I have lived a life of great good fortune in health, faith, family, and profession. Emblematic of that good fortune is my membership in this society, its encouragement, inspiration, fellowship, and the occasional worthy golf partner. My gratitude for the privilege of this podium is beyond my means of expression, but despite my perceived lack of eloquence, it is no less heartfelt.
It has been my privilege to live, work, and teach during the ascendancy of surgical science and practice. Many accomplishments that benefit our patients and students have been a source of warmth, pride, and just plain fun. I would, therefore, trade places with no other man or woman.
During these years, I have been party to a multitude of presidential addresses on a host of subjects. In my attempt to find a way to make this often-painful process tolerable to each of you, I asked myself the question, “What is the purpose of a presidential address?” Is it to enlighten, to entertain, to excite, to educate, or is it simply to be endured? I hope not the latter.
I would first like to pay tribute to members of the Southern Surgical Association of special significance and influence on my life. First, Dr. Harwell Wilson, president of the Southern Surgical Association in 1970, was my professor and chief. He provided me with a residency, gave me my first, best, last, and only job in surgery at the University of Tennessee. Dr. Wilson loved this association. He encouraged each of us to attend these meetings and make membership a major goal of our professional career. He led our department by example as he was intensely devoted to the art and science of surgery and to the education of young people.
The second member of great merit and affection is Roger Sherman, who stands alone as the best teacher of young surgeons that I have ever known. He convinced me to pursue a career in academic surgery, taught me to operate, and provided friendship, support, and advice throughout my career.
The third major personality is, of course, Jim Pate, who is somewhere in this audience today wondering when I will get through. Jim, our chairman for 15 years, continuously displayed the most brilliant mind that I have been associated with during my career. An incomparable surgeon and colleague, he stimulated me and did his very best to teach me all he knew about running a department of surgery. Jim, the first cardiac surgeon in Memphis, conceived and created our renowned trauma center and skillfully dealt with major challenges to surgical education, ever-increasing governmental influence, a growing town–gown controversy, and a myriad of other issues with great success.
Finally, the most important member of this group, known to all in the Southern tradition as Miss Betty, is also my best friend, my conscience, and an ever-present force for good in my life. She has relished her role as part of the Southern Surgical Association for the past 30 years. I use this photograph with great fear of the consequences, but she is also a master gardener and some would say my master.
In preparation for this talk, I have received warm advice and much-needed help from a host of colleagues. I believe the best advice was from Jim Thompson, who said, “Talk about something that you feel passionate about.” My three passions are my family, surgery, and golf. Golf and surgery share much regarding attitude, aptitude, and reward.
Golf is certainly the perfect game for surgeons. Not for its relaxation potential, as it’s anything but relaxing; however, it fits the surgical personality perfectly—obsessive–compulsive—the feeling that one can and will and must be perfect.
I chose as the title for this talk “The Southern Solution to Our Current Malaise,” which I hasten to add are only my opinions and in no way reflects policy voiced by this great association.
By nature, surgeons are optimists. Our future, though clouded, can and will be influenced by organizations such as the Southern Surgical Association. It seems that we are witnessing the deflation of our work and that of those who have brought us here. I hope to present elements of that decline in some areas as I view them and suggest a few simple remedies. I believe that much of our current woe, particularly in surgical education, is due to abdication from our responsibility and failure to confront our critics.
The great historian, Arnold Toynbee, in his comparative study of civilizations asserted that the decline of civilization resulted in the abdication by the elite of the responsibility to lead, to innovate, and to establish and maintain standards. Instead they capitulated and often imitated the masses for fear they might be undone, resulting in the ultimate disintegration of society. Harry Truman, a more familiar and understandable figure, characteristically took a similar but more direct stance regarding critics and threats when he said, “I shall continue to do what I think is right whether anybody likes it or not.” I believe that much of our current woe, particularly in surgical education, is due to our abdication and our failure to confront our critics, our reluctance to assert our primacy in the conduct, definition, and direction of our profession and in the education and training of our surgical posterity. Have we lost confidence in our ability to do what we have done so well for so many years? This is the unspoken foundation of the process by which we began the study of medicine, continued in surgical training, and were eventually inducted into societies such as the Southern Surgical Association. Reality, then, is that there are those who know and those who don’t know. More importantly, it defines those who are responsible for the perpetuation of that which is good and the creation of that which is better.
I intend to briefly address four problems that stir my soul: surgical education, surgical recruitment and evaluation, fragmentation of surgery, and threat to academic medical centers. Although we are not responsible sometimes for the difficult circumstances we find ourselves in, we are responsible for the choices we make and our response to those circumstances.
