key: cord-0005673-h2kvzltx
authors: Anderson, Kimberly D.
title: Presidential address: awakening the hero within
date: 2006-01-06
journal: Am J Surg
DOI: 10.1016/j.amjsurg.2005.03.040
sha: 763e53f6161b04006649e4ace595ba8278b30784
doc_id: 5673
cord_uid: h2kvzltx

nan

When I was a faculty member at Michigan State University we had a department custodian named Dallas. Dallas was a Viet Nam war veteran who proudly wore his Viet Nam Vet baseball cap as he went about his work. My father, who had been a mobile Army surgical hospital surgeon in Viet Nam, and Dallas, began talking one day and they determined that they had been stationed in the same general vicinity at the same time. Dallas had been badly wounded on 2 occasions and as it turns out, the care he received was at the same unit where my father was based. Over the years, they developed a friendship, and when my father retired as Chair of Surgery, Dallas presented him with his Purple Heart stating, "on behalf of all the soldiers who were wounded and never knew who saved their lives, I'd like you to have this . . . I'd like to think you are the man who saved my life." Such stories of friendship and heroism are not the norm in our everyday lives but this story serves as a testimony to the fact that we make differences every day. We may feel that we are just doing our job, but to the person who is the recipient of our gesture or effort, we may be a hero.

One of my favorite movies, a true chick flick, is "While you Were Sleeping." In this movie, Lucy, who works in a train station, jumps on the tracks to save a man she has worshipped from afar. When he finally emerges from his coma he tells her "we don't get to do many heroic things as an adult." She replies, "you give up your seat every day on the train." "Well," he states, "that's not heroic." And she responds, "it is to the person who sits in it."

Since the tragedies of September 11th, the severe acute respiratory syndrome epidemic, the ongoing fight against terror in Operation Enduring Freedom, and the tsunami of December 26th [2004] , we have heard much about heroes . . . hundreds of thousands of people have died, and in their wake thousands of heroes have been born. Few of us would discount the importance of heroes. But in the past few years we have rediscovered the importance of them as living examples of desirable character traits that we would like to see reflected in our society: traits like honesty, civility, courage, perseverance, loyalty, self-restraint, compassion, tolerance, fairness, and responsibility for the common good over and above individual advantage.

In my research for this presentation I came across a fascinating study by Tony Sanchez [1] , who was addressing the Indiana Council for Social Studies. The purpose of his study was to compare and contrast individuals' definitions of heroes across generational lines for notable trends in patterns. Forty males and 40 females who ranged in age from 10 to 90 were divided into 4 life-span phases based on their ages (phase 1, Ͻ20 y; phase 2, 21-40 y; phase 3, 41-60 y; phase 4, 61-90 y). Each subject was asked to define the term "hero/heroine," and to name any personal heroes and why they were chosen. Eighty percent of the subjects in phases 1 and 2 confined their heroes to media personalities and sports figures. They viewed their heroes in terms of fame and fortune (the outcome), not on an accomplishment that was to be admired or emulated. In fact, among school-aged subjects, many recalled reading or learning about historically famous individuals but they did not make the connection between "traditional" heroes and their personal lives. As one student said, "Yeah, I read about a lot of people in my history class. You know, like the people who made the country great and stuff like that. I've forgotten who most of them are, but it's just as well. I mean, why should I remember or admire some guy who's been dead a hundred years? They don't mean a thing to me."

The older subjects in phases 3 and 4 (ages, 40 -90 y) reflected a much different perspective. They took a far more comprehensive look at their heroes and their definitions. As they aged, these subjects noted that their heroes had to possess something more than "imagery." "Humanitarian factors" were consistently important in their definitions. They tended to describe their choices as "traditional" he-roes. Sanchez noted that our changing culture has produced a "nontraditional" kind of role model, that heroes reflect the culture, and what the culture values will determine the type of heroic act that is to be rewarded. He concluded by stating that "Heroes symbolize something greater than attaining wealth and fame, performing death-defying acts, or being comfortably shrouded in media-promoted status. They reflect our values, ideals, dreams, and making the right difference. Their qualities endure as the guide and inspiration for all of us to be heroes."

