Professionalism, passion, and surgical education.

Let me begin by telling a story—a true, real-life story.

A medical student was about to start his general surgical rotation at our institution and scheduled a meeting with me. It was March of this year. Because I normally get together with medical students for a brief introduction to the service prior to the beginning of their rotations, it was unusual that a student would want to meet beforehand.

Nonetheless, the meeting was arranged, and he began our conversation in this manner: “Boy am I scared to start this rotation.” The student said, “scared” and repeated it several times. Somewhat surprised, as the word caught my attention, I asked why he was scared.

He replied that while on a previous surgical rotation in another state, residents were “mean to one another and mean to the medical students.” He went on to say that the surgical residency program was very hierarchical and medical students “weren't allowed” to speak with senior level residents let alone speak with the attending surgical staff. The student related being the target of verbal abuse and told of attending surgeons throwing instruments, swearing, and being verbally abusive in the operating room. Nursing staff were also disrespected and verbally abused on the floor.

I was astonished at the conversation. It was almost as if we were discussing physician and surgical resident behavior of the 19th century. As we spoke, I couldn't help but question the veracity and accuracy of the story the student was telling. But the student, who had done well on previous rotations in our institution, was clear on the particulars of the scenes he had witnessed and sincere in his description of them.

The door to my office was closed, and we took time to fully review that off-site rotation. After the student finished outlining his fears, I carefully assured him that such behavior would not be tolerated in our program. My manner was calm, and, I hope, that of a senior surgeon calming and allaying the fears of an excitable young medical student. But, within, I was anything but calm.

The conversation troubled me. This is the early 21st century, and surely such arrogant, unprofessional behavior could not exist today, even as an isolated incident. However, the more I thought about the matter and the more I considered the stressors our fellow surgeons endure, the more it seemed possible that such events just might occur. And perhaps more often than most of us would suppose.

For example, a recent study of attitudes, training experience, and professional expectations of US general surgery residents suggested that there is an attrition rate of 17% to 26% for categorical general surgery residents.[1] Surgical attrition rates are higher than that of other medical residencies and have remained relatively unchanged over the past decade.[2] In the same report, residents' satisfaction with their training program varied across training year. The lowest level of satisfaction was reported to be in the PGY 2 and PGY 3 level (82.8% and 83.2%, respectively, were satisfied with their training), and the highest level of satisfaction was in PGY 5 (89.7% were satisfied). Among PGY 2 residents, 19.2% had considered leaving their programs the previous year.[1] Negative perceptions continued to be documented in this study with only 68.3% of PGY 2 residents stating they could turn to faculty when having difficulties in their program compared with 76.1% of PGY 5 residents who responded to the same question.

Juxtaposed with these findings is the fact that the number of general surgeons per 100 000 population, in relative numbers, decreased 25.9% during the 25-year period 1981 through 2005.[3] There were 17 394 general surgeons in the US in 1981 (7.68 per 100 000) compared with 16 662 general surgeons in 2005 (5.69 per 100 000 population), a decrement that represents a 4.2% decrease in the absolute number of general surgeons during a 25-year time period. During this same 25-year period, the US population grew from 226 million to 292 million persons.

Add to these facts the trend that more general surgery residents are seeking postgraduate fellowship training, and it is obvious that the pool of general surgeons is being further reduced. Approximately 55% of graduating chief residents sought a fellowship position in 1992. More recently, >70% of graduating chief residents have chosen to seek fellowship training.[4]

There is a serious and immediate problem of a reduced general surgery workforce. For the health of our nation and the health of our communities, surgical trainees must be nurtured and encouraged to practice general surgery. It is necessary for all surgeons—teaching and nonteaching—to serve as an appropriate role model for young trainees. These surgeon-mentors must demonstrate the highest standards of professional, ethical, and moral conduct so that medical students and residents know a life in surgery can be one of joy and satisfaction while high professional standards are maintained.

For regarding professionalism, medicine, and, by extension, surgery is one of “the three common, noble and learned professions” along with Law and Divinity.[5] Speaking of the professions in 1635, Sir Thomas Browne noted issues with each of them:

And to speak more generally, those three noble Professions, which all civil Commonwealths do honor, are raised upon the fall of Adam and are not in any way exempt from their infirmities; there are not only diseases incurable in Physick but cases indissolvable in Laws, Vices incorrigible in Divinity.[5]

It was true then as it is true now.

To further understand what professionalism and being a professional entails, Wright, in the 1951 Canadian Bar Review, iterated 6 elements that characterize a profession:

1. A professional offers a service that incorporates the moral duty of not refusing a client or patient without cause or explanation.

2. The professional person has a special skill.

3. A professional is trained and educated such that they are inspired to relate their daily work to the life of man and the problems of mankind.

