Words From a “Wise Old Hand”—Guideposts for the Future

Mr. President, distinguished members of the Council, Fellows, New Fellows and guests:

I am honored and humbled to be made an Honorary Fellow of the Royal College of Surgeons. My induction today is one of the highlights of my professional career.

I am most grateful to Mr. Ian Leslie, immediate past president of the British Orthopaedic Association, for my nomination, and to the Council for granting this honor. To be made a Fellow of this venerable institution is quite a thrill for someone from the colonies; and I thank you for the honor.

Firstly, let me offer my sincere congratulations to the new members; it is a great day for you and your families and I am so pleased to be able to participate in the festivities.

I was very flattered to be asked to provide you some words from a “wise old hand”. In fact until I received the invitation I hadn’t thought of my self as an old hand but instead one who is just reaching the peak of my career. I am not at the point in my career that I am what is referred to as a “podium surgeon.” I am still operating two full days per week; seeing patients two days a week; doing research; taking level one emergency call; and working on various outside national orthopaedic activities. So as I share my comments with you, I hope you realize that, I have for the last 36 years and continue, to “walk the walk.”

However, on further reflection I realized that if one compares a surgical career to a round of golf; one might say I am on the “back nine”. As I look back; I have learned a thing or two about the course and I hope that these ruminations will be of some help to those of you who are about to tee off.

I would briefly like to touch on six guideposts for your future. The first guidepost, and one that you will need to work on your entire career, is Maintenance of Public Trust. You have chosen a career in a noble profession, one that still enjoys a great deal of prestige and respect in the community; Your contract with society as a physician is totally based on professionalism and your ability to maintain public trust. This public trust is based on the perception by the public that physicians are altruistic; that they always put the patient first; that they employ scientific integrity; and that there is the absence of bias in medical decision making. Each of you, and all of us in the profession, need to constantly work at maintaining these values to ensure that public trust is maintained throughout your professional life.

In the current environment, there are many forces threatening to erode that trust; not the least of which is the ever increasing relationships of physicians and surgeons with industry. While surgery in many instances lacks a strong evidence base; surgeons are the innovators of new procedures and techniques; and they invent devices. In that activity, they must work closely with industry. In fact, surgical translational research is often dependent on collaboration with industry. While these relationships are critical to progress in medicine, as Jerome Kassirir, former editor of the NEJM wrote in his book “On the Take”; “Patients must be able to trust that their doctors’ motives are not subverted by financial gain, that their doctors are recommending treatments that benefit them, and that their doctors are involving them in research projects for the right reasons. Their doctors must not only be at their sides, but on their sides.”¹

This maintenance of public trust is implied and embodied in this Colleges’ mission statement and must be the main guide post of your career.

The second guide post relates to Lifelong Learning and Continuing Education. While this may seem obvious to you; you will find that as your practice expands and your family life increases in complexity, this is one of the more difficult areas to budget into your schedule. It is however critically important that you do find the time.

You are currently laying the educational foundation for the future. As I reflect back on my training and what I am now doing in practice, very little resembles what I was doing in my training. Thanks to dramatic technologic advances the diagnostic tools and therapeutic interventions I am now using have all developed since I finished my training. For all of you and for your patients, these are also especially exciting times to be in medicine as we are currently in the midst of a biologic revolution that will profoundly change our practices. The key to this future is to continually build on the educational foundation that you are laying today through lifelong learning.

In parallel to your lifelong learning, the public is continually educating itself through the internet. Today 7/10 adults in the US, and I imagine it is similar in the UK; get their healthcare information through the internet. As your patient’s advocate, it is your responsibility to stay abreast of the scientific developments to help your patients navigate the treacherous waters of internet misinformation, self-promotion advertising, and direct-to-consumer marketing.

