success of their practices. The bottom line is that a good general surgeon will be successful and have total job security for the next several decades. Name another desirable profession that can make that claim. You have total job security, and job security is a good thing. 8. the pay is not bad I live in Seattle, Wash. Not a week passes that does not provide me the opportunity to meet a “Microsoft millionaire.” A Microsoft millionaire is usually between the ages of 40 and 50 years, is worth millions, and has not worked for about 5 years. They do serve a purpose. They have the time to coach our children's Little League teams, which, regrettably, busy general surgeons do not. Yet, it does not seem fair. I work harder, am better educated and more skillfully trained, and deal with significantly more stress than they do. The surgical locker rooms of America are filled with surgeons complaining about inequities of financial compensation. I could relate to you countless examples of corporate greed, of insurance executives collecting obscene compensation packages, but I will not do that. Rather, let us look at the facts. The facts are that the average general surgeon in the United States has an annual salary of $280 000 per year.8 Pay increases progressively for the first 17 years of practice, peaking at about $300 000 per year. This pay scale puts him or her in the top 99.9% of income of employed Americans. The median household income in the United States is $44 000 per year.9 The average annual salaries of lawyers, computer/information systems, engineers, financial managers, financial advisors, and architects are $110 000, $102 000, $66 000 to $97 000, $96 000, $82 000, and $68 000, respectively.10 The Bureau of Labor Statistics calculates the average hourly wage for all professions in the United States.11 They provide data for 427 possible jobs in 2002. The highest hourly wage in the US is airline pilots, $95 per hour. The catch here is that pilots only work an average of 23 hours per week. The lowest salary, the 427th in the list, is that of waiters and waitresses, $4 per hour. The second highest hourly wage in the United States is that of physicians, $61 per hour. Physicians average 41 hours per week.11 The data are not broken down into physician specialty groups, but general surgeons are among the highest-compensated physicians. Lawyers and financial managers are ranked 14th and 34th in hourly wage, respectively. Are there inequities when it comes to compensation of general surgeons? Of course there are. If you are a general surgeon, 17 years into your career you likely have annual earnings ($300 000) that are substantially less than those of the radiologists or radiation oncologists in your institution ($450 000)—certainly not a fact that is based on common sense or justice. Even the anesthesiologist ($340 000) drinking coffee in the lounge while you are performing a Whipple resection is making more than you are. That is not fair or appropriate. However, the fact remains that general surgeons are paid very, very well. Our salaries afford us a lifestyle that is better than 99.9% of people in Western civilization. We should be embarrassed if we complain in public about our pay. 7. your mother will be proud of you The prestige of physicians and surgeons in the eyes of the American public has declined over the last 4 to 5 decades. The reasons for this are complex, and time does not permit me to discuss them at length. The condensed version or explanation of this decline in prestige is that we have “what we deserve.” My father practiced urology in northern Michigan for 40 years. One of his pet peeves was the phenomenon of physicians driving expensive cars with personalized license plates advertising the fact that they are physicians. I recently saw a Porsche with a license plate that said “skin doctor.” How can we, as a profession, complain that we have lost the respect of the American public when we do things like that? Thankfully, however, the fact remains that our patients, and the residents of the communities we serve, respect us a great deal. Surgery was ranked as the most prestigious occupation in a recent national survey, outranking the positions of college presidents, astronauts, big-city mayors, lawyers, and all other physicians. Recent data compiled by the National Opinion Research Center concluded that surgeons are the most respected professionals in the United States.12 We are highly respected for our technical skills, and the public values our ability to deal with very high on-the-job stress and appreciates our work ethic. Surgeons are respected in their communities. At work, surgeons are treated with respect and admiration by all levels of coworkers, from nurses to the hospital maintenance workers. Surgeons are revered by their patients. Your family is proud of you; even your mother-in-law is proud of you. Most important, however, your mother is proud of you. 6. surgeons have panache: the surgical personality and the culture of surgery As described before, surgeons are admired by the public. While you may argue that your life bears little resemblance to that portrayed by surgeons in Hollywood and modern television, there must be some justification for the dozens of movies