The Center for Surgical Health: A Compassion-Driven Urban Surgical Mission

Abstract

We are the Center for Surgical Health (CSH), an academic community partnership that supports, educates, and advocates for vulnerable Philadelphians with surgical diseases, founded in 2016 by Dr. Jon B. Morris, a leader in surgical education and a general surgeon at the University of Pennsylvania, and Dr. Alan Herbst, a current third-year Penn general surgery resident. At the time, Dr. Morris, raised in a Reform Jewish household, had been participating in an RCIA Program to convert to Catholicism. The mission of providing surgery to uninsured patients, primarily undocumented individuals, by helping them obtain insurance and see Penn providers was seen by Dr. Morris as a form of Catholic charity, which he has continued to remain dedicated to as his faith in Jesus Christ has deepened. Dr. Herbst, now Associate Director of Clinics for the CSH, recalls working with Dr. Morris as a sub-intern during his conversion, beginning with passion and a neon poster board inviting people to “See the Surgeon.” Since that time, the CSH has grown from an organization with 10 volunteers, called “personal patient navigators,” who provide insurance support and advocacy at every step of the perioperative continuum, to one with over 50, who have now seen 156 patients and assisted in providing 49 needed procedures. Much of this growth has been brought about through the dedication and vision of Dr. Matthew Goldshore, the Deputy Director of the CSH and a fifth-year Penn general surgery resident, as well as Dr. Carrie Z. Morales, Associate Deputy Director of the CSH and a recent Perelman School of Medicine graduate. Through their leadership, and the talent and commitment of other members of the CSH board, overseen by Director Dr. Morris, the CSH now has policy and research divisions, a surgical equity curriculum, and continues to develop new ways of providing better care.

Introduction

In Luke 7:13, Jesus raises the widow’s son from the dead. It is said that “when the Lord saw her, he had compassion on her, and said unto her, ‘Weep not.’” The word “compassion” here comes from the Greek verb Splagchnizomai, based on the noun splagchna, meaning “internal organs” or “entrails.” The word translates most literally to mean being moved in the bowels, one’s innermost core, where the first century Greeks believed human emotions resided (Theology of Work Project 2011). The word is used only twelve times in the Scriptures to refer to either Jesus’s outpouring of love and compassion or that of the Good Samaritan or the father in the parable of the Prodigal Son.

As surgeons, we have the privilege of working on the innermost core of people and are called to show that same compassion, from deep within us, in our care for patients, especially patients who have been marginalized by the healthcare system. Yet, in surgery, it can be difficult to provide this level of patient-centered care due to long work hours; emotional stress; limited patient continuity; and the challenge of balancing clinical, research, and teaching responsibilities. While there are a large number of mission-minded professionals in the field, it can be easy to lose one’s sense of purpose when good intentions are confined within a demanding role.

Founded at the University of Pennsylvania, Philadelphia’s Center for Surgical Health (CSH) (https://www.centerforsurgicalhealth.org/) is a unique academic-community partnership that walks with individuals requiring surgery throughout the perioperative care continuum, connecting patients to high-quality, evidence-based surgical care. The CSH educates, conducts research, and advocates for vulnerable Philadelphians with surgical disease. By recounting my experience with the CSH and my conversations with its leaders, I share the story of how this small group of surgeons reclaimed their sense of purpose and found a way of reimagining urban academic surgery as mission work, showing compassion and bringing critical healthcare to patients whose voices often go unheard.

Finding a Mission Field

As a Catholic, I came to the Perelman School of Medicine with a commitment to community service, viewing it as part of my calling to practice medicine. Though I am originally from the Boston area, I went to the University of Notre Dame for undergrad, where I was inspired by friends and mentors to participate in their RCIA Short Course and become confirmed in the Catholic Church. I was especially drawn to the Church’s Social Teaching, emphasizing the dignity of the poor and vulnerable, and the ability to affirm these truths as a physician fueled my passion for medicine. Entering medical school at Penn, I prayed to find a new community to support me in living out my faith, and for opportunities to serve patients in Philadelphia who were unable to access high-quality healthcare. God was incredibly faithful in directing my path.