Our heroes come from mythology and folk lore where journeys are taken, dragons are slain, and the champion discovers the true meaning of self. They come from the literature where those born with every disadvantage believe that they are meant to be heroes and fulfill their destinies. They come in the form of children, and as recently as on December 26th in Phuket. There, Tilly Smith, a 10-year-old British schoolgirl, saved her family and 100 people staying at her hotel because she remembered the warning signs of a potential tsunami from a geography class. They come in the form of those serving in the National Guard or Reserves, like the Association for Surgical Education's (ASE) own P. J. Schenarts, who was awarded the Bronze Star for distinguishing himself by heroic and meritorious achievement. They come in the form of statesmen and presidents. When Harry Truman died, Mary McGrory of the Washington Star wrote "he was not a hero or a magician or a chess player, or an obsession. He was a certifiable member of the human race, direct, fallible and unexpectedly wise when it counted [2] ." David McCullough wrote, "ambitious by nature, Truman was never torn by ambition, never tried to appear as something he was not. He stood for common sense, common decency. He spoke the common tongue. He held to the old guidelines, work hard, do your best, speak the truth, assume no airs, trust in God, have no fear [3] ."

The numbers of students pursuing careers in surgery started to recede in 1996, demonstrated a brief swell in 2000, and then plummeted again . . . and it was that tsunami in surgery that finally got our attention. The warning signs were there, we just didn't pay attention. We forgot about the simple acts of embracing our roles as heroes to our students. According to Lane Gerber [4] , author of "Married to Their Careers," medical students may not care for or wish to emulate many of their teachers; at the same time they are under great pressure to perform and conform. The stressors today's students face are probably only slightly different that what you faced in your training: interpersonal conflicts with faculty and fellow students, fear of increasing responsibilities and the potential consequences of bad decisions, death of patients, dealing with chronic or terminally ill patients, fear of infections such as AIDS [acquired immune deficiency syndrome], discomfort in discussing personal and sexual issues, discomfort in performing physical exams, and loneliness and loss of frequent contact with friends on other rotations. However, these factors can add up to a fellowship of suffering. This is important in understanding of how a professional identity gets formed. A student may not like the residents or faculty with whom he works, but because they have shared common experiences and because those individuals are already "members of the club," they can exert significant influence on a student who is forming his personal and professional identity.

In an effort to understand (1) how career choices are formulated by preclinical students, (2) how preclinical students develop an interest in surgery, and (3) where negative perceptions toward surgeons originate, my colleague Rosemary Kozar and I [5] studied second-year medical students at the University of Texas-Houston. We found that career choices for students interested in surgery originated primarily from pre-medical school experiences and interactions with surgeons. In contrast, students not interested in surgery made career choices during medical school and those choices were primarily made through exposure to their second-year preceptors. Students interested in surgery felt that their happiness was dependent on the congruence of career and personal satisfaction. Students not interested in surgery tended to separate happiness derived from career versus happiness derived family. Negative perceptions toward surgery were developed and reinforced by media, preceptors, and classmates. All students had minimal exposure to surgeons during their preclinical years and generally agreed that increased involvement with surgeons would be beneficial, particularly through preclinical experience.

As we were conducting the study several disturbing perceptions regarding surgical behavior emerged from the focus group sessions. Comments included "I don't have to be nice, I'm going to be a surgeon." Media had a more pronounced effect on non-surgery-bound students that portrayed surgeons as jerks. While students appreciated the theatrical license taken, they also admitted there was likely some underlying truth to the image. And given their limited exposure to surgeons during their preclinical years, most students had no reason to challenge the stereotype.

In a recent study published in the Journal of the American College of Surgeons by Drs. Colletti and her colleagues, nearly 50% of students believed they were an inconvenience to the service [6] . And 30% of residents and 27% of faculty believed this to be true. Even more shocking was the fact that 17% of medical students felt that faculty and residents would rather not even have them present on their teams at all. Yet in spite of this, almost all faculty and residents stated that they wanted medical students on the service. Students wanted more instruction, more opportunities to practice procedural skills, and more feedback on their performance.

I'd like to take literary license from a movie, "The American President." In one scene the Press Secretary is challenging the president for not standing up to personal attacks that have been waged against him. He says "People want leadership. They are so thirsty for it that they will crawl through a desert toward a mirage, and when they discover no water, they'll drink the sand." I believe this is a wonderful metaphor illustrating the disconