The American Journal of Surgery (2015) -, -–-
Perspectives on the profession
Ronald M. Stewart, M.D.*
a
Department of Surgery, University of Texas Health Science Center at San Antonio, University Hospital,
7703 Floyd Curl Drive, MC 7840, San Antonio, TX 78229, USA; bUniversity Health System, San
Antonio, TX, USA.
KEYWORDS:
Profession;
Professionalism;
Perspective;
Surgery;
Photography
Abstract In his presidential address to the Southwestern Surgical Congress, he examines surgery as a
profession from three different perspectives: his experience as a patient, a surgeon, and a photographer.
He uses photography to illustrate the importance of perspective and illumination. He respectfully suggests that we should consciously choose to reframe the profession from a different perspective that
accurately reflects its beauty. He also advises that we take effort to shine a gentle, soft light on the profession, a light that will reveal the beauty, the true beauty, of the profession. And finally, he submits that
it is our responsibility to consciously and faithfully maintain and defend the profession from enemies
inside and outside its borders.
Ó 2015 Elsevier Inc. All rights reserved.
It is a great honor to give the presidential address for the
Southwestern Surgical Congress (SWSC). Professionally, I
have grown up in this organization and will always be
indebted to the Congress and its members. I wish to thank
the leadership and members of the Congress for the
opportunity to serve the organization and Dr. Carey Page
for strongly encouraging me, as a young resident, to
participate in the Southwestern Surgical Congress. In
1985, as a fourth year medical student, I began work on
my first surgical article, later presented at the SWSC. I owe
a debt of gratitude to my family, my dear wife Sherri and
my three children, Elizabeth, Jackson, and Mary. Thanks to
my brother, Donald Stewart, MD, who has always been a
role model for me. I will be forever grateful to those who
There were no relevant financial relationships or any sources of support
in the form of grants, equipment, or drugs.
The authors declare no conflicts of interest.
Presented at the Annual Meeting of the Southwestern Surgical
Congress, April 26, 2015, Monterey, California.
* Corresponding author. Tel.: 11-210-567-5705; fax: 11-210-5673447.
E-mail address: [email protected]
Manuscript received September 18, 2015
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2015.09.002
helped me to become a surgeon, J Bradley Aust, Arthur
McFee, Tony Cruz, David Root, Carlos Pestana, Waid
Rogers, Ken Sirinek, and Wayne Schwesinger. My time in
Memphis made an indelible impact in my life and I
similarly am forever grateful to Timothy Fabian, Martin
Croce, Liz Pritchard, and their team. Finally, I wish to
thank all my contemporaries and friends who are so
cherished and critical in my life. These colleagues along
with our residents do all the work that I don’t do back at
home. Thank you to Dan Dent, John Myers, Brian Eastridge, Lillian Liao, Michelle Price and the entire surgical
faculty and residents in San Antonio. Thank you Brian for
giving such an entertaining and comprehensive introduction. And, thank you to all my wonderful friends and
colleagues in the SWSC for your time, professionalism, and
friendship.
I am going to focus on perspectives on the profession of
surgery. Specifically, I am going to examine the profession
from three different roles as (1) a patient, (2) a surgeon, and
(3) a photographer. I will use the third role to illustrate how
perspective and illumination may radically change both our
actions and our perceptions of the profession we call
Surgery.
The American Journal of Surgery, Vol -, No -, - 2015
2
(collectively) are choosing to view the profession from an
unflattering perspective and in an unjustifiably harsh or unflattering light. If we viewed it from a more correct perspective with appropriate illumination, we would see the
profession with the glory it deserves. By a change in
view, we would then naturally respond differently to our
profession. But not to leave this to chance, I am going to
offer what I believe is a more correct perspective by
retrieving words that were never intended for us to see;
words written by a country doctor in a primitive outpost.
But first let me provide my perspective as a patient.
Perspective as a patient
Ronald M. Stewart, M.D.
