Editor’s note: The following is an edited version of the Presidential Address that Dr. Maier delivered at Convocation at the American College of Surgeons (ACS) Clinical Congress 2018 in Boston, MA. The presentation has been modified to conform with Bulletin style.
Good evening and welcome to the 2018 Initiates of the ACS and their families and friends, as well as our newly elected and current Honorary Fellows and esteemed guests.
To our Initiates—congratulations! You represent our largest class ever, with 1,359 coming from the U.S. and Canada and 613 from many other countries around the world—a truly global representation of surgery today. Give yourself and your colleagues a round of applause. You each richly deserve this recognition.
This occasion is indeed momentous. You have just earned entry into the ACS and have taken a major step in solidifying your standing in our profession. Surgery is not only a great profession, but also the best profession in medicine. It is a profession, I would argue, that will provide you with the recognition and rewards that you deserve based on the years of hard work, dedication, and commitment it takes to become, and remain, the best surgeon you can be. And, as a surgeon, you will help to sustain our profession through self-regulation, altruism, and constant demonstration of the highest ethical values.
Our profession
Becoming a surgeon places you into a great profession, and with that, your patients will give you a great honor. You will be revered by people for knowing what you have learned and what you know how to do. Patients come to you vulnerable, and you will return them to strength. Patients will come to you with diseases and with dysfunction, and you have the skills and the technology and the capability of returning them to a position of health and function. Of the honors one may receive, none is greater than the daily respect and faith our patients place in us as they place their care and lives in our hands. In return, as stated in the Fellowship Pledge of the College declared by each Initiate moments ago, “I pledge to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else. I promise to deal with each patient as I would wish to be dealt with if I were in the patient’s position, and I will respect the patient’s autonomy and individuality.”
In fact, in recognition of our increasingly diverse society, this tenet based on the Golden Rule has been revised to the Platinum Rule, where we, in fact, deal with our patients not only as we would wish to be treated ourselves, but as they wish to be treated based on their own unique ethnicity, gender, background, experiences, culture, and the entirety of their intersectionality. Always remember their valor, their dignity, their humor, and their determination. That is a lot on your shoulders, but you are up to the challenge.
Our focus is to deliver the most effective and efficient care to our patients. Always remember to be kind, thoughtful, and respectful to your patients. We need to always hold our patients and their needs first. Remember the Platinum Rule. No matter how famous you become, remember whom you serve. Be humble. Accept with an open mind what your patients teach you daily. If you do, they will find a way to keep you humble in so many unique and challenging ways. Also, as Thomas J. Nasca, MD, MACP, chief executive officer, Accreditation Council for Graduate Medical Education, told the Georgetown University School of Medicine, Washington, DC, graduates in May, “Every patient has a ‘why.’ We need to listen. We need to hear it, so we can help them with the ‘how’ so that they can achieve it. Your soul will be enriched by each person you care for. Pursue your calling with vigor, with commitment, with kindness and whenever in doubt, remember the ‘why’ that’s in your hearts today.” And, we need to always remember for whom we work—our patients—and to commit the totality of our careers to improving their care.
A lifetime of learning
Maintain your love for attaining new knowledge and be open to a lifetime of learning. As you enter practice, if you believe you have all the answers, you are in the wrong profession. Science and technology are constantly changing. Be humble and recognize your gaps and acknowledge your deficiencies. It will take a constant commitment and daily work to stay current. Develop your skills as you develop your knowledge. Remember to stay conscientious in your pursuit of competence and to always deliver care with compassion. Similarly, always assess your outcomes. Each year, be better than you were the prior year.
Use your membership in the College. Not only will self-assessment and comparison with others be an expectation for reimbursement going forward, but knowing that your outcomes are comparable with benchmarks will be expected and is warranted by your patients. Value-based care is here to stay. And being able to assure your patients of high-quality care will require honest assessment of your outcomes.
