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Why I Chose Cardiothoracic Surgery

Monday, January 22, 2007

When I was asked to write a statement on why I chose to become a Cardiothoracic Surgeon, that request resulted in setting aside some time for deep reflection and thought.  As one reflects over a practice career of 32 years in academic medicine plus seven years in training, it causes one to think - Why I did it, and would I do it again?

Let me start with a brief autobiographical sketch.  As a senior in high school in 1958 in Atlanta, Georgia, I had decided to attend Georgia Tech and pursue a career in engineering.  In January of 1958 my father said, “Son, why do you want to be an engineer?  Anybody can do that.  Be a doctor, and help people.”  I heard what he said, but I paid little attention.  Two months later, in March of 1958, my father died at age 44 after his third myocardial infarction.  He had previously undergone a Vineberg procedure after his first two myocardial infarctions two years previously.  His death caused me to rethink what my father had previously said two months before.  With the encouragement of my high school sweetheart, and now wife of 43 years, I made a change of life plan and decided to become a physician. 

In April of 1958 I notified Georgia Tech that I would not be coming and that I would be going to Emory University. 

I entered Emory in September 1958, and it turned out to be the correct decision for me.  I did well academically and was actively involved in campus affairs, serving as President of the Student Body in 1961.  It was at that point I applied, and was accepted, to Emory University School of Medicine, and I started classes in September of 1961. 

Four years passed quickly, and I decided to become a cardiothoracic surgeon.  In my senior year, Dr. Osler Abbot, who was Chief of Cardiothoracic Surgery at Emory, told me:  “If you want to be a Cardiothoracic Surgeon, you need to go to the Mayo Clinic and study with Dr. John Kirklin, he’s the best”.  I applied, was accepted, and in 1966 my wife and I moved to Rochester, Minnesota, where we would stay until 1972, where I was a Resident in General Surgery with training interrupted by a two-year obligation during the Viet Nam War.

At the Mayo Clinic, I met men who were to become my mentors and heroes.  Individuals such as Dr. John Kirkland, O. T. Clagett,  Phillip Bernatz, Dwight McGoon, Robert Wallace, Bunky Ellis, Oliver Beahrs, and others became a focal point in my thought and career development.

Their importance to me during my time at the Mayo Clinic, and subsequently, can be summed up in the statement of Dr. David Faxon, who said, “I ask you to recall your own personal mentors and how your lives would have been less fulfilling without them.  I ask you to whom do the students of today turn?  From whom do they seek wisdom, guidance and insight?  Who teaches them patience, perseverance, and practice?”

As Richard E. Clark, in his Presidential Address to the Southern Thoracic Surgical Association, so eloquently stated, “As we age singularly and collectively, we have forgotten the importance of the hero in our lives.  Heroes are our beacons in the downpours and in the fog.  Heroes enrich us and inspire us to persevere and help us feel that our lives are worthwhile”.

Such has been the presence of heroes in my life.  The names Kirklin, Clagett, and McGoon have been previously mentioned, but there have also been others.  Dr. Penfield Faber and Dr. Hal Urschel have helped me tremendously along the way.  They have been beacons of light and have provided mentorship and friendship.  For the collegiality and friendship of Dr. Peter Pairolero, Dr. William Baumgartner, Dr. Timothy Gardner, Dr. Fred Crawford, and Dr. Doug Mathisen, I will always be grateful.

Dr. Kirklin stressed that a Cardiothoracic Surgeon is “a surgeon and something more”.  During my time at the Mayo Clinic, the individual that I bonded the closest with was Dr. Dwight McGoon.  I never met a man with such surgical dexterity and equanimity.  His career was cut short because of Parkinsonism, and later it was my privilege, along with Dr. Gene Berry of Baton Rouge, Louisiana, to help establish the Dwight McGoon Mayo Medical scholarship.

In 1972 I left the Mayo Clinic to return to Emory University where Dr. Charles R. Hatcher, Jr. had just become Chief of Cardiothoracic Surgery. He offered me a Cardiothoracic Surgical residency position with the potential for a subsequent job offer.  Upon completion of the residency in 1974, I was offered the opportunity to join the Department of Cardiothoracic Surgery.  Dr. Hatcher became another one of my heroes and mentors.  He asked only three things:  “One, do your best; two, the term never or can’t does not exist in your vocabulary; three, be the best”.