Although not often explicitly considered, as surgeons,
each of us is the recipient of a great gift; not something we
earned, but a true and precious gift. We are the direct
beneficiaries of the toil, the dedication, the innovation, and
the service of all of those surgeons who came before us. My
grandmother was a child at the time of the first JB Murphy
address at the sixth annual meeting of the American College
of Surgeons more than ninety years ago. In delivering this
address, Sir Berkeley Moynihan shines a soft and gentle
light and provides a timeless perspective on our profession:
Our calling, by common consent the noblest of any,
dignifies all who join its ranks. The honour of the
profession is the cumulative honor of all who, both in
days gone by and in our own time, have worthily and
honestly laboured in it. for it is, as Ambroise Pare said,
‘‘beautiful and best of all things to work thus for the
relief and cure of suffering.’’1
As one contemplates these words, the gentleness and
reverence conveyed are striking. We live and practice
surgery in a wonderful time. Sir Moynihan, in his wildest
dreams, could not have envisioned the fruits of modern
surgery, yet why do a large percentage of modern surgeons
seem to view the profession so negatively. This why is the
subject of this address, or to be more precise, this address
explicitly hypothesizes that the reason why is because we
I am writing today from the exact chair where I sat (at our
home dinner table) on December 21, 2011. By fate, I was
home rather than traveling through a remote swath of
Southwest Texas to visit a series of rural hospitals. Instead,
I was doing some last-minute online Christmas shopping,
when suddenly my visual field seemed to contract, followed
by a progressive filling of my visual field with the color of
gold. I immediately recognized I was losing meaningful
consciousness and could feel the muscles in my right arm
involuntarily contract lifting my arm. Straining, I struggled
to maintain consciousness, but this was a losing battle. After
a brief, unclear period, I started to regain conscious thought,
and I could hear the words of my eldest daughter, Elizabeth,
asking, ‘‘Daddy, are you ok?’’ Curiously, I did feel ok, but I
immediately realized I had a dense right hemiparesis, and,
on trying to speak, recognized I had a severe expressive
aphasia. Quickly, similar to a computer rebooting, my
cognition was sequentially returning. I had lived with lone,
paroxysmal atrial fibrillation for the previous decade, so I
quickly realized I had most likely sustained a stroke, but
trying to articulate these thoughts was strangely challenging.
Words started to come. As I was trying to say, I need a
doctor, instead what I was actually saying is, ‘‘I need my
friends.’’ When I tried to say I need to go to the hospital, I
instead said, ‘‘I need to go home.’’ My daughter was
momentarily confused and thought that I may be joking.
After a few repeat attempts with the same result, I tried
substituting words. I realized I could say, ‘‘I need a
neurologist.’’ Words were now returning at a greater pace.
I managed to say, ‘‘I have had a stroke or a seizure.’’ My
daughter jumped into action and called 911 and her mom.
Within minutes, an ambulance team was in our home, and
shortly, I was being transported to University Hospital,
where I was met by ‘‘my friends.’’ Literally, my friends, who
were prepared to treat me. Within minutes, I had a CT scan
of my brain, was seen by both our trauma and our stroke
teams, and was diagnosed with an embolic left hemispheric
stroke. I was already dramatically improved from the event.
At approximately one hour from onset of symptoms, I had
systemic tissue plasminogen activator administered and was
continuing to improve by the minute. By the evening, I was
near normal with return of speech and motor function.
R.M. Stewart
Perspectives on the profession
I was blessed to have an uneventful and rapid recovery. I
was home by Christmas Eve, and I was administratively
back at work in early January. What of my perspective as a
patient might be relevant to this audience?
Although my feelings may be somewhat stronger, because
of my background, I believe my emotional response is very
typical of patients you treat everyday. How did I feel? My
dominant emotion during this period was one of indescribable
gratitude. Gratitude of a magnitude that today I still cannot
adequately express. Gratitude to my daughter who came to
her father’s rescue, the paramedic team, my wife and family,
my treating physicians, nurses, and technicians, most of
whom are my close friends, and, finally, a gratitude to God.