or television shows depicting surgeons in action. The panache of the surgical personality is glorified by Hollywood. Surgeons on the movie screen are portrayed by people like Elliot Gould or Donald Sutherland, on television by the beautiful young men and women of Grey's Anatomy. Internists are portrayed by people like Robert Young in Marcus Welby, MD. The surgical personality is part of the culture of surgery. The recently published book, The Scalpel's Edge was written by a psychologist who had the opportunity to observe a team of academic surgeons.13 The author, Pearl Katz, very accurately describes the surgical personality and the culture of surgery. Like the writers of MASH, she observed that surgeons have a demeanor of confidence and apparent arrogance. She then attempts to explain why that might be the case. She suggests that: The kind of work that surgeons do influences their demeanor and behavior with others. What other profession makes decisions and takes risks that literally control patients' lives or deaths on a daily basis? Who but a surgeon routinely and boldly cuts into the most intimate depths of people's live bodies, penetrates their innermost body cavities? . . . Surgeons' detachment from their patients may be understood as necessary protections from these routine sights, smells, acts, and dramatic confrontations with mortality. Their demeanor of confidence and apparent arrogance may be partially explained by the almost superhuman requirements of their work.13(pviii) Katz observed that the surgical personality is characterized by a preference for acting over not acting. It has been part of the culture of surgery, since it was distinguished from medicine in the second century. “Surgeons' reluctance to admit doubt and uncertainty or error was likely to have permitted them to be sufficiently bold to carry out extremely difficult and risky procedures.”13(pviii) How is it that surgeons can deal with the stress of performing life-threatening operations on a daily basis? Katz's hypothesis is interesting. She was fascinated by the rituals of the glove and gown process, of the draping procedure that shielded the face and personality of the patient from the surgical team. She believes that: The rituals that are enacted in the operating room also shield surgeons from the emotions of other patients and from their own emotions. . . . In addition to separating the head of the patient from the rest of his body, operating room rituals facilitate a mind-set which focuses [on the technical aspects of the case, not the patient] . . . they facilitate surgeons' existing penchant for action and to avoid responding to distressing emotions.13(p110) The dominant themes of surgical culture—action, heroism, certainty, and optimism—are not compatible with identification with, or communication with, helpless, hopeless patients. . . . The process of repressing normal feelings of empathy is necessary during surgery. . . . Otherwise, they [the surgeons] would be forced to experience intolerable feelings of disgust, horror, fear, or excitement, and their own confrontations with death.13(p123) For decades, the culture of surgery was dominated by men. Is the traditional surgical personality by necessity masculine? The answer is no. Will the surgeons of the future have “panache”? The answer is yes. Katz accurately observed that “Surgical culture perpetuates itself by the recruitment and training of residents through a long apprenticeship process. Residents are often attracted to surgery by the image of the surgeon, with its prestige, power, and heroic mystique that is shared by most people in North American culture.”13 There is nothing related to gender in this attraction to surgery and the surgical personality. I would agree with Katz, who believes that women in surgery will make our profession better. The new surgical heroes may rather be those who can admit doubt and uncertainty when it exists, and can admit limits and be comfortable with palliation. They may communicate sensitively with patients. . . . The new surgical heroes may not be those men who make decisions and take risks for their patients, but rather those men and women who make decisions and take risks with their patients.13(p210) Women in surgery will enhance the prestige of our profession, while maintaining the culture and panache of surgery and, more important, improving the product. The culture of surgery is further illustrated by the WSA. Name another career that has resulted in organizations like the WSA, that drives busy professionals to spend thousands of dollars to spend time, learn, and socialize with colleagues from around the country. There is a bond, cemented by a profession that is greater than any other, that connects us all. In summary, if you choose surgery for a career, you will join a culture like no other. 