Outcomes assessment was a foundational value upon which the College was established, and the ACS has remained a worldwide leader in this respect. Whether it is developing the structure to improve the outcomes of your trauma system, measuring the effectiveness of your bariatric center, or evaluating the individual surgeon, the ACS offers programs that allow surgeons to compare outcomes against data generated by other surgeons, rather than arbitrary standards developed by an accountant.
Our leadership
You are given great opportunities to achieve your goals. You are granted a unique leadership status. But to succeed you need a finely tuned team based on strong collegiality and mutual respect. Become a true leader. Bullying, implicit bias, and exclusion will not make you a better surgeon. Teaching and mentorship comprise a long-standing core tenet of surgery. In fact, the word “doctor” comes from the Latin docere, which means “to teach.” We are the teachers, coaches, sponsors, and constant supporters of our mentees and team members. Take the time to teach others, whether it’s a patient and his or her family, a trainee, a mentee, or your health care colleagues; share your knowledge willingly and daily. As consumer activist Ralph Nader has said, “The function of leadership is to produce more leaders, not more followers.”
Be nice to one another. Our profession is a lifetime commitment, with an increasing cadre of friends and colleagues; treat each other as such. Treat each other the way you would want to be treated, with kindness, professionalism, and respect. How often can a bad outcome be avoided if the nurse or any member of the team is respected, encouraged, and empowered to speak up? To be effective, your colleagues—including all members of the health care team—must trust you. And, in return, you must trust that they are hardworking, committed, and dedicated to the care of our patients.
You must decide how best to succeed and lead. Some recommend doing only what you need to do to advance your career goals. Avoid “distractions” such as teaching and mentoring or advancing the goals of the institution through committee involvement. Saying “no” is not the way to fulfillment. You need to lead and to be invaluable. You need to say “yes” to provide help when asked, to provide mentorship and support. I recommend you strongly consider a leadership based on service. As stated by the philosopher Lao Tzu, “A leader is best when people barely know he exists, when his work is done, his aim fulfilled, they will say: we did it ourselves.” As Michael Zinner, MD, FACS, Past-Chair of the ACS Board of Regents, recently stated, if you want to be a leader in surgery, the most important skill is the ability to bask in the reflected glory of other team members. Put another way, Jack Welch, former chairman and chief executive officer of General Electric, says, “Before you are a leader, success is all about growing yourself. When you become a leader, success is all about growing others;” and as basketball great Michael Jordan has said, “Earn your leadership every day.”
Our community
Surgeons are outliers in society because they are exceptional. While our professional colleagues may understand us, nonmembers of our community sometimes perceive us differently. Surgeons must work with one another and with the ACS to expose the outstanding traits of surgeon-leaders, such as decisiveness, skill, and independence. Assume the societal leadership role willingly. Work with your patients, your community leaders, and our elected officials to do what is right for our patients. Be an advocate for our patients to have reasonable access to surgical care and the guaranteed right to medical care. Be a leader, whether in your hospital, your hometown, or your professional organizations.
I would argue that the ACS is the best advocacy group that we have for ourselves and our patients, and we need to get involved with those advocacy efforts. Always push to raise the bar and advance the expectations higher. However, do not be the one always pointing out the problems and providing negative input. Always remember it is better to be a positive leader; identify the problems and advance your suggestions to improve and resolve the challenges. As anthropologist Margaret Mead said, “Never doubt that a small group of thoughtful, concerned citizens can change the world. Indeed, it is the only thing that ever has.”
The world needs you to embrace your role as a moral leader in society—a moral leader who inspires us to reflect our values in our words and actions and who leads by example. Whether you have a special calling for a social mission to work in rural areas or to treat poor and low-income populations, our profession requires us to fight to achieve equity for the most vulnerable among us. Being a moral leader means standing up for truth, reason, and science. It means not being afraid to stand up for your principles or hold elected leaders accountable for meeting the needs and the values of our communities. We’ve been told that we should shy away from political controversy. But your obligation from today onward is to stand up for the vulnerable and the voiceless.