Gratitude: I want to thank each of you for everything that
you do for the individual patients you treat everyday. And,
just because your patients may not be able to articulate it or
express the gratitude, do not for one second doubt that it is
there, because it is there. Culturally, our society is not strong
in expressing gratitude, and many of your patients may be unable to articulate it, but you should know your patients are
sincerely grateful. Even though I have told you how I feel, I
don’t believe to this day, I have adequately expressed how
grateful I am to the people who rescued me and allowed me
to walk, talk, and feel. Speaking of feeling, the other feeling
was unmitigated joy on multiple levels. Indeed, in many
real ways, having a stroke was one of the best things that
has ever happened to me: Joy. You may think your speaker
is a bit incoherent, maybe even with more residual cognitive
dysfunction than what you would have guessed from the
event, but many good feelings have come from this experience. In addition to gratitude and joy, further revealed truth
from the other side of the bed rail is the knowledge of being
a dependent patient; the knowledge of understanding the
love of your family and friends, the knowledge of how special
it is to simply be able to speak, and on that day, I gained much
greater understanding of time. You and I do not have unlimited time on this earth. The time to do what you need to do
is today, not tomorrow, not next week, but today. Today is
the time to mend a broken relationship. Today is the time to
do meaningful work, and today is the time to do what I ought
to do. Today: And finally and a bit sadly, the knowledge that I
must go down that path again of December 21stdwe only
have a certain amount of time and our time, all of our time
will eventually come due. We often behave as if we have unlimited time, but the opposite is true, and this knowledge is no
longer an abstract concept for me.
Table 1
3
Please learn from me as a patient, speaking to you
honestly. Your patients are grateful and joyous over a cure
or relief of suffering. And, you do have very limited time to
do the things you have set out to do. Love your family and
your friends. Love your work. Choose to be happy today,
rather than chasing happiness tomorrow. And finally, follow
your dreams, love your chosen work, and do not fail to take
a chance or stance when you need to for the betterment of
your patients, the profession or your family. Be conscious
of these things. In my role as a Department Chair, it is far
more likely to do unconscious harm than unconscious good.
Be mindful and true to what we set out to do, because it
really is true what Ambroise Pare said, reportedly at twelve
years of age, ‘‘beautiful and best of all things to work thus
for the relief and cure of suffering.’’2
Definition of the profession
What is an appropriate definition of our profession?
There are numerous appropriate perspectives, but I will
summarize with a set of criteria, a general principle, an
encapsulation of how professions came to be, and my short
definition of our profession.
Dr. Rakesh Khurana, Dean of Harvard College, with the
goal of encouraging organizational management to assume
characteristics of one of the professions, has written
cogently about the professions from a wide range of
perspectives. Table 1 provides a comprehensive set of
criteria from Dr. Khurana and his team.3 I believe these
criteria provide a sound modern definition of a profession.
I personally prefer his more concise statement of principle
which broadly characterizes a profession, ‘‘I will create
value for society rather than extract it.’’4 The term profession, derived from Latin, is illustrative of the origins of
the Professions. Likely, the original professions were divinity, medicine, and law. In the beginning, each of these
began with a profession of faith or of a set of defining beliefs; so, those inducted into the profession did so by literally professing. So, in the beginning, the professions began
with a profession, thus the term. To me, it is critically
important for surgeons to understand what it is that we profess. I believe our profession, passed down for at least
2,500 years, outliving the societies which spawned it, is
concisely summarized as (1) we dedicate ourselves to the
service of humanity, and most importantly, we place the
needs of the patient above those of the surgeon, and (2)
Criteria for defining a profession
A common body of knowledge resting on a well-developed, widely accepted theoretical base;
A system for certifying that individuals possess such knowledge before being licensed or otherwise allowed to practice;
A commitment to use specialized knowledge for the public good, and a renunciation of the goal of profit maximization, in return for
professional autonomy and monopoly power;
A code of ethics, with provisions for monitoring individual compliance with the code and a system of sanctions for enforcing it.