5. you will have “heroes”; you will be a hero The Halstedian teaching model, the apprenticeship model, provides mentors. Mentors become role models and they become heroes. While many careers potentially foster a “hero-worship” relationship between the pupil and the teacher, I would contend that the relationship between surgeons and their mentors transcends that of all other careers. Claude Organ incorporated a feature called “Surgical Reminiscences” in the Archives of Surgery that illustrated the uniqueness of this bond. Each article describes what I call “hero-worship” between student and mentor. Western Surgical Association member Byron McGregor talked about his relationship with fellow WSA member and WSA president Chester McVay, who quoted the 12th-century chancellor Bernard in his classic anatomy text, saying that “we are like dwarfs seated on the shoulders of giants. If we see more and further than they, it not due to our own clear eyes or tall bodies, but because we are raised on high by their bigness.”14(p1) Byron astutely observed that McVay transformed himself from a humble dwarf into one of the very giants he so admired, “thereby making room up there for the rest of us . . . and, the view is fine!”14(p1) Doctor Organ wrote about his first interaction with Lester Dragstedt. Claude was a junior resident doing basic science research in a gastrointestinal physiology laboratory; the legendary Dr Dragstedt was a visiting professor. During the visit, a young Dr Organ had the opportunity to discuss his research with Dragstedt during a one-on-one meeting in his laboratory. Claude then transported Dragstedt to his hotel. As they departed, Dragstedt presented Claude with his card and offered to communicate with him about the research project. It was a moment, Claude observed, “in my surgical training and surgical experience I shall never forget.” He observed that “others might possess the card of legendary sports figures, but I had the card of Lester L.R. Dragstedt, MD, FACS, Professor of Surgery and Physiology.”15(p1) My mentors are heroes. I could list dozens of heroes . . . many are sitting in this room. I need to acknowledge two, both members of the WSA: Bill Fry and Robert McClelland or “Dr Mac.” It was my privilege to sit on Bill Fry's shoulders for 10 years in Dallas. He is the most talented surgeon I know. Dr Mac, the originator and editor of Selected Readings, has done more for surgical education than any surgeon ever. Dr Mac's knowledge of the surgical literature dwarfs that of any other individual on earth. A Dr Mac–trained surgeon knows that good surgical care can only be delivered by a surgeon who gets better every day. The best way to accomplish that goal is to read the surgical literature every day. I have photos of Drs Fry and McClelland in my office. I look at them daily for inspiration. To quote Dr McGregor, the view from their shoulders is “just fine.” Every surgeon in this room is somebody's hero. Whether you are in private practice in a small community hospital or a department chair at a major university, there are young surgeons, young medical students, or young people thinking of a career in surgery who had the privilege to work with you in a hospital and think of you often. You are somebody's hero. Of all the letters I have received from graduates of our program thanking me for being part of their training, perhaps the one that affected me most profoundly ended like this. “How does a student thank a mentor? . . . How do we thank you for those gifts? We emulate you.” What a great career. We have a profession and a culture that fosters heroes, we sit on the shoulders of giants, and we too can impact others' lives profoundly. 4. there's spirituality if you want it What do I mean by this? I can illustrate what I do not mean with a joke you have all heard. Although there are many variations on the joke, the short version goes something like this: “What is the difference between surgeons and God? God knows he is not a surgeon.” My circulating nurse of 17 years, Thea Nortness, told me that joke. I do not recall exactly the circumstances that prompted it, but I have encouraged her to retell the joke any time she feels it is appropriate. We would all probably benefit from having a hospital employee tell us this joke on a frequent basis. What I do mean is that, as surgeons, we are dealing with people on a daily basis who are using their spirituality to navigate through very stressful and/or life-threatening circumstances. A recent poll shows that 59% of the US population considers religion extremely, or very, important in daily life. However, being a surgical patient is not “daily life.”16 Nearly 100% of our patients use their spirituality during their surgical care.17 How is that relevant to the career of surgery? If spirituality is important in your life, if spiritual interactions give you strength, give you peace, surgery will make your life better every day. Surveys of hospital inpatients report that 77% of patients believed their physicians should consider their spiritual needs, 48% wanted their physicians to pray with them, but 68% said no physician had ever inquired about their spiritual or religious needs. . . . 