I met Dr. M, a general surgeon at the University of Pennsylvania, Director of the CSH, and one of the CSH’s original founders, in the second half of medical school, when I was seeking advice after deciding to apply into general surgery. I was a member of our Catholic Medical Association student chapter and was told Dr. M was a fellow convert; yet at the time, I knew almost nothing about the Center. I was surprised to learn that it took only one physician’s sense of vocation to care for the vulnerable and marginalized, and the energy, ideals, and compassion of a small group of trainees for the organization to start doing this vital work.

Every Important Change Starts With a Conversion

“My story begins in childhood, being raised as a Reform Jew,” explained Dr. M. “However, I was in fact a secular Jew and slowly over time grew away from the faith. I attended Saint Joseph’s University, which was an extremely positive experience for me, where I had the privilege to interact with several brilliant Jesuit professors and was particularly attracted to my theology and philosophy courses.” He discussed how he would also meet his future wife, a Catholic, at the 96% Roman Catholic school. Enamored with the power of a Jesuit education, Dr. M attended Georgetown University School of Medicine. Over the years, he stayed in touch with several of his St. Joseph’s professors and returned to his college roots to receive the Edward C. Bradley, S. J. MD ’51 Award on November 1, 2015, in recognition of his loyalty and dedication to the mission of the University.

“Being married to a Catholic woman meant that I had extensive exposure to Catholic events such as baptisms, first holy communions, weddings, and funerals,” he noted. Dr. M would go on to recall a particularly impactful summer family trip to Italy. “The visit to Rome included the Vatican and the Sistine Chapel, and I suspect something began to stir. A visit to the summer residence of Pope Benedict XVI at the Apostolic Palace of Castel Gandolfo and seeing him deliver greetings in multiple languages to several hundred visitors from a balcony maybe 30 feet away was powerful to say the least, and kindled the flame for sure. I have no idea what he said, in multiple languages, but the reaction of the people around me from all over the world was amazing.”

The inauguration of Pope Francis finally convinced Dr. M to take the next step: “I was so inspired by his story. This remarkable event served as the impetus to meet with Father Dennis Gill, rector and pastor at the Cathedral Basilica of Saints Peter and Paul in the Archdiocese of Philadelphia, which led me to the RCIA program there.” Dr. M began attending class every Thursday night after clinic. After a second year of RCIA at his local parish of St. Margaret of Antioch in Narberth with Monsignor Paul Dougherty, he was baptized, received communion, and was confirmed. His confirmation name, unsurprisingly, was Francis. While he admits, “my Jewish friends thought I lost my mind when I converted, my Catholic friends thought it was brilliant.” Dr. M now serves as the godfather of his niece’s child and was able to appreciate watching his granddaughter, who is half Mexican and born on December 12, be named in honor of Our Lady of Guadalupe.

“The CSH began as a form of Catholic charity during my first year of RCIA,” Dr. M explained. Of course, he is no stranger to wearing many hats and navigating a packed schedule. For decades, he has held a variety of leadership roles, including serving as the Program Director for General Surgery at the University of Pennsylvania (2003–2018) and the Associate Dean for Student Affairs at the Perelman School of Medicine (2005–2020), while he currently serves as the Department of Surgery’s Vice Chair of Education. Throughout this time, he has gained a reputation for being an incredible student advocate, and he has mentored scores of trainees who have relied on his guidance. For spiritual nourishment, he studies the Bible regularly, prays the rosary, reads the weekly liturgy, and listens to Bishop Robert Barron’s sermons on the Word on Fire podcast. For Dr. M, attending Sunday mass at St. Margaret’s “is truly a peaceful and reflective highlight of the week.” As he has recently transitioned out of his role as Associate Dean to focus on clinical work full-time, he has continued to invest further in the CSH. “Despite my now much busier clinical practice, my faith in Jesus and the Catholic Church is the single most important factor which drives me to continue our CSH work.”

Humble Beginnings

When the CSH (previously known as the Agnew Surgery Clinic) began in 2016, the organization was little more than Dr. M, then senior Penn medical student Dr. H, and a neon yellow poster board inviting anyone with concerns to “See the Surgeon.” Dr. H, third-year Penn general surgery resident, now Associate Director of CSH Clinics, and one of the original Agnew Surgery Clinic founders, recalls the day the idea for the organization materialized: “I was a sub-intern for general surgery with Dr. M. He was going through his conversion at the same time.” Dr. H had been a medical student board member with the student-led community clinic University City Health Coalition (UCHC) for the last 4 years, volunteering in the food line and in a hospitality role since his time as an undergraduate: “He [Dr. M] knew that I was a part of that and that I had been a board member. I remember the day, I was in his clinic office, and we were seeing patients, and he asked, could you do a surgical clinic from it? And I said, ‘yeah I think so.’”