The next guide post was alluded to when I spoke about maintaining public trust, and that is Putting patients first by practicing Patient Centered Care. The concept of Patient Centered Care has been around for more than 30 years and has many definitions; the definition I like best is that PCC is “quality health care achieved through a partnership between informed and respected patients and their families, and a coordinated health care team.” The key words are partnership, informed and respected patient.²

In this paradigm, the patient is the source of control, not the physician; knowledge is shared as information flows freely; decisions are evidence-based whenever possible; transparency is necessary; and cooperation among physicians is a priority. Patient Centered Care is the cornerstone of the current quality movement in health care.

What does PCC really mean? It is the kind of care process and interaction that you expect for yourself and your family. Put yourself in the situation of a loved one having a serious medical condition for which you are not the expert and then ask the questions; what do you expect from the doctor? from the hospital or clinic staff? and from the entire health care team? I think you can picture in your mind what is meant by PCC.

The delivery of Patient Centered Care offers the strong probability of increasing your job satisfaction, decreasing liability risk, and increasing patient satisfaction. From the patient’s perspective, it ensures better outcomes and lower health care costs.

The next guidepost is particularly germane to the surgical disciplines: that is the Avoidance of Overconfidence. You spend years acquiring and enhancing your surgical skills. You will glean great personal satisfaction in your practice using your skills to save lives or limbs; restore function and relieve pain. But it is critical to avoid the natural pitfall of over confidence; it is a matter of patient safety. When you become overconfident you are “at risk” for error that could profoundly affect a patients life. Never view surgery as routine. You must, as a surgeon, always pay attention to detail even if you have done the surgery 1000 times. You are granted a sacred privilege to be entrusted with a human life. Each and every patient puts their trust in you; that you will do your best and take care of them. This is your obligation.

The next to last guide post is that you must pay attention to the external environment. It would be nice if you could practice medicine free from outside influence; but this is increasingly not the case. With healthcare consuming a greater % of GDP in every country and with a better-educated public and increasing focus on medical errors and accidents, everyone has begun looking for quality assessment, including physician performance. In the United States, working under the premise that value purchasing in health care should be the rule as it is in other areas of industry, the US business community has targeted high quality medical care as a significant objective. When Ford Motor Company pays more for healthcare than it does for steel for its cars, it asks the question; are we getting value for our Dollar. While you have a different healthcare system, all payers of healthcare, be it employer or the government are asking that same question: Are we getting good value for our money? In the US, healthcare will be the number one issue in our 2008 presidential election.

Some of you will become health care policy researchers; some will become leaders of the specialty societies; and others leaders of this college; all of you need to keep yourselves informed about the issues and participate in someway. It is not in physician culture to be politically active but I suggest that in the future it will be in your best interests and that of your patients to be involved. You need to be advocates for your patients and your profession. If you don’t; government bureaucrats will be making decisions for you. I would strongly encourage you to be an active part of the healthcare debate and have as many seats at the table as possible.

The last guide post is Balance. As your career progresses; the most difficult challenge you will face is balancing your professional career with your personal life. This balance will be affected by pressures from your patients, your colleagues, the government as well as from factors yet unknown. As practitioners of surgical disciplines; much of what you do may not be predictable and fit into neat time blocks like our medical colleagues. You will miss family meals and important family events. For some of you your spouse or partner may also have a demanding career that needs to be considered. You may become a parent which adds to your responsibility. Sensitivity to the needs of your loved ones and maintenance of a constant homeostasis between personal and professional life will be one of the most important and challenging tasks that confront you throughout your career.

Ladies and Gentlemen, I hope that these six interrelated guideposts—maintenance of public trust; lifelong learning, practicing patient centered care, insuring patient safety by avoidance of overconfidence; being an active participant in the healthcare dialogue and maintaining balance in your personal and professional life will be of some help to you as you embark on the exciting road ahead.

This is a great day for you and I am so happy to be part of this celebration. Congratulations on this wonderful and hard earned honor. I know that your families are justifiably proud of this accomplishment and the many that lie ahead. These are exciting times and you have before you never-ending highways of opportunity. I wish you well on your journey.

Thank you.