These are criteria for a working definition of a profession by Khurana et al.3
4
The American Journal of Surgery, Vol -, No -, - 2015
we will base our knowledge and actions on scientific truth
as best we can determine it.5 This is the profession of our
Profession, and to me, it is best viewed as a gift passed
down from those who have come before us.6 If we are fully
conscious of the modern world, we would see there are
many challenges to the practical concept and implementation of a profession. These exist in the form of challenges
external to the profession and challenges internal to the profession. I will focus only on those internal to the profession
as these are most directly under our influence, those in the
profession of surgery. Arthur McFee, MD, PhD, a graduate
of Harvard College with a degree in Romance Languages
told me, as I misused the word surgery, ‘‘Ronald, operations
are what surgeons do: Surgery refers to the Profession or
Field of the Specialty,’’ after which he whacked me on
the head with his ring, so here forward, I will use the
term, Surgery to represent the profession of surgery. So,
what are the modern internal threats to surgery, the profession? I believe they may be grouped into four broad categories: (1) problems of perspective, (2) a failure of
adequate vision, (3) a failure to recognize the consequences
of a lack of vision and perspective, and (4) finally, our bad
behavior (fear, anger, selfishness, egotism, and so forth). I
will concentrate only on the first three, as there is a wealth
of information on the latter, and I believe the first three are
the greatest threat to surgery.
meager pay and our exorbitant debt brought on a horrible
morale. We all became angry people. Angry at our patients
for being sick, angry at our colleagues for calling., angry at
our administrators for squeezing every last ounce of work out
of our bodies. I intend to change careers to a nonclinical position as soon as possible.’’ The second comment comes from
a more senior physician in the survey: ‘‘Physicians age 45
and over have gone through a very demoralizing career.My
peak earning capacity occurred in the 8th year of my 23-year
career so far. We have physicians around age 60 who are having to leave practice or find some outside source of income
because their overhead is so high in comparison to their ability to generate an adequate income practicing medicine.’’8
Personally, these more strident statements do not seem to
me to represent most of the surgeons I work with, but I
concede these sentiments are not far below the surface. In
the recent surveys of US surgeons, approximately 40%
meet the criteria for burnout; almost one half would not
recommend surgery and/or medicine as a career for their
children, and in some specialties, more than one third would
not choose to become a physician again.9,10 Surgery is obviously demanding and stressful, but it has always been so,
indeed likely more demanding and stressful in earlier times.
There are definitely lifestyle modifications and social support mechanisms which can increase our resiliency and
lessen the risk of burnout; however, once behavioral patterns are well established, it is difficult to change, and it
is often hard to follow even a simple change of routine.
Change only occurs naturally and easily when one person,
or the group, views the world or the problem differently,
either by a change in perspective or a change in illumination. Many scientific examples of this principle exist, obviously the germ theory of disease led to significant change
because of an illumination of the cause of the disease, as
did the recognition that coronary artery disease causes
myocardial ischemia. Recognition of appendicitis, coronary occlusion, bacterial infection, and viral infection all
naturally led to changes because of a shift in vision or
perspective. These same factors are relevant in the social
sciences, and they are true in art as well. Please consider
the context and consequences of an earlier quote. About
500 years ago, a boy of 12 years of age recognized something that changed his life forever and then subsequently
transformed Surgery forever. Once this young person’s
view and perspective changed, he changed. He was of
modest means, and the story is highly improbable, but it
did happen. Here, we have it in an English translation of
Ambroise Pare’s own words:
Modern perspectives on the profession
What is our perspective and how clearly do we see? Or
restated, what contemporary views concerning the profession are most often articulated by surgeons?7–10 We have
plenty of information on how we view Surgery, from our
own conversations with colleagues, to news reports, and professional surveys. In 2007, the Washington Post, quoting a
responsible orthopedic surgeon reported on a common sentiment: ‘‘It’s our responsibility to take care of these patients,
because that’s what we do. That’s part of our inherent fiber
of being an orthopedic surgeon. But there’s no question
that as the inconvenience and fatigue and poor compensation
and difficulty in having appropriate resources to take care of
patients build up, you get this perfect-storm effect where
more and more people are thinking, ‘Gee, I don’t know if I
want to do that anymore’.’’7 Based on my experience, the
surgeon in this article is articulating how many surgeons
feel or at least at some time feel. He cites most of the reasons
physicians offer for not providing or not wanting to provide
service: inconvenience, fatigue, poor compensation, and difficulty with resources. The only factor left out in this quote is
malpractice risk. Digging below the surface, or simply
listening in some surgeon lounges, darker sentiments are
evident. In a 2006 survey from the American College of
Physician Executives, two excerpts are illustrative, the first
from a young physician: ‘‘I saw firsthand the serious issue
we as residents had with our morale. At my particular institution, the rigorous workload, long hours, lack of respect.,
‘‘I was but twelve years old when this appetite was
awakened within me; seeing and recognizing, after a
difficult and skillful operation of which I was a witness,
how useful and helpful was the science of surgery. It
appeared to me to be beautiful and best of all things to work
thus for the relief and cure of suffering. From the moment
when I promised myself that this should be the task of my
life, the desire and pleasure to be useful was my principal
aim; and since then I have always moved towards that end.’’2
R.M. Stewart
Perspectives on the profession
Before we get to a treatment for our modern malady, I
suggest we look at our perspective and our view of the
profession. As Dr. Eastridge pointed out so well and so
joyfully, I have a photographic hobby. Besides people, my
favorite subjects are Texas wildflowers. I am going to
display one of my favorite subjects, the Bluebonnet
(Lupinus texensis) as a symbol of our profession. In so doing, I believe I will concretely demonstrate the importance
of perspective and vision play in how we view our profession, and once perspective and vision are correct, actions
happen naturally.