While great efforts went into overcoming the logistical barriers of providing patient care to under-resourced populations and defining the role of trainees to ensure the sustainability of the group, Dr. H noticed that the identification of surgical patients was even difficult in those early days: “The biggest obstacle at the very beginning was just getting credibility as a surgical provider in the community. It took almost a year from the inception of our idea to actually having our first patient go through surgery. The way we got through that is every single week I would go to UCHC and announce that we had a clinic coming up. So unfortunately (or fortunately), a lot of times you just have to dig in and do it yourself to let people know what’s going on.”

Yet, the work was rewarding, confirming Dr. H’s excitement about the practice of clinical surgery. “Having the chance to work more closely with Dr. M on the project, working on what was Agnew at that time, definitely solidified my choice of specialty. I think it played a big role in solidifying my desire to be a surgeon while continuing to help others in need throughout my career.”

Exponential Growth With a Sustainable Mindset

As of August 2021, the CSH has cared for 156 patients and provided 49 procedures to individuals facing significant roadblocks to accessing surgical care. Our approach to breaking down barriers to access is unique. We have residents and medical students see patients at regularly scheduled intervals at well-established community clinic sites. Once a patient has been identified as having a surgical disease, we partner them with student volunteers (personal patient navigators, PPNs) who liaison between the surgical health system and the patient. PPNs regularly communicate with patients and support them throughout every stage of the perioperative continuum. This includes, but is not limited to, applying for the insurance coverage needed to access care. Once insurance has been obtained, the PPN goes on to attend appointments with the patient, scheduled at Penn Medicine with providers connected with the CSH. Ultimately, many PPNs are able to scrub into the definitive surgery and then track the patient’s post-operative recovery.

We have expanded from solely a general surgery clinic to a program with over twelve surgical subspecialties. While improving our own protocols, we have developed extensive relationships in the community and at Penn, including with Penn Law, Penn Nursing, and the Penn School of Social Policy & Practice. The goal of our new research and policy divisions is to utilize our collective skills to change the healthcare landscape in the long-term. We have also developed a translation task force to aid our primarily Spanish-speaking patients; a social needs questionnaire to ensure we connect patients to any service they may require in the community; a surgical equity certification via a semester-long curriculum; and other trainings, which volunteers and board members attend in addition to our weekly organizational meetings. Finally, this past year, we received significant funding for 3 years of infrastructure development and support from Mr. Kevin Mahoney, CEO of the University of Pennsylvania Health System and himself the product of a devout Irish Catholic upbringing.

Along with Dr. M and Dr. H, an essential ingredient to CSH’s success has been the unwavering commitment and steadfast vision of several residents and students, who believe that academic surgeons have a responsibility to serve anyone within their reach who requires care. It has been incredible for me to serve as CSH Education Co-Chair during my last year at Penn, volunteering alongside this passionate, talented, and diverse group of people who are united by a desire to show compassion to those most in need. Particularly vital to shaping the vision for the organization’s future have been Dr. G, a sixth-year Penn general surgery resident and CSH Deputy Director, along with Dr. ZM, a recent Perelman School of Medicine graduate and CSH Associate Deputy Director, who will be continuing her role during her first year of plastic surgery residency at Penn. When asked about the mission and vision of the CSH, both Dr. G and Dr. ZM noted that the organization’s goal is “to support, educate and advocate for vulnerable Philadelphians with surgical diseases.” They envisioned creating a sustainable infrastructure through which all members of the Philadelphia community would be able to access high-quality, cost-conscious surgical care, despite socioeconomic, political, racial, cultural, or gender-based disparities.

