Heroes, citizens, and the shoulders of giants

Summary

Is the hero role the best self-image for surgeons in the modern world? As Donald Berwick, founder of the Institute for Healthcare Improvement, has pointed out, health care is an exercise in interdependency, not personal heroism. In my president’s address to the Canadian Association of General Surgeons, I examine the role of the surgeon as hero and citizen.

Not long ago, driving along the side roads in my neighborhood, I saw what I thought was a traffic pylon on the street ahead. Drawing closer, I realized it was actually a small child standing alone on the street. I stopped, picked up the child, and walked from house to house until I saw one with an open front door. And it was there that I saw his mother, her face white as she saw what had happened. I handed the child over into her arms.

And that was it. She closed the door, and I turned back toward my car and drove off. I will never forget the feeling that enveloped me in that moment. I have worked as a surgeon for the past 2 decades, and I recognized that feeling well. In that moment, I felt like a hero.

In our lives as surgeons, we perform acts of heroism on a daily basis, without a second thought. Our heroic personas are supported by the trappings of our jobs: having the final say about what happens to “my” patient in “my” operating room, graciously and modestly accepting the gratitude of worried loved ones in the surgical waiting room.

But is the hero role really the best self-image for surgeons in the modern world? As Donald Berwick, founder of the Institute for Healthcare Improvement, has pointed out, health care is an exercise in interdependency, not personal heroism. The romantic image of the surgeon — as the powerful maverick who sweeps in to solve a problem once all other options have been exhausted — is not as constructive now as it may have been in another time.

We all have a role to play in improving the world in which we live and work. But each of us is really here for only a short time. Our collective challenge is stewardship — to use that precious time to leave our community better off than we found it. Our legacy must be a sustainable system that continues to provide care for Canadians and supports all of the social and economic objectives that are important for Canadian society.

Our current moral environment requires us to fulfill a different role than that of hero. Our role should more properly reflect that of a citizen. Society has vested us with rights and privileges, but these rights and privileges come with duties and responsibilities. The full realization of our citizenship can be achieved only through our fulfillment of the obligations and functions of our profession.

If you ask any school-age child who invented the light bulb, they will answer Thomas Edison. But that answer is only partially correct. Beginning in the early 1800s, a variety of people created the key innovations that ultimately led to the development of the electric lamp. The first incandescent filaments were invented in the early part of the nineteenth century, and James Bowman Lindsay demonstrated a functioning incandescent light as early as 1835. Experiments with vacuum tube enclosures and gas-filled globes in the 1840s and 1870s led to the now familiar appearance of a light “bulb.” It was not until 1880 that Edison created a better light bulb than others had already manufactured over the previous 80 years. Edison tinkered with the incandescent filament materials, vacuum chambers and electrical resistance in his prototypes. Light bulbs, in one form or another, had actually been around for decades, as curiosities that shone for only a few seconds and quickly burned out. But Edison was able to build on what others had achieved to create a product that was commercially viable: a light bulb that burned for days instead of seconds.

There is no shortage of similar examples. In fact, almost all of the singular events that we consider historic “breakthroughs” are actually only incremental contributions to what was already known. Take the more intimate story of the discovery of insulin at the University of Toronto in 1921 and 1922. The medical world knew well before the 1920s that a hormone produced in the pancreatic islets could treat diabetes; the problem was that no one was able to create an extract of the islets that wasn’t degraded by the digestive enzymes of the exocrine pancreas. Frederick Banting had the brilliant insight that ligation of the pancreatic duct of a dog would result in atrophy of the exocrine glands, leaving only the islets from which viable aqueous preparations could be extracted. If Banting had not had his epiphany, Canada’s gift of insulin to the world would surely not have happened in 1922. But do we truly believe that if it wasn’t for him, the world would still be without a therapy for type 1 diabetes today? Obviously, somebody, somewhere, would have made a similar discovery.

It is tempting for us to take credit for our achievements. But none of us is self-made. We are able to do what we do because those who preceded us paved the way and built the edifice upon which we now find ourselves. Thinking of ourselves as citizens instead of heroes reinforces that our profession is our duty and that our real rewards are the privilege of doing meaningful work and the opportunity to make a huge impact in peoples’ lives.

We may raise huge amounts of money for hospital foundations to help treat cancer, and we may receive the adulation of hospital foundation chairs and executives. But we didn’t invent cancer, we didn’t invent cancer surgery, and even the most skilled and creative among us are largely performing procedures that others have described. We have the incredible blessing of being here, at this time, working in the noblest profession there could ever be, and for that we should all be grateful.

There is no shortage of challenges that we face as Canadian surgeons. The health system is under financial strain in all the provinces and territories, as the cost of care continues to outpace what governments and people can largely afford to pay. Nobody but us can figure out how to reduce the cost of what we do to make our care part of a sustainable health system; for example, by decreasing our dependence on the inpatient beds that are becoming more scarce in our hospitals.

Poor access to care continues to erode Canadians’ trust in the health care system. Canada ranks worst among developed countries in terms of timeliness of care, especially wait times for elective surgery and specialist visits. Creative solutions abound; as surgeons we can lead health system transformation and restore public confidence in the health system.

We find ourselves squarely in the midst of a global epidemic of opioid misuse. Somehow the notion became popular that it is a good idea to provide packets of the most addictive psychoactive substances ever invented to regular people experiencing pain. We must reinvent our approach to managing postoperative pain and chronic pain — not by focusing on eradication of pain through pharmacologic means, but by being able to have a difficult conversation with our patients about how to cope with pain that can never truly be eliminated.

We have a human resources crisis. Many of our newly trained surgeons cannot find good jobs. Some older surgeons have difficulty transitioning out of the only profession they have ever known — a career that has sustained and enriched them their entire working lives. Our colleagues who are women and visible minorities face challenges and subtle biases that others may never completely recognize. We must remain unrelentingly attentive to how our own words and actions — intended or not — affect the health of our communal workplaces.

The full expression of our professional identities as general surgeons is under threat. Growing administrative demands and the burdens imposed by modern electronic medical records systems affect our ability to focus on our patients and pursue the work that we love. We must remember why we chose to do this work in the first place. All of us were once young, idealistic medical students, wanting nothing more than to dedicate our every waking moment to the care of the sickest patients in the hospital, using nothing but our hands and our minds to prevent death and suffering. By creating ways to experience joy and meaning in the work we do, we can avoid succumbing to the burnout that affects many of our colleagues.

We have a unique opportunity to make positive change in the world, building on the foundation that our previous leaders, teachers and mentors constructed for us — one small step at a time. We all must be poised to rise to the occasion. Sometimes what looks like an ordinary traffic pylon is actually a child in need; we must be constantly vigilant for the moments where life calls upon us to report for duty. Our truly heroic acts are those that we create together.