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The Joys and the Value of a Career in Cardiothoracic Surgery

Tuesday, June 7, 2005

I rarely sit down and reflect on the joys and value that a career in cardiothoracic surgery brings to my life. I seem instead to be thinking about what I’m doing. Namely, that I love going to work; that I enjoy working with my colleagues; that I still like to write first authored scientific papers; that I beam when the team concept (all of us) results in a new finding that makes a material difference in patient care; that I’m touched when a child looks at me with some gratitude after a life-saving operation; and regretfully that my reflection on the order of things undergoes a pause when a child dies after an operation. And in some important measure, I like to talk to my colleagues about other things such as baseball, philosophy, food, wine, and the upcoming triathlon season. There is more, however.

Our profession is based on ethical behavior, which extends far beyond the rule of law. Ancient medical oaths have reminded us that ethical behavior is a learning process and as Aristotle would iterate, moral virtue is the habit of choosing the golden mean between extremes as it relates to an emotion or an action. Each choice is different depending on the circumstances. Each requires choosing the correct response after careful deliberation depending on the circumstances, this deliberation is based on education, keen observation of others, and spirituality. In fact, our post medical school education is not called, “education” or “learning” or some other appellation. It is called, “training.” We learn the fundamentals of surgery as if the subject comes to be second hand knowledge (first hand being instinctual knowledge). We learn the fundamentals of moral behavior in the same manner. “What is the hematocrit, Dr. Intern?” The answer is not, “around 35.” The answer is “36”, or the answer is, “I don’t know but I will find out”. Kantian moral philosophy, the foundation of modern bioethics, supports this notion. We don’t lie; we don’t ever lie. There is no calculus of utility that condones lying.

Those who determine the rule of law are trying to codify certain aspects of our moral code. The 80 hour work week places guidelines on physicians who could ordinarily choose for themselves when they are too tired to attend to their duties. New safety standards codify and standardize certain “check-lists” that must be satisfied before an operation can start. Guidelines and in some cases, state laws, ensure that physicians and hospital administrators must tell a patient when a significant complication has occurred. No matter what laws are enacted, no matter what restraints are implemented, there is no substitute for living the ethical life. There can never be enough laws to govern our behavior. Kant has emphasized a moral theory, the categorical imperative, which calls us to act only on the maxim that if we could will it, that action would become a universal law of nature. In other words, comport yourself and act on such principals and in such a manner that if you could make it happen, your action will become a universal law. It would be applicable for any such situation for all time and for all circumstances pertaining thereto. This is quite compelling. All the more so since we make these judgments every day; judgments that are more important and far reaching than the previously mentioned enacted laws and regulations. Our main purpose is to attend to our patients and place their needs above ours. Our predecessors have acted in this manner and we will continue to do so.

The issue of commitment and dedication is embedded in our American ethos. Our Founding Fathers stated, “We mutually pledge to each other, our lives, our fortunes, and our sacred honor”.  It is interesting to note that the words, lives and fortunes were not modified; seemingly because it was just life and money, important but not that important. After all, life is fleeting and money gets spent. It was “honor” that was modified with the adjective, “sacred”. Honor accompanies us everywhere and lives after us. We have a sacred trust with our patients. We worry about them; we are pained by their complications; and we grieve when they die. I can think of no other profession that demands and gets this kind of commitment and dedication from its members.

And so what makes us get up in the middle of the night to see a patient who may or may not have an aortic tear after a closed chest injury? Lowery, a modern day philosopher, examines the concepts of fear, duty, and courage in a medical setting, noting that fear does not always oppose duty. Fear of censure, of losing prestige, and of losing one’s own self-esteem may be powerful forces propelling one toward action. We get up in the middle of the night to care for our patients not just because we ought to get up, but also for fear of what will happen if we do not get up. It may, in fact, take more courage to stay in bed than to get up and see the patient, considering the scrutiny, said and unsaid, that will be awaiting us the following morning. Galen, personal physician to Marcus Aurelius, is reputed to have fled from the plague in Rome in 180 AD despite the anger of his emperor. Galen found it necessary to give an elaborate series of excuses explaining his failure to return, and historians today still argue whether his behavior was defensible. Eighteen hundred years is a long time to bear a charge of cowardice; he might have done better to return to Rome and face the uncertainties! The physician, after all, does not desert his patient; to deserve honor, the physician must act honorably.  