First, medical, or better surgical education is in a constant state of flux. We receive counsel from every conceivable source that curricular change is necessary and essential in order to keep pace with an ever-changing environment. The surgical component of the medical school curriculum is becoming increasingly shortened and diluted, resulting in a lack of appropriate experience for our students. At the same time, we are told we must modify, which really means to shorten, surgical residency training programs to satisfy economic and lifestyle considerations. Burgeoning technological advances are appearing so rapidly that it’s difficult to even pronounce their names, much less embrace them. In the midst of this information and technological explosion, we are asked to embrace Web-based learning, virtual reality, and a host of new teaching systems unfortunately not based on productive give-and-take between student and teacher. What we cannot forget are the intangibles of a complete medical education, which are not obtainable on the Internet. The “We” in surgical education does not mean somebody else; it means me and it means you.
In my view, the principles of professionalism, compassion, competence, consultation, communication, collaboration, and a critical spirit long demonstrated by surgeons and surgical educators must be preserved and expanded. These are the core values that we have taught and need to continue to teach. The question is, how do we accomplish this in an era when technology draws us away from the bedside? To me the answer seems obvious: teach by example. This has been and must continue to be the foundation of the professional educational process. Everyone in this room can vividly and fondly remember a professor who had a lasting impact on their lives, both professionally and personally. If we live our lives as examples for our trainees, they will remember us longer for what they saw in us than what they heard from us. We can only provide the polish that produces a sophisticated end product by setting this example and most importantly by being a role model. We’ve then assumed and embraced our responsibility to an increasingly critical society that our end product meets their expectations.
We must regain control of the surgical education process. We must review and approve curricular changes and be more actively involved in their design and implementation. We must vigorously protest and confront efforts to legislate changes such as work hour restrictions that make unnecessarily punitive threats to our programs.
Our critics find fault in our educational process, our work hours, our humanness, our lifestyle, our love of income, and on and on. They seek to formalize and to stamp out what they perceive as wrong and thus produce a new breed of surgeons trained in a “kinder and gentler” environment. Although we are unable to measure compassion, humanism, a genuine caring spirit, good manners, and civility, all virtues said to be absent now; but presumably will be present in the future when the new ideal curricula are implemented.
Clearly some form of curricular uniformity is necessary, but the headlong pursuit of a guaranteed minimum standard, I believe, will result in the loss of the pursuit of excellence which we must never abandon. The simple truth is that we already know the fundamentals. A liberal dose of hard work and study and demonstration of the highest ethical and moral standards have and will continue to be the basics on which a good surgeon is developed. For these, there are no substitutions.
The next major concern is that of resident recruitment and evaluation. Our general surgery residencies are going unfilled. The most recent match results were a wake-up call. It appears that this year’s match will continue this downward trend. Unmatched positions are no longer a hallmark of the marginal program, but a reality for all of us. Our medical school graduates appear to be voting with their feet and over their departing shoulders they toss us the reasons of “lifestyle, long hours, lack of recognition, and diminishing prestige.” We formerly watched this catastrophe with poorly concealed glee as our internal medicine colleagues suffered this fate. Now we are perplexed that it is happening to us. How could this life, our life, be rejected and subjected to ridicule?
To paraphrase Julius Caesar, the fault lies not in the stars, but in ourselves. We too often engage in a recitation of our woes and a prolonged state of unhappiness. Pride, hard work, continual study, and challenge emblematic of the surgeon have been replaced by feelings of doubt and chagrin easily interpreted by impressionable medical students who believe that we just don’t like being a surgeon. It is difficult, if not impossible, to teach by example and be a convincing role model if we convey self-doubt about our conviction and dedication to our craft. We need to re-examine and celebrate all that is fundamentally right about being a surgeon and convey that sense of accomplishment and pride to our aspiring medical students. If we succeed, more of them will pursue a career in surgery.
Accurate evaluation of surgical residents by its nature is difficult and will always be more or less subjective. The ABSITE examination and the American Board of Surgery qualifying examination test cognitive knowledge and general competence, which when coupled with the certifying exam are indications of surgical judgment and the possession of an orderly approach to patient care. Do we fail to address one of the most important aspects of the surgical armamentarium, operative skill? No degree of sophisticated critical care can compensate for a poorly done or ill-conceived operation. What is the best teaching method in regards to technical competence? It is a recurring theme: we teach by example! Our technical skills are hopefully emulated and assimilated by our residents. There must be both thorough demonstration and critical evaluation of operative technique by faculty during residency training. Evolving technology, including skills laboratories and computer-based virtual reality exercises, may be helpful as manual dexterity tests, but no matter how sophisticated, fail to completely duplicate the stressful environment of the operating room. The faculty and chair must ultimately be responsible for this critical maturation process and evaluation by repetitive observation in close quarters.
I know of no way to teach professionalism, morality, and ethics except by example, nor do I know how to test our effectiveness in teaching these qualities. Since there are not objective measures, we must depend on society to be the eventual judge of our success, and they will render the final grade. It is our responsibility to ensure that society’s perceptions, as far as possible, are based on appropriate criteria and not superficial qualities such as affability or social standing that fail to reflect professional excellence. Competency initiatives applied to all levels of medical education are being promoted and developed, but local control of individual programs may be more desirable than mandates from on high. These tend to generate large amounts of paper in the form of reports of questionable value. Let’s keep as much power within the local programs as possible and hold the chair, program director, and faculty accountable for a thorough and honest evaluation process.
