Presidential Address: The joys of learning, collaborating, and giving back

Editor’s note: The following is an edited version of the Presidential Address that Dr. Rusch delivered at Convocation at the American College of Surgeons (ACS) Clinical Congress 2019 in San Francisco, CA. The presentation has been modified to conform with Bulletin style.

Thank you, [Ronald M. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon)] for your generous introduction. May I extend my warmest greetings to all of you gathered here today: to the Regents, Governors, and Officers of the College; to David B. Hoyt, MD, FACS, Executive Director of the College; to our new Honorary Fellows and ACS awardees; to the Initiates and your friends and families; and to our wonderful ACS staff who work hard behind the scenes every day to make all of this possible. I am grateful for the privilege of serving as your ACS President during the coming year.

The Convocation has always been one of my favorite parts of the ACS Clinical Congress. It is a joyous occasion that provides an opportunity to recognize Fellows who have made outstanding contributions to the College; to welcome as Honorary Fellows highly distinguished surgeons from around the world; and, perhaps most importantly, to celebrate all of you—the Initiates—becoming new Fellows of the College after many years of very hard work. Congratulations on this wonderful milestone in your career.

Viewed over the past decade, you, the Initiates, not only represent the largest number of new ACS Fellows but also reflect the increasing diversity of our membership. Today, roughly 30 percent of new Fellows are women, 40 percent work outside of North America, and 40 percent practice in specialties other than general surgery. As I look around this auditorium, I see diversity in gender, race, ethnicity, and countries of origin. This diversity not only strengthens the College as an organization, but also benefits our patients. This is a far different situation from what I recall when I became an ACS Fellow in the mid-1980s.

Key principles for success

Each of us stands on the shoulders of our predecessors, both professionally and personally. A few years ago, when I was visiting professor at the University of Washington in Seattle where I did my residency, one of the faculty remarked to me, “You probably don’t remember, but when I was a resident, you helped me place my first chest tube.” Indeed, I didn’t recall this particular event, but it was a reminder of the myriad ways each of us is influenced and elevated by our predecessors, mentors, colleagues, hospital staff, friends, and family. I, too, have benefited from the support of many throughout the course of my career. For me to name just a few would be to do a disservice to the many. Suffice it to say, I will always be grateful for the guidance and help that I have had along the way.

Perhaps each of us is most indelibly marked by our family environment and childhood experiences. Like many parents and their children, I didn’t always agree with my parents. However, they steadfastly instilled several important life principles that have stood me in good stead through my career.

Commitment to education

First, was the supreme importance of education. My mother, who came of age during the Great Depression, and who was only able to attend college because of a scholarship and a part-time job, always impressed upon us the privilege and transformative effect of higher education. My father, a physician who came from a more privileged background and had many interests outside of medicine, was multilingual and an accomplished musician. Thanks to him, we children also had multilingual and multicultural educations. To their last years, both of my parents remained avidly interested in the changing world around them and were good examples of lifelong learning. Occasionally, such interests bordered on the quixotic. Long before climate change was recognized, my father decided that hydrogen power was going to be the solution to the world’s energy needs. Who knows—perhaps he was right!

Commitment to excellence

The second life principle exemplified by my parents was the importance of hard work, integrity, and the pursuit of excellence. Idleness was not part of the family ethic. When we children were not in school, we were expected to be avidly pursuing a wide range of extracurricular activities. Even when all of this stretched the family financially, my parents did their utmost to ensure that we had the best possible educational opportunities. High levels of achievement were expected. At one point early in my medical career, when I was talking with my father about the difficulties of being among what was then a very small number of women in surgery, his simple answer was: “No one can argue with excellence.” End of discussion.

Commitment to diversity

The third principle was a commitment to equality irrespective of race, ethnicity, religion, or gender. Both of my parents were politically active in the turbulent period of the 1930s through the 1960s. Long before it was politically correct or even acceptable, they impressed upon us the pivotal importance of racial equality and respect for religious preferences. My mother was a feminist before the term came into common use and regularly asserted that there should be no barriers to women achieving their highest professional ambitions. Both of my parents emphasized the rewards and importance of being involved in activities that extended beyond oneself and in some way benefited others.

If all of this sounds like a dress rehearsal for residency training and a career in surgery, indeed it was. However, I believe that these principles would stand any of us in good stead professionally and personally, and they parallel many of the principles upon which this College was founded and how it functions today.

Paradigm-shifting science

As new Fellows of the College, most of you are in the early phase of your career at a time that could not be more exciting. In fact, as I witness recent extraordinary scientific and technological advances, I wish that I, too, were just starting my career. Allow me to borrow an example from what I do every day—the care of patients with non-small cell lung cancer. For many decades, we saw relatively little progress in the treatment of this difficult disease. The past 15 years have seen a rapid evolution in our understanding of fundamental tumor biology (as shown with the discovery of many so-called driver mutations in lung adenocarcinomas) and the development of many novel therapies—either therapies targeting specific mutations or immunotherapy with checkpoint inhibitors—leading to more precise treatment with far better outcomes. These novel therapies, shown definitively to improve survival in patients with advanced disease, are being rapidly moved into the care of patients with earlier stage, resectable tumors.

Most of the diseases that we care for as surgeons (and not just in oncology) are now being touched by rapid, paradigm-shifting scientific and technological advances. Never before has the science of what we do been more exciting and the opportunities to advance treatment greater. However, achieving those advances in ways that truly benefit our patients requires that we be nimble in our thinking, adaptable in learning new techniques and technologies, highly collaborative in our work, and rigorous in evaluating outcomes. “Lifelong learning,” “team science,” “team care,” and “quality care” have become overly popular bywords, but they are indeed now central to achieving clinically meaningful progress.