94% thought it appropriate for physicians to inquire about their spiritual beliefs if they became gravely ill.16-20 How should these data influence my surgical care? I am not sure. I do know that the bond that can form between surgeon and patient is profound. The act of making a skin incision may be a simple technical exercise, but as the tissues open, the patient and the surgeon are bonded. From the patient's perspective, undergoing general anesthesia, being put to sleep while lying prone, is cause for thought. Is that spirituality? It usually is. All of us acknowledge the value of the recent emphasis in medical care on “patient-centered care” and the paramount importance of health-related quality of life. As John and Maggie Tarpley21 observe, if the majority of our patients view spirituality to be important in their ability to deal with illness, and “if the patient-centered approach to medicine is the gold standard, then spiritual aspects of each person must be considered.” Spiritual well-being is a major component of health-related quality of life.22 However, despite increasing evidence that patients would like their physicians to do so, spiritual issues are rarely addressed by 21st-century Western physicians.21 Clinicians who ignore the spiritual concerns of patients are, in effect, asking many patients to alienate themselves from beliefs that deeply define them. Astute clinicians pick up clinical clues from patients.23 The Hindu amulet, a copy of the Qur’an, rosary beads, a Bible, or Shabbat candles on the nightstand next to the bed may be as much communication to the surgeon as they are spiritual aids to the patient. They are signs of what the patient holds most dear. All that may be needed is a simple, open-ended question to engage the patient on a spiritual level. Showing respect for such defining features of a patient's life may constitute a healing act and can be integral to the care of the “whole patient.”23 How many careers can document that 90% of their customers use prayer or spirituality to help them through their relationship with the provider of the service? I can only think of a couple: airline pilots and casino dealers. In the case of commercial airlines, there are few atheists in the passenger section. However, the pilot has no personal or emotional contact or spiritual bond with the client. In the case of casinos, the dealer is the devil. The problem for me is that none of my training taught me to address the spiritual needs of my patients. How should physicians examine and engage religion in the lives of their patients? As a program director in general surgery for the last 14 years, I have supervised the curriculum of about 2100 didactic conferences. Ninety percent of my patients want me to address spirituality, yet I have never put the topic “on the table” for my residents. I have no great expertise or insight into this dilemma; I just know it is important. Jerome Groopman recently addressed this dilemma in an editorial entitled “God at the Bedside.”24 One of his dying patients told him she was frightened and said “Doctor, I want you to pray for me.” Groopman, however, had no training for dealing with this request. He eloquently describes the uncertainty of the boundary between professional and personal relationships. Finally, he drew on the customary practice of his teachers and answered a question with a question. He asked his patient: “What is the prayer you want?” “Pray for God to give my doctors wisdom,” the patient said. To that, he silently echoed, “Amen.” I will summarize with a statement that I will boldly call “Thirlby's dictum”: There are no atheists lying on operating room tables. Virtually all of your patients who are about to undergo major surgical procedures are having conversations with a being that is bigger than you or me. If you wish to do so, you can acknowledge this. You can do it with words, most patients welcome it, or you can do it with a smile, a gentle touch, and a few seconds of eye-to-eye contact that communicates clearly the spirituality of the moment. Few careers involve daily situations in which this intense, yet peaceful, exchange can occur. Name another career that evokes such emotions from the recipient and provider of services. 3. you will change patients' lives On the advice of a colleague a few years ago, I started saving thank you letters I receive from patients. They are in a file in my office. All of you have received these. I suggest you save them as well. If you read them again, it will convince you that you are in a great career. It will keep you going. You truly do change patients' lives. Here is a sampling from my file: “Thank you for successful efforts. It's great to have my life back.” “He was sick for a long time, but thanks to all of you, he has been given a chance to live a normal life again.” “Thank you all in helping rid me of a condition which gave me no peace. . . . Love you all for who [you are] and what you’ve done.” “Thanks so very much . . . you have freed me from an outer shell of anguish. God bless you.” “I intended to write this note a while ago to thank you for the wonderful care all of you provided during my recent surgical experience. You made such an impact on my life and I feel as if I have been given a second chance after having gone through this ‘miracle surgery.’ I am so thankful you have dedicated your lives to help improve the lives of others. I will never forget the incredible impressions all of you have made on my life and in my heart.” “I am doing wonderful! I can't even thank you enough. My appetite is crazy . . . too good! My system is finally feeling and doing its own natural things once again.” “Thank you so very much for all your kindness and care. I feel better than I have in years.” “I don't know how to begin to express my thanks and the thanks of my family.” “It is truly life changing. It's awesome.” “After living with UC [ulcerative colitis] for 25 years, for the first time in my memory, I know what ‘health’ feels like.” From another patient with UC, “I count my blessings every day to have had you as my surgeon. I think of my scars as beauty marks that remind me of how much I have to be thankful for. I wear them proudly.” And another patient with UC. “You have totally changed my life. . . . I had an absolute blast at the ninth-grade dance. My friends . . . said I looked gorgeous. And I owe it all to you . . . I will be eternally grateful, you erased the disease that had ravaged my body for 3 years.” “I am so thankful you have dedicated your lives to help improve the lives of others.” Many letters will draw on the importance of spirituality that I discussed above. “I know it was God who placed you in that ER room that Monday.” “God has given you the best gift of all . . . the ability to save lives. Thank you for everything.” “We have faith in you and a deep faith in God and He’ll watch over both of you.” “I thank God every day. . . . May you continue to be blessed with His healing gift.” “I don't know if you are a spiritual person, but I believe you are an angel.” While reading these may seem a bit self-promoting, that is certainly not my intent. All of you have received letters nearly identical to this; all surgeons have. I read these to remind all of you that you are truly changing patients' lives. Save the letters and reread them when you are down on your luck. It will remind you that you have a great career. 2. patients will change your life A patient, J.S., developed testicular cancer when he was a young man. His treatment included high-dose, external-beam radiotherapy to the pelvis. He presented to the Virginia Mason Medical Center a few years ago in his early 40s with a destructive, high-grade sarcoma of the left pubic ramus. The only effective treatment was radical excision. Our orthopedic oncologist, our vascular surgeon, and I performed a radical en bloc excision of the pubis and the hip joint. I reflected structures such as the colon and ureter out of harm's way; the femoral vessels were divided and reconstructed. The pubis and part of the acetabulum were resected en bloc. My orthopedic colleague assured me that ambulation would be possible despite the loss of the essential bony structures of the left hip, but that it would “hurt a little bit.” During J.S.'s preoperative evaluation, he was always remarkably upbeat. He never expressed any blame on the medical community for this “radiation-induced” tumor. He never seemed the least bit scared, bitter, or sad. He never intimated that he had been dealt an unfair circumstance; he only asked what we, and he, needed to do to get on with treatment and healing. He did not change after his operation. His pain management used the typical patient-controlled, narcotic analgesic techniques. On his second postoperative evening, his care team decided that he needed to mobilize to a bedside chair the next day. I entered J.S.'s room that morning on rounds. He was in the middle of his chair transfer. A nurse was in attendance. Every vein in J.S.'s forehead was popping out, sweat was beading on his brow, he was clearly in great pain, but was determined to transfer to the chair as he had been told to do. As I sized up the situation with my residents, I told J.S. to “hold on,” we could lift him to the chair. J.S. stopped his agonizing transfer, somehow managed to smile at me, and said “Don't worry Doc, I don't need any help.” That moment is etched in my brain. I shall never forget it. With tears in my eyes, I thanked him for changing my life. How many times have you treated a patient with a disabling or lethal disease? Despite pain, despite the prospect of mortality or severe disability, despite potential financial ruin, our patients routinely smile; they routinely exhibit a strength of spirit, mind, and body that transcends normal human behavior. Many times we see the anger. Many times we see the fear. Many times we see difficulty dealing with pain. However, when it is all said and done, what we are privileged to see on a daily basis is a strength of spirit that trivializes our daily worries. How can we, in good conscience, complain about anything in our daily life on the same day that a patient with a lethal cancer who is in extraordinary pain says “he doesn't need any help”? When our patients thank us for all our work on their behalf, our response should be “No, J.S., thank you. You did all the work. I did the easy part. Thanks for the privilege of getting to know you.” 1. i love to cut Rolling the right colon in a thin young patient with ulcerative colitis, putting a suture in the stomach, putting a stitch in Cooper's ligament: I could go on and on. A tough operation is completed with intuitive and clear anatomic dissection, minimal blood loss, a perfect anastomosis. You know the patient is going to do well. My vascular surgical colleagues tell me it is completing the perfect carotid endarterectomy in the perfect plane with a perfect feather. The patch looks like it