The past 32 years have been a wonderful journey through cardiothoracic surgery while remaining at Emory.  I have had the opportunity to grow at both a university level and at the national level.  After serving on both the American Board of Thoracic Surgery and the Thoracic Surgery Residency Review Committee, I developed a much greater appreciation for resident education in cardiothoracic surgery. 

In 2003 I had the honor of serving as the 50th President of the Southern Thoracic Surgical Association.  The title of my presidential address was:  The Complete Cardiothoracic Surgeon:  Qualities of Excellence.  The remainder of this narrative will be a paraphrase of this address and some comments.

In this address, I listed 13 qualities of the complete Cardiothoracic Surgeon 
(Table 1).  A few comments about some of these:

Table 1

Qualities of the Complete Cardiothoracic Surgeon

1. An excellent technical surgeon with good judgment.
2. A detailed knowledge of cardiorespiratory physiology.
3. An excellent teacher and have knowledge of cardiothoracic surgical education.
4. An excellent radiologist.
5. Have knowledge of healthcare economics.
6. Have knowledge of new surgical technology.
7. A leader.
8. Be adaptable.
9. Have a historical knowledge of the specialty.
10. Have a quality of persistence.
11. Should be a humanist.
12. Should have a hobby.
13. Should have a faith.

1. The first quality of a complete Cardiothoracic Surgeon is that of being an excellent surgeon.  There is no substitute for technical excellence.  Ultimately, our ability as surgeons will be determined by how effectively we perform surgical procedures as measured by the standard of our fellow cardiothoracic surgeons, our professional colleagues, and our trainees.  Whatever our work environment, be it in the private sector or academic sector, we as practitioners of the highest art must be the best technical surgeons that we can be and assure that our trainees develop to be the best that they can be.

Andrew Morrow has pointed out that the attributes of an expert surgeon include the wisdom of selecting patients for surgery and the conduct of the operative procedure.  Morrow stated, “A surgeon, and only the surgeon, should make the all important final decision as to whether a patient is a candidate for an operation and, if so, what procedure is the most appropriate.”  He reminded us of one of the most poignant statements of Blalock, “The fact that a patient is going to die does not necessarily mean that he should be operated upon.”  Judgment is almost as important as the technical ability to carry out the procedure itself.

2. In today’s time, a Cardiothoracic Surgeon must have knowledge of healthcare economics.  The complete Cardiothoracic Surgeon must have a detailed knowledge of the impact of government on thoracic surgical education and healthcare economics.  He must be willing to grapple with economic issues and work toward their solutions.  In addition, he is required to know the consequences of outcome parameters in adult cardiac, thoracic and congenital heart surgery.  The outcome parameters will be the standardized measure by which all surgeons are compared.

3. The complete Cardiothoracic Surgeon must also be a leader.  The complete 
Cardiothoracic Surgeon must be a leader in the local healthcare environment; he must be a leader in the training of residents; he should strive to be a leader in national specialty organizations; in essence, he becomes a Renaissance human, or Thomas Moore’s “A man for all seasons.”  He is an individual that others will want to emulate.  Leadership involves taking responsibility to direct the action of others and taking the responsibility and accountability for both successes and failures.  In his excellent book “Leadership Secrets of Attila the Hun,” Wes Roberts points out that “You must have a passion to succeed, a passion that drives you to prepare yourself and your colleagues to excel.  By their actions, not words, do leaders establish the morale and integrity of the subordinates, and by their ability to make timely and difficult decisions.”  He points out that “Leadership Effectiveness = Results x Personal Qualities.”   

4. The complete Cardiothoracic Surgeon must be adaptable to change.  He must 
consider new ideas, and he should never fail to keep an open mind.  Larry Cohn stated:  “The most successful thoracic surgeons are, by their very nature, adaptable because they deal with new predicaments every day in the operating room, in the ward, and in the clinic”.  

As J. Cassell in 1987 pointed out, “Surgeons are rarely allowed the luxury of second thoughts.  At the operating table, the surgeon must manifest decisiveness, certitude, control; emergencies must be resolved, unexpected  findings anticipated, and the advantages exploited”.