4. A professional is recognized by the state with certain privileges derived from the relationship.

5. A profession is a self-disciplined group.

6. For a calling to be a profession, it must have an unselfish aspect of public service.[6]

A profession is, therefore, a self-disciplined group of individuals who present themselves to the public as possessing a special skill derived from training or education and who are prepared to exercise that skill primarily in the interests of others.

Surgery is, thus, a profession. But, it is a unique profession, because it combines science and art. Surgery is a science inasmuch as it involves “the observation, identification, description, experimental investigation, and theoretical explanation of natural phenomenon.”[7] And surgery is also an art, as it demands “a special skill in adept performance, held to require the exercise of intuitive faculties that cannot be learned solely by study.”[7]

A surgeon is a special medical professional of high ethical character who not only diagnoses disease but also has the skill to operate on that disease. He or she harnesses physical skills to a well-developed, compassionate intellect.[8]

A physician is transformed into a surgeon by rigorous training, lengthy didactic curriculum, repetitive skills practice, and prolonged exposure to skilled mentor surgeons who have high moral and ethical standards. This latter, exposure to mentors with high moral and ethical standards, may be the most important aspect of a surgical resident's training experience. Mentor surgeons who exhibit qualities of dedication, self-effacement, self-criticism, and self-sacrifice are cherished and revered by residents. A professional life, when infused with these qualities, can be lifted into poetry.

Who among us cannot recall the outstanding surgeon who “in our youth, touched our hearts with fire,”[9,10] touched us with a passion for operating, a passion for the operating room, and a passion to learn every aspect of the art and science of surgery. There are probably only just 1 or 2 such role models in each surgeon's career, but one is enough.

Despite the severe pressures brought to bear on the profession of surgery—burdensome paperwork, government intrusion into the physician-patient relationship, exorbitant malpractice premiums, “managed” care, and declining reimbursement—it is critical that established surgeons remain professional. Professional not only for our patients' sake and for the health of our communities but also to serve as role models for future generations of surgeons.

What then of passion and what does passion have to do with the making of a surgeon?

Passion is the spark that triggers the train of events that leads to surgical residency and a career in surgery. Recall the very first time you entered an operating room. The memory comes alive for me as I remember in vivid detail my first observing an operating team of the late 1960s working together in perfect harmony and with absolute purity of purpose. It was an awesome sight that seemed to capture the spirit of the old saying: “To the Glory of God and the Service of Man.”[11]

Surgical training is an arduous journey, requiring long hours of study and long years of training, an arduous journey followed by a life of service. With but rare exception, a spark of passion was kindled in the mind of a medical student and triggered the chain of events that led that student to surgery.

Once ignited, passion is never forgotten. Justice Oliver Wendell Holmes in discussing passion and his experience as a soldier in the American Civil War noted that “in our youth, our hearts were touched with fire.”[9] He never forgot the defining moment when passion was ignited in him. As surgeons, we are privy to know in intimate detail that life is a profound and passionate thing.

But, even if the decisive moment when passion was ignited cannot be forgotten, passion can be extinguished. Note well the story of the medical student's experience with a training program that exposed students, nurses, and surgical residents to the dark side of unprofessional behavior.

Unfortunately, there is probably more than just one isolated incident of unprofessional behavior in our field. There are far too many residents leaving surgical residency. Some reports suggest that approximately 25% of surgical residents will not complete training and that 20% of those who complete training will be dissatisfied with their job.[2,12] In an elegantly written article, Dr. S. Eva Singletary[10] argued that the availability of role models is key to generating and maintaining passion for surgical practice. She is correct.

My sense is that surgeons as proper role models are the most important factor in maintaining passion in our students and in our residents. Passion for surgery will sustain residents when they are tired, when they are disgruntled, when family relationships are strained and when their spirits are low. As Justice Holmes suggested, passion can be spread by “contagion,” that is by contact with exemplary role models.[9]

It is up to us who are charged with educating and mentoring surgical residents, to protect that first spark of passion and help sustain it, to show in our professional lives the joy of academic exploration, the satisfaction of clinical practice and the profound good of glory to God through service to man. In other words, to lead a life worthy of being a surgeon.

For, should we fail to serve as role models at the highest level, there will be more “stories” of frightened medical students and disgruntled surgical residents—leading inexorably to a loss of surgical services for all.

As you can tell, I hold the writings of Oliver Wendell Holmes in high regard. He spoke of a poem in his “The Soldier's Faith Speech of 1895” given at Harvard University May 30th of that year.

The poem, whose author is unknown, struck a resonance with me; and I would like to share 2 stanzas with you. (You might want to substitute the word surgeon for the word soldier.)

As for me, my days of taking call, seeing patients in the office, and operating are drawing to a close.

Whatever joy was felt in performing a “good” operation must now be lived only in memory.

But, I do not regret departing the field for, like Justice Holmes, my heart was touched by fire, and I have known the passion of life.

I am content.