Dr. G: “I think there is actually a significant history of surgical volunteerism … it is common to find programs that go into socioeconomically vulnerable communities and support very marginalized people.” However, in academic surgery, he noted there are unique challenges, despite this precedent. “Academic surgeons are pulled in many different directions (education, research, and of course, clinical practice), so there’s just not a lot of time to do this type of work. That, in addition to the fact that the most valuable time a surgeon can invest [to the healthcare system] is in the OR …. When the bottom line is a financial one, …. there’s going to be incentive structures built in to spending more time on the most lucrative aspects of our lives. There must be senior leadership commitment that investment in this space is valuable, that there’s a benefit to this type of work. I have observed [Dr. M’s] transformation during this experience, and what makes him so remarkable is both his awareness of the importance of this work, and his tireless advocacy for us as a program. He communicates the value of the [Center] to the health system as frequently as possible.”

Dr. ZM: “You asked about academic and community buy-in, which is an essential part of the puzzle. And I think you initially get traction by having a trusted person like [Dr. M] who opens doors and initiates connections.” In order to convince academic institutions, Dr. ZM advised that “you show up to every meeting ready to convince people with your lives, and you do your best every single time.” In contrast, she noted “I think you convince community partners by listening to them. You don’t form a community partnership through a presentation. You form a partnership by being continuously trustworthy, effective, and reliable, and striving to understand what your partner needs and how you can serve them.”

Dr. G: “When health systems are building hospitals, there is a significant investment in understanding the needs of the community. The Agnew Surgery Clinic started at UCHC, but really the CSH started with this idea that marginalized members of our community are not receiving equitable care, and that we were going to try to figure out a pathway towards surgical equity. Rather than trying to throw a model together, we decided to develop a program driven by our knowledge of health policy, surgical practice, and community relationships to improve access for people in need. What we learned from this experience is that the community has to drive the program. I feel strongly that clarifying community need through a comprehensive surgical health needs assessment is the most critical thing to do before we implement the program anywhere else.”

Dr. ZM: “The most important thing to us is sustainability. An organization that puts a band-aid on a problem and later leaves ultimately makes the community worse off—people could utilize a resource for a little bit, and then it’s gone. Guiding ourselves with foundations in policy, research, and education allows us to both thrive where we currently are at Penn Medicine and as we develop nationally. There would be nothing sustainable about a group of students and residents trying to figure out how things work as they go. Dr. G was very clear from the start that it was worth the time to really gather knowledge and develop systems to make us a long-lasting community-serving organization.”

Dr. G: “I agree, and I think that it is an iterative process. If you look at non-profits that are really successful, service organizations that are really successful, you will probably see zero that have the exact same organizational structure they had 10 years ago. But as you know, we transitioned the organization from an interest group in just 12 months.”

When asked whether what the CSH has done could be repeated elsewhere, Dr. ZM was emphatic: “Yes! Everything here at the CSH is based off (1) Understanding your local community; (2) Performing a Surgical Health Needs Assessment and Surgical Resource Assessment; (3) Gaining knowledge of the local policy and legal landscape; and then (4) Growing leadership and building partnerships to support areas where you have knowledge gaps. For example, we are not legal experts, so we found partners who are legal experts to fill in those holes …. I think if [anyone anywhere in the country] does an assessment of what the exact surgical needs are of their community, explores the policy and legal regulations surrounding those issues, identifies current resources you have, and what resources you are lacking, and then finds the rest …. it is a completely reproducible program. In fact, we have developed a CSH Operationalization Worksheet to help others implement the CSH model in their own community.”

Dr. G: “We don’t have the market cornered on surgical equity, but to Dr. ZM’s point, I know we both feel very strongly about this: we don’t want a monopoly, but I also don’t believe multiple organizations that do exactly the same thing are effective. This decentralization confuses people. The reason why the American Red Cross is great is because there is one American Red Cross …. and people know that in disaster situations, the American Red Cross is going to help them. And it’s not the Red Cross and the Yellow Cross and the Green Cross; it’s the Red Cross, and it’s everywhere. And I think that what we are trying to build is that program. It’s not about us; it’s about the centralization of resources so that as a world community, we will have a set of principles that we stand by. We are going to go into communities that have been terribly decimated (in terms of surgical health and wellness) for as long as surgery has been as discipline, and really revitalize them to wellness, to surgical health. We think we can do this, and we want to work with everybody to do it together. Everyone who wants to be is a part of the CSH family.”

Dr. ZM: “We don’t have a shortage of big dreams …. We believe that things can truly change and evolve with persistent effort.”