5. The complete Cardiothoracic Surgeon should develop, to the best of his or her ability, the quality of persistence.  Persistence is perhaps the most important quality that a complete Cardiothoracic Surgeon can develop.  It is often the key to a successful outcome.  As Cohn pointed out, many times we have experienced success in a very difficult operation by simply adhering to our game plan in the operating room, no matter what the obstacles are.  Gustav Mahler stated:  “For success, nothing in the world can take the place of persistence; talent alone will not be successful because nothing is more common than the unsuccessful human with talent.  Education alone will not be successful because the world is full of educated fools.  Persistence and determination are alone omnipotent.  It is the ability to keep on going and trying through the valleys in the late night hour in the operating room when success often comes and a successful outcome for the patient results”.  For the surgeon who is persistent and has expert knowledge and technique rarely is there an adverse outcome.
6. The complete Cardiothoracic Surgeon must also be a humanist.  Dwight McGoon, in his Presidential Address to the AATS in 1984 said:  “All efforts in research, education, administration, writing, editing, and long hours of intensive labor at the operating table have inherent and transcendent value only in one respect … as an unselfish expression by skilled and dedicated surgeons of a concern for the welfare of needful human beings.”  We must remember that our patients are our primary concern, and it is for them that we have dedicated the long years of training.  We must never lose our compassion for the patient.  As Aldo Castanaeda stated in his Presidential Address to the AATS,  “Our specialty is not merely an applied science and technical discipline, it also involves an important aesthetic component, juxtaposing art and science, and demanding, in addition, honesty, courage, judgment, vision, compassion, and a commitment to the pursuit of excellence.  The privilege to participate in preserving and improving life provides us with our purest professional satisfaction.  There is a widening gap between science and the humanities.  Often we find well-trained professionals who have mastered scientific facts, statistical proofs, and surgical techniques but who lack more elusive qualities such as respect for the dignity of humans, empathy, humility, and interpersonal skills”.                         

7. The complete Cardiothoracic Surgeon should also develop a hobby.  The complete Cardiothoracic Surgeon should have a hobby outside of medicine.  There must be something to sustain one’s interest besides the core of medicine; otherwise the surgeon will become stale and introspective with increasing age.  Dr. Richard E. Clark, in his Presidential Address to the STSA in 1989 entitled “Who, Hobbies and Heroes” points out the necessity of hobbies in our life.  He quotes from Dr. William Osler:  “No human is really happy or safe without a hobby, and it makes precious little difference what the outside interest might be … anything will do as long as he straddles the hobby and rides it hard.”

8. I would like to close with two short thoughts.  Dr. Floyd Loop stated that the qualities of the ideal surgeon are scholarship, leadership, courage, and faith.  I would agree that these are absolutely correct.  I would also like to quote from an extremely close friend of mine, Dr. Clement A. Hiebert, now retired.  In one of the most eloquent addresses ever given in cardiothoracic surgery, Dr. Hiebert, in his 1988 Presidential Address to the New England Surgical Society, pointed out the five attributes of surgery:  one, it has a beginning and an end; two, it can be completed in a number of hours; three, it has an attribute of stress to overcome; four, it has a focused activity; and five, it has the quality of “in-chargeness.”   He asked the questions:  “Can we achieve fulfillment?  Is the grail beyond our reach?  Are we fettered forever by the mundane and the material?  Can we recapture the sense of wonder and worthwhileness in surgery?”  He stated:  “The only true happiness comes from squandering ourselves for a purpose.  The best-kept secret in surgery is to find fulfillment.  You must lose yourself in something larger than the operative field.  It is then that we can achieve the fulfillment of mind, heart, and spirit.”

In conclusion, despite the increased length of training, governmental regulations, declining reimbursement, the 80-hour work week, and the demands to produce, I find the field of Cardiothoracic Surgery a grand and glorious profession.  Surgery is still fun.  It is the staff of life. 

When asked, “Would I do it again?”, the answer is an emphatic “Yes”.  I think we will continue to attract the best and the brightest when we educate them in the Hippocratic saying that “Life is short – but the art is long.”  Henry Adams stated:  “A teacher affects eternity; he can never tell where his influence stops.”

We, as Cardiothoracic Surgeons, have a unique privilege  - to be caretakers of our fellow human beings.  Let us do so as doctors, as teachers, as mentors, and, above all else, as men and women who can make this world a better place in which to live.

I would encourage any resident to consider Cardiothoracic Surgery as it is a glorious and wonderful field of medicine.

These remarks are dedicated to my two physician children:  Dr. Laura Dovan, a pediatrician in private practice, and Dr. Joe Miller, III, a cardiologist at Emory University.    



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