Shelp, a noted medical ethicist, points out that the desired virtues of the physician, compassion and competence, meld with the desired virtues of the patient, gratitude and compliance, to form the framework within which the physician and the patient will interact. Each is faced with unknowns such as the nature of the operative procedure, progression of the disease, and uncertainty of the outcome, which will require from them a collective courage and fortitude. This interrelated courage will no doubt require endurance, trust, and moral conviction. It is the element of uncertainty that distinguishes courage from confidence. We do not always know whether the desired goal will be worth the risk and suffering that must be borne to achieve it. Are there fundamental virtues that can be assigned to surgeons? I suppose that there are. In reflection, the ancients wrote about the cardinal virtues of Temperance, Prudence, Justice, and Courage. Later, during the early Christian era, Faith, Hope, and Charity emerged as the theological virtues. During the construction of the great cathedral at Chartre, it was planned that the cardinal and theological virtues would be sculpted on the North Porch of the cathedral to link the great thoughts and virtues of antiquity and the Christian era. The problem of symmetry emerged. There were four cardinal virtues and three theological virtues. This problem was solved by adding the virtue, Humility, to the theological side. It was an excellent solution especially since both Plato and Aristotle spoke about this important virtue in their writings.  How all of this relates to surgical practice is more than important. Some of our practicing virtues are mentioned herein and perhaps a more descriptive treatise on surgical virtues awaits us in the future.

The idea of self-evaluation is part of our ‘second hand knowledge” which comes with surgical training. Our morbidity and mortality conferences highlight this process that allows critical analysis for the purpose of improved patient care. These conferences are only as good as the leadership and the institution. A new metric has been instituted over the last 20 years that has been based on voluntary sharing of data for the expressed purpose of improved patient care. The Society of Thoracic Surgeons National Database, which now includes Adult Heart Surgery, General Thoracic Surgery, and Congenital Heart Surgery, has emerged as the leading instrument for data gathering, data analysis, and patient care improvement protocols, which have favorably impacted our profession in numerous ways. In an unprecedented study, practicing cardiovascular surgical groups from the same geographical area (New England) visited each others’ institution and gathered data on all aspects of patient care referable to coronary artery bypass. Time honored techniques fell by the board; innovations were shared; outcomes improved; and patient care benefited. The congenital heart surgery community is now moving in this direction for the purpose of improving outcomes across all programs. These kinds of initiatives are based on unselfish data sharing and free exchange of ideas. The surgeon has to have the courage to participate, have the courage to change if necessary, and be worthy of the trust that the patient has in him or her.

Teaching others to perform an operation, care for a patient, and allow them in turn to teach others is a joy that has been revered since antiquity. Independent staged responsibility after appropriate training has been the framework in which our residency system has thrived. This system has been difficult to maintain because of attending surgeon presence demands and the wish for every patient to have the very best technician perform their operation. Attending surgeons nowadays can be seen holding a retractor while the chief resident assists a junior resident perform an operation. Attending surgeons can help chief residents without affecting their rhythm or judgment and act only when necessary. There is nowhere in surgery where this challenge is more daunting than in congenital heart surgery. To help a resident perform a ventricular septal defect closure in a 2.5 kilogram child requires the attending surgeon to know the anatomy from both sides of the table and be able to communicate in no uncertain terms how the resident is to place the sutures, how the resident is to respect the neonatal tissue, and how the resident is to gain the necessary temperament to finish the operation. The congenital heart community has been rightly criticized for our reticence in handing down difficult cases to our excellent residents, myself included. There is however a movement through The Congenital Heart Surgeons Society, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery to address this very important issue and to stimulate publications, video tapes, and e-learning modules which will help attending surgeons be better teachers. The theme is, “How I help a resident perform a case”. This initiative ought to place this issue at the forefront of thought for congenital heart surgeons and reinvigorate the process that allowed us to learn and thrive in the first place.

In the end, the joy of performing an operation is like setting the sails for a friendly regatta. If one sets the sails correctly and pays attention to the details of wind velocity, current direction, and technical wizardry then all will be well. Uncertainty, however, always enters our theater at unexpected and difficult moments. These are the times that, through training, knowledge, and compassion, our profession has repeatedly proven the timber and character of its members.

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