Lupinus texensis is at once beautiful and delicate,
yet also enduring and tough. It is a small lupine, a weed
of the pea family. It is endemic from Texas to Oklahoma.11
It was popularized by Lady Bird Johnson in her highway
beautification projects. Is the flower an obscure weed or a
stunningly beautiful flower that should be protected, preserved, and revered? It really depends on your perspective,
and indeed in the modern world that perspective will determine the fate of the Bluebonnet. Fig. 1 shows a typical field
of bluebonnets in a vacant lot on loop 1604 in San Antonio,
Texas. The bluebonnets are in the lower corner of the
photo. The vacant lot sign is obvious as is the hotel and a
bushy tree. Without conscious attention, the specimens of
the Lupinus species are hardly noticed. In Fig. 2, our bluebonnet is shown in correct perspective. In Fig. 3, our delicate, but enduring lupine is seen in correct perspective, now
with a soft, gentle, and flattering light on the flower. In doing so, we gain a full appreciation of the flower and the
context of her surroundings. Although the sky is ominous,
in context the flower is all the more beautiful. Then, literally, as one watches the little flower, in an instant sunset
happens, the sky changes, and the flower is truly seen in
all its beauty. Only by viewing the flower from the ‘‘right’’
perspective and shining a soft and gentle light on the subject is one able to view the flower in all its glory, thus
Figure 1 The photo displays a field of bluebonnets growing in a
vacant lot. These flowers are simultaneously delicate in form, but
incredibly hardy, growing in rocky, inhospitable soil. From this
perspective, there is nothing particularly remarkable or beautiful
about the flowers. From this view and under this light, the bluebonnets appear as weeds of the pea family.
5
Figure 2 When viewed more closely from the same level of the
plant, at the least, the bluebonnet becomes recognizable as a
flower; however, the beauty of the flower is still not completely
evident because it is viewed under an unfavorable light.
the importance of perspective, illumination, and context.
To move from abstract to concrete, for those who care
about the profession, we must view it from the correct
perspective, shine a soft and gentle light on the subject
and view it in beautiful context. This is not easily done in
a noisy, distracting modern world. It risks becoming lost
in a vacant, corporate-owned parking lot. This must not
happen.
What is the correct perspective on surgery? Let’s turn
back the clock about a century and a half and move to the
frontier of Texas. Sherman Goodwin (1814 to 1884), a New
Englander by way of Ohio, was a physician and surgeon
who practiced in Victoria, Texas.12,13 At that time, Victoria
was a small frontier outpost. Dr. Goodwin meticulously
kept a personal journal from the time of his arrival in
Victoria until the year before his death (1849 to 1883).
‘‘Talking to himself in his journal became Goodwin’s
way of rounding out his ideas of life.’’ This text was discovered by the prominent Texas scholar, Harry Ransom. In my
favorite section of the journal as recorded by Dr. Ransom,
Dr. Goodwin is writing to himself as to why he practices
medicine. I don’t believe he ever expected anyone to read
6
The American Journal of Surgery, Vol -, No -, - 2015
Figure 3 The remarkable beauty, nuance and glory of the resilient little plant becomes evident when viewed from the ‘‘correct’’
perspective and under a soft gentle light. This is the exact same
flower at the same moment in time as in the first two figures.