was placed with a precise sewing machine. At the completion of a complex operation, you take your gloves off, take a cleansing breath, thank the operating room staff (and, in ingenuous fashion, the anesthesiologist), and find the family to relay the good news: you tell the family that “all is well, your loved one is going to be just fine.” What satisfaction! What other career provides both the rush of operating and the satisfaction of guiding a smooth perioperative course? I love to cut. Many a resident has heard me say, while rolling the right colon during an ileoanal pouch, “I can't believe somebody is paying me to do this.” With the exception of professional baseball, I cannot think of another job where the pay is so good to do something so fun. The cynics in the audience might respond, “Yes, but what about all of the baggage outside of the operating room?” My response to that is that the prize makes the other stuff worth it. We have a career that affords us the opportunity to be paid to do something that is truly fun. It is why we are all in surgery. Cherish it. In conclusion, members and guests of the WSA, you are all very fortunate indeed (Table). You were born with the mental and physical attributes necessary to excel as high school, college, and medical students. You were blessed to be provided with the opportunity to utilize your talents. At some time in your education, you were injected with the addicting drug called “surgery.” You had and/or developed panache. You have become a very successful surgeon, which affords you job security, financial comfort, great respect in your community, and daily personal interactions that are profound and fulfilling. Best of all, when you go to work, you get to cut. Don't ever complain; you have the greatest job in the world. Table. View LargeDownload Top 10 Reasons Why General Surgery Is a Great Career Back to top Article Information Correspondence: Richard C. Thirlby, MD, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, PO Box 900 (C6-SUR), Seattle, WA 98111-0900 (gtsrct@vmmc.org). Accepted for Publication: December 5, 2006. Financial Disclosure: None reported. Previous Presentation: This paper was presented as the Presidential Address at the meeting of the Western Surgical Association; November 13, 2006; Los Cabos, Mexico; and is published after peer review and revision. Acknowledgment: The author gratefully acknowledges Cynthia Kirtland, chaplain at the Virginia Mason Medical Center; Susan Long, MLS, at the Virginia Mason Medical Center Medical Library; and Elisabeth Davis, MA, of the American College of Surgeons for invaluable support with literature search and review. References 1. Evans SRT A year like no other [editorial]. Arch Surg 2005;140592Google ScholarCrossref 2. Powell ACMcAneny DHirsch EF Trends in general surgery workforce data. 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US Department of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook: Physicians and Surgeons. 2006;http://www.bls.gov/oco/ocos074.htm. Accessed August 2, 2006 9. Fronczek P American Community Survey Reports: Income Earnings, and Poverty From the 2004 American Community Survey. Washington, DC Housing and Household Economic Statistics (HHES) Division, US Census Bureau2005;1- 20 10. US Department of Labor, Bureau of Labor Statistics, Occupational employment and wages: 29-1067 surgeons. May2005;http://stats.bls.gov/oes/current/oes291067.htm. Accessed August 2, 2006 11. Buckley JE Research summary: rankings of full-time occupations by earnings, 2000. Mon Labor Rev 2002;12546- 57Google Scholar 12. National Opinion Research Center, General Social Survey. Chicago, Ill National Opinion Research Center1991; 13. Katz P The Scalpel's Edge: The Culture of Surgeons. Needham Heights, Mass Allyn & Bacon1999; 14. McGregor DB Chester Bidwell McVay, MD: the practicing anatomist. Arch Surg 2002;137226PubMedGoogle ScholarCrossref 15. Organ CH Jr Lester is coming [Surgical Reminiscence]. Arch Surg 2001;1361087PubMedGoogle ScholarCrossref 16. Maugans TAWadland WC Religion and family medicine: a survey of physicians and patients. J Fam Pract 1991;32210- 213PubMedGoogle Scholar 17. Hinshaw DB Spiritual issues in surgical palliative care. Surg Clin North Am 2005;85257- 272PubMedGoogle ScholarCrossref 18. Koenig HG Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J 2004;971194- 1200PubMedGoogle ScholarCrossref 19. King DEBushwick B Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 1994;39349- 352PubMedGoogle Scholar 20. Ehman JWOtt BBShort THCiampa RCHansen-Flaschen J Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;1591803- 1806PubMedGoogle ScholarCrossref 21. Tarpley JLTarpley MJ Spirituality in surgical practice. J Am Coll Surg 2002;194642- 647PubMedGoogle ScholarCrossref 22. Sulmasy DP Spiritual issues in the care of dying patients: “ . . . it's okay between me and God.” JAMA 2006;2961385- 1392PubMedGoogle ScholarCrossref 23. Puchalski C Spirituality in health: the role of spirituality in critical care. Crit Care Clin 2004;20487- 504, xPubMedGoogle ScholarCrossref 24. Groopman J God at the bedside. N Engl J Med 2004;3501176- 1178PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: May 1, 2007

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