Challenges in health care

However, we also face many challenges. To paraphrase Charles Dickens, this is the best of times, but also the worst of times. Rapid changes in today’s health care environment are leaving some surgeons feeling overwhelmed and isolated. Recent studies report that burnout affects 30 to 50 percent of residents and practicing surgeons, with perhaps surgical residents and women being at greatest risk.^1-4

While the factors responsible for this situation are not fully understood, increasing administrative and documentation demands, the loss of personal autonomy related to the corporatization of medicine, and long work hours and work-life imbalance are consistently cited as culprits. Added to this are national problems in health care delivery. While lower- and middle-income countries often struggle with a lack of resources and infrastructure, the U.S. has a highly resourced but also highly politicized and dysfunctional health care system with many disparities in the provision of care. It is easy to focus on the daily frustrations of our work environment while losing sight of the great opportunities to improve the care of our patients.

How can we best move forward under these challenging and often frustrating circumstances? As discussed in the August issue of the ACS Bulletin, collaboration with others and participation in efforts that address a common need or common good not only lead to more effective results, but also can be personally rewarding.⁵ For those of us who practice oncology, multidisciplinary collaboration is inherent in what we do every day. Increasingly, though, this is true of all surgical specialties. Today, such collaborations may reach across surgical specialties, reach across specialties outside of surgery, or reach across disciplines outside of medicine. As new ACS Fellows, many of you may look to various subspecialty societies as the primary source for education and a forum for scientific presentation in your area of interest. By contrast, the ACS provides a unique environment for the multidisciplinary collaboration that is needed to ensure the highest quality care for our patients.

ACS Quality Programs

The ACS has more than a century’s experience in establishing and running programs designed to ensure high-quality patient care (see Figure 1). These programs run the gamut from cancer to trauma to bariatric surgery to pediatric care, and then some. In the U.S., the ACS Commission on Cancer and the ACS Committee on Trauma ensure quality care at more than 1,500 cancer centers and across a nationwide network of all levels of trauma centers. The accreditation program for breast centers also now extends internationally.

Figure 1. ACS: 100+ years of value improvement

Ample published data show that these quality and verification programs are successful in improving patient care. For instance, the development of standards for bariatric surgery and an ACS program of accreditation for bariatric programs directly led to a significant national decrease in operative mortality.

Each ACS program follows four principles of quality improvement: first, the establishment of evidence-based standards that can be individualized by patient; second, the assurance of optimal infrastructure; third, assessment through rigorous data extraction and analysis; and fourth, external peer-reviewed verification that creates public assurance.

As exemplified by the ACS National Surgical Quality Improvement Program or NSQIP^®, the approach of containing health care costs by rigorously ensuring higher quality care is a concept understood by physicians and patients that also has proven to be a very persuasive approach in national discussions regarding health care reform. It also is a concept that is applicable both nationally and internationally.

No matter what your personal career focus, the ACS offers an extraordinary breadth and depth of activities. As illustrated by the expanding reach of ACS international chapters, it also is an organization with great international reach.

The educational reach of the ACS is perhaps best illustrated by the success of the Advanced Trauma Life Support^® (ATLS^®) course. Figure 2 shows the many countries around the world where ATLS is now offered; this course is considered the foundation for teaching trauma care. The ACS is working to make many other of its superb educational products available internationally.

Figure 2. ATLS worldwide

The ACS also is increasingly seeking to engage and support younger surgeons from around the world, especially from lower-resource environments. Each year, generous support from ACS Fellows enables many international surgeons to receive support for their academic work, to travel to the Clinical Congress, and to visit institutions here in North America (see Figure 3).

Figure 3. International Guest Scholarships

One of the ACS programs that speaks to the highest ideals of our profession is Operation Giving Back (OGB), which seeks to leverage the passion, skills, and humanitarian ethos of the surgical community to effectively meet the needs of the medically underserved, both domestically and internationally. While originally organized in 2004 to coordinate the efforts of interested volunteers, OGB has, in the past few years, developed a more formal program to develop sustainable partnerships to promote surgical education and quality in low-resource international environments. This past year, in collaboration with more than a dozen U.S. academic institutions with established expertise in global surgery, OGB inaugurated the first such partnership in sub-Saharan Africa, specifically at Hawassa University, Ethiopia.⁶

None of the ACS activities that I have described would be possible without a veritable army of enthusiastic, talented, and very hard-working surgeon volunteers. They come from all surgical specialties and from all corners of the ACS membership. Their efforts benefit all of our patients. They exemplify the joys of learning, collaborating, and giving back. These may be the best of times and the worst of times, but on balance, I think that, together, we can make them the best of times. To those of you who have already been involved in these activities as residents and Associates, I extend my gratitude. To all of you as new Fellows of the College, I invite you to join in the process. I predict that you will find it exciting and rewarding.

References

1. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
2. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: A systematic review. J Am Coll Surg. 2016;222(6):1230-1239.
3. Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011;254(4):558-568.
4. Pulcrano M, Evans SRT, Sosin M. Quality of life and burnout rates across surgical specialties: A systematic review. JAMA Surg. 2016;151(10):970-978.
5. Alimi Y, Alteri MS, Kauffman JD, Kandagatla P, Quinones PM, Torres MB, Williams-Karnesky RL. Training resilient surgeons: Where do we go from here? Bull Am Coll Surg. 2019;104(8):45-51. Available at: bulletin.facs.org/2019/08/training-resilient-surgeons-where-do-we-go-from-here/. Accessed November 7, 2019.
6. Hoyt DB. Looking forward. Bull Am Coll Surg. 2018;103(11):9-11. Available at: bulletin.facs.org/2018/11/looking-forward-november-2018/. Accessed November 7, 2019.