Only by a change in perspective and an intentional, soft gentle
light is this beauty fully evident. Note how the flower is all the
more beautiful when viewed with stormy clouds in the
background.
Figure 4 If the observer of the flower is carefully watching from
the correct perspective and under the correct light, in an instant the
true glory of both the flower and the environment are briefly displayed as the sunlight changes. If however, the perspective is
incorrect, or the light is wrong, this is simply a weed in a vacant,
harried, commercial lot. And, then, who really cares about preserving a weed in a vacant lot? Would we even notice?
this other than himself and maybe his family. He was obviously a devout religious person, and he provides himself
seven reasons which summarize his view of the profession.
In his own words with my commentary and modern
interpretation:
‘‘Third, there is education of the doctor’s own nature,
educable by very slow pursuit of science and art.the
physician needs only knowledge as his reward at
first.but he cannot live with knowledge alone; it is
nothing unless he joins himself with life.’’
‘‘First, the sense of life going on, of questions outcropping, of natural and expected answers, of startling ones.
This sense of active, unpredictable life is perhaps keener
in medicine than in any other pursuit.’’
The science of medicine may be enough in the
beginning, but it is nothing without joining into the service
to humanity.
Medicine has a sense of wonder that is keener than any
other pursuit.so much more so today, than in his time.
‘‘Second, there is the working of a cure.’’
Too often the people I work with do not celebrate cures
that literally transform people’s lives. Cures that were not
apparent to Dr. Goodwin are now routine today: appendicitis, cholecystitis, trauma, transplant, cardiac disease,
stroke, and so forth. These should be causes worthy of
celebration in the daily practice of surgeons today.
Fourth, as [the physician] knows the good of man
among other men, he learns medicine’s service, and they
are a reward. The physician’s view of man changes and
is a challenge to everything he has learned. Is his patient
evil? He will strive to save him as if he were good.the
physician ‘‘does not profess to understand all human
existence’’; our ‘‘undertaking is only to sustain and
improve it.’’
Our responsibility is not to judge the patient;
our responsibility is to care for the patient as if they were
our own loved one, especially when it is most difficult to do so.
R.M. Stewart
Perspectives on the profession
‘‘Fifth, there are the rewards of companionship with the
tradition of the faculty of medicine in [the physician’s]
community and in the world, tradition down all the
roads... which companions have labored to bring away
life from pain.’’
There is a rich tradition of work that leads to significant
improvements in our patients’ lives that is shared by all
who are true to the profession.
‘‘Sixth, in time he must rise up to enlistment against
powers of evil. Then we join the powers that cleanse
and build; and though man cannot here be perfectly
cleansed or his building last beyond his season, it
is something to have labored for the betterment of
life.’’
He is correct, it is indeed something to have labored for
the betterment of life. In his thoughts one hears the echoes
of Ambroise Pare, ‘‘.beautiful and best of all things to
work thus for the relief and cure of suffering.’’
‘‘Finally, through the very pursuit of science, the doctor
comes into the service of God.’’
Reflecting on Dr. Goodwin’s words, and considering his
circumstances as compared to my own, my thoughts lead me
to a series of questions: ‘‘Is my work as a surgeon more
onerous and demanding than Dr. Goodwin’s work in frontier
Victoria, Texas? Is my practice more inconvenient? Am I
more fatigued? Do I get paid less than Dr. Goodwin? And, do
I have more problems with resources than what he had’’?
Of course, the answer to each of these questions is
certainly no; therefore, I submit that somewhere, or
sometime we lost some critically valuable perspective,
and for reasons not well understood we have chosen to
shine a harsh, unflattering light on such a beautiful subject.
This must be corrected.
Conclusions
I respectfully suggest we consciously choose to reframe
the profession from a different perspectivedin my mind at
least, a more correct perspective. We should take care to
7
shine a gentle, soft light on the profession, a light that
reveals the beauty, the true beauty, of the profession. And
finally, I submit it is our responsibility to consciously and
faithfully maintain and defend the profession from enemies
inside and outside its borders.
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