Future Directions

With the CSH currently helping scores of patients via the volunteer patient navigation program, underserved patients around the Philadelphia area are finding a new pathway for securing needed care, while students at Penn are gaining experience applying for insurance and advocating for marginalized communities. From the organization’s initial partnership with UCHC and Puentes de Salud, a community clinic serving uninsured LatinX patients in South Philadelphia, to its newest partnership with HUP Cedar Avenue, formerly Mercy Catholic Medical Center, a longstanding hospital in West Philadelphia which has been committed to service to the marginalized, the CSH remains dedicated to community-informed care which is continuously improved through experience and input from its multidisciplinary team. In addition to taking on approximately 100 new student volunteers this year alone, the CSH has developed a surgical equity curriculum and is focused on research and policy to change the landscape of care to better advocate for patients, while hopefully 1 day soon, bringing their mission-mindset to surgical practices everywhere.

In summary, the story of the CSH is a story of finding one’s mission within academic surgery. For those in medical training with a faith identity, like Dr. M, there is an acknowledgment that medicine is more than a job, but rather a calling, part of one’s God-given purpose, and that by doing this sort of work, one can reflect the God who heals the outcast and the downtrodden. As care becomes less holistic, and other motivations like status or earnings seem to confuse the issue; we can use Christ as a model, remembering his deep-seated compassion, and the reason we entered medicine in the first place, and be reinvigorated in our calling.

Biographical Notes

Dr. Emily Scire, is a graduate of the University of Notre Dame (BS, 2017), where she majored in biochemistry. She is from the Boston area originally and has had a long-held desire to become a physician and participate in medical missions. She recently graduated from the Perelman School of Medicine at the University of Pennsylvania with a dual MD/MBE (Master in Bioethics) and certificate in Academic Surgery, after having served as an Education Co-Chair for the Center for Surgical Health for one term, and looks forward to beginning general surgery residency at Beth Israel Deaconess Medical Center in Boston, MA.

Dr. Carrie Z. Morales, is a graduate of Tufts University (BS, 2015) and the Perelman School of Medicine (MD, 2021). She has spent dedicated years developing her research skills in the NYU Department of Population Health, Division of Healthful Behavior Change and at the Children’s Hospital of Philadelphia, Division of Plastic and Reconstructive Surgery. Dr. Morales is the Associate Deputy Director of the Center for Surgical Health and will continue to hold this role as she begins her residency in plastic and reconstructive surgery at the University of Pennsylvania.

Dr. Alan Herbst, graduated from the University of Kentucky in 2010, earning a dual BA degree in history and psychology. He completed the University of Pennsylvania 1-year Pre-Medicine Post-Baccalaureate program in 2012 and attended medical school at the Perelman School of Medicine from 2013 to 2017. In 2017, Dr. Herbst started general surgery residency at the University of Pennsylvania, where he is pursuing a Master of Science in Translational Research, serves as the Associate Director of Clinics for the Center for Surgical Health, and is pursuing a career in academic cardiac surgery.

Dr. Matthew Goldshore, graduated from the University of Texas at Austin with degrees in biochemistry and secondary science education, and he spent a short time teaching high school chemistry before matriculating into the MPH program at the George Washington University (GWU) School of Public Health. Dr. Goldshore completed medical school at GWU and holds a PhD in Public Health (concentration: perinatal epidemiology) from the Johns Hopkins Bloomberg School of Public Health. He is currently the Deputy Director of the Center for Surgical Health and a sixth-year general surgery resident in the Department of Surgery at the University of Pennsylvania, with plans to pursue a career in academic pediatric general surgery.

Dr. Jon B. Morris, is a graduate of Saint Joseph’s University (1979) and the Georgetown University School of Medicine (1983). Following a residency in general surgery at the University Hospitals of Cleveland, which included a 2-year research fellowship at Johns Hopkins Medical Center, he was recruited to the University of Pennsylvania in 1990. Dr. Morris, the Ernest F. Rosato-William Maul Measey Chair in Surgical Education, Vice Chair of Education for the Department of Surgery, and Director of the Center for Surgical Health since its founding, is also the former Program Director for General Surgery and past Associate Dean for Student Affairs at the Perelman School of Medicine at the University of Pennsylvania.

ORCID iDs

Emily Scire https://orcid.org/0000-0003-1105-4437

Alan Herbst https://orcid.org/0000-0002-1301-7851