For example, with respect to trauma, no preventable injury can ever be justified. And if that means engaging in controversy, then do it. Because as former U.S. Surgeon General and founder and president of Doctors for America, Vivek Murthy, MD, MBA, has said, “Principles are only worth having if you have the courage to act on them.” Remember, we have much more in common than our parochial interests and differences. Embrace our commonalities. Don’t underestimate the impact you can make, whether for the individual patient or the greater social good. Our imperative is to advance human health for all.
Ourselves
But please take heed: Health care professionals are under more stress than ever, as evidenced by increases in demand for better services that are more efficient and thorough, higher costs of providing care, reduced staffing, and diminishing resources. Many health care workers are putting in longer hours for less pay. As Atul A. Gawande, MD, MPH, FACS, a general and endocrine surgeon at Brigham and Women’s Hospital, said at the Yale School of Medicine’s 2004 commencement, “The life of a doctor is an intense life. We are witnesses and servants to individual human survival. The difficulty is that we are also only humans ourselves. We cannot live simply for patients. In the end, we must live our own lives.”
Physician burnout has been reported to be occurring in more than 50 percent of our colleagues and is increasing. As Toby M. Cosgrove, MD, past-president and chief executive officer of the Cleveland Clinic, OH, stated at Clinical Congress 2016, burnout among physicians is “one of the most pressing issues facing the medical profession.” The primary driving force is not unhappiness at home or global depression; rather, it is unhappiness at work. A major source of this unhappiness is that the physician-patient relationship, which has provided happiness and strength in the past, is now threatened daily by the increasing insurer-employer-provider relationship—a relationship born in part of the enormous size of loans and debt accumulated during training, eliminating other, more traditional practice options. Along with this new relationship is an increasing cynicism in medicine as patients routinely change physicians; employers change insurers; and insurers change physician panels during frequent employer-insurer negotiations, absent input from either patients or physicians—who are left powerless and without a voice in the process. Thus, the passion for our profession erodes, and we become more and more isolated. These challenges continue to be pervasive and have become an increasing part of the life of physicians.
As a result, it has become increasingly critical to remember to practice self-wellness. You cannot provide optimal care to your patients if you are not well yourself. It is time to heal the healers. Avoid burnout and the attendant loss of compassion. As challenges and pressures continue to change and mount, you must develop an active strategy to prevent overload and depression.
Amazingly, it is the young that have been shown to have the greatest risk for burnout. The best long-term approach is to develop tools and skills to generate and protect resilience. One of the recognized best tools in the development of resilience is the establishment of friendships, communities, and support on which to rely. And one of the best ways to develop these relationships is through joining and working within professional organizations and their attendant communities. By being involved in these organizations, communities and activities are available to develop important support groups and friendships among those individuals who are facing, and successfully overcoming, these challenges.
In addition, commitment and involvement in the development of organizational goals and advocacy programs provide an excellent avenue for self-gratification and satisfaction.
The ACS provides extensive web-based self-assessment tools to achieve the primary step in addressing burnout: identifying whether you are at risk. The ACS provides, throughout the entirety of your careers, a wealth of opportunities for growth, involvement, and reward. Personally, a major reward and source of professional satisfaction was the 20-plus years I spent involved and immersed in the activities of the ACS Committee on Trauma (COT)—from state chapter member, to State and then Region Chief, to national COT member. The positive rewards of working within, and for, a community of like-minded professionals committed to improving the care of the injured patient was an unbelievable opportunity to continually reenergize, enjoy, and experience positive self-worth as I have advanced through my career. Regardless of your specialty or your personal interests, the College provides a multitude of avenues and opportunities for you to become involved, to work with your colleagues and elected officials, and to improve the care of our patients. You will be well rewarded, and your resilience will grow.
As I close, I again congratulate you on this momentous event in your professional lives. You will be honored and respected. Remember your mentors and teachers. Be kind to one another and respectful of all. Truly, no man is an island. And always remember to take care of your family and loved ones. They will be there to support and care for you. May you find the true joy and satisfaction in our profession, the best there is, and fulfillment through your life’s work in caring for our patients.
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