There is increasing fragmentation of the broad specialty of general surgery as we have known it. Among those entering a surgical career, a significant minority and in some years a majority enter only as a prologue to subspecialty training. This trend has caused much hand-wringing or conflict in our surgical councils and has prompted vigorous debate regarding the allocation of precious clinical experience and material. Divergent training pathways must be developed to best serve the interests of our residents, but more importantly, serve society. Proposals for shortened “basic curricula” are not new but may lead to a descent to mediocrity rather than pursuit of excellence. A shortened curriculum will, I believe, inevitably produce a number of procedural surgeons who operate well in a narrow field but who are unwilling or unable to accept responsibility for the entire patient. This produces care by organ system or “the multiple doctor syndrome,” a nightmare in our modern hospital and especially in many critical care units. We must maintain programs that teach the resident how to operate rather than how to do an operation. Or, said another way, teach not an operation but how to operate.
Do we have too many subspecialists now? Probably not, but I know we will have too few general surgeons within 5 or at most 10 years. Smaller communities and hospitals will suffer disproportionately. Colleagues in general practice have acknowledged that without a well-trained general surgeon, their hospital’s patients and practices will suffer.
So far, no definitive answers are available, but it is critical that surgeons remain involved in this process or the numbers and types of surgeons we train will be determined almost exclusively by some governmental agency on the basis of questionable data from some unknown source. I am sure that new ideas and concepts will emerge. I am also sure that our voices must be raised in unison once a consensus is developed among ourselves. Is American surgery the finest in the world, and if so, why? Although there are pockets of tremendous ability throughout the world, for sheer brilliance in a myriad of fields, this country remains the envy of the world. Is it because we have been doing something right, or is it just happenstance crying out for change? We must answer this question to our satisfaction before we radically change our methods and our systems of training.
The status of our academic medical centers has reached crisis proportions for a number of reasons, including reduced governmental funding, reduced research dollars, and, most importantly, severe reductions in clinical income to faculty. Consolidation of many large centers and the purchase of others to remain competitive have created anxiety within the academic community, with ripple effects all the way down to the medical student. Many large private hospitals have contributed to and created this turmoil by consolidation, movement to suburban areas, and withdrawal of support from their traditional educational role. A prime example is the Baptist Hospital in my home community. Once the largest private hospital in the country, it now stands empty and its activities have moved to an area of Memphis away from the medical center and the university. These and similar change stress our teaching programs. The initial responses by the academic institutions and private hospitals have produced a flurry of competitive activity. Although these moves may lead to improvement in efficiencies, the spirit of competition is self-defeating and would be better served by a spirit of cooperation.
A renewed partnership between academia and the practicing surgeon should be developed and nurtured. These practitioners who share our values and vision represent a resource beyond replication. This partnership can ensure a vast amount of educational opportunity for present and future resident training. To do this successfully may require a fresh approach by groups such as the RRC for surgery, such as altering the definition of scholarly activity by a faculty member and place greater emphasis on the definition and recognition of the good and willing teacher. There should be an increased premium placed on the surgeon who is willing to share his clinical knowledge through teaching residents, not simply counting or weighing publications. This process will obviously produce anxieties on both sides of the street, but I believe is not a return to the pre-Flexnerian era, but a turn toward our future.
What can we do as the Southern Surgical Association? Regional societies were developed for dissemination and the sharing of knowledge. An additional role has been to provide a congenial forum for a development of long-lasting relationships. Surgical societies such as ours certainly have served as an emblem of recognition for achievement and contribution to the art and science of surgery. On the other hand, the explosion of information technology and ease of travel may no longer validate or accurately necessitate these initial reasons for the existence of these societies. Now, more than ever, these surgical societies have a new and more critical role to play. We are not alone in our failure to use these bodies as an area of influence to address the concerns that cause so much dejection among us. Perhaps it’s time for this association to take the lead and become more active in establishing a collective voice for surgeons.
The Southern, as an organization, has several appointees to important organizations of leadership on the national surgery stage such as the American Board of Surgery, the Advisory Council for Surgery, and the ACS Board of Governors. In addition, members of this organization occupy and frequently dominate other organizations by the strength of their personal excellence and individual achievement. Through these individuals, the avenues for influencing the direction of American surgery are there. We should share ideas regarding the areas of soul-searching explored here individually and collectively with our representatives and help them opine and negotiate for stability and truly useful change.
The Southern Surgical Association needs to take the lead in establishing an active and open forum as a voice for the members of today to preserve and improve the status of our profession for our members of tomorrow. I know it’s not easy sometimes to be a surgeon, but the heartening thought is that we really do know what needs to be done, we just need to do it. I believe this association represents the elite of surgery and that we must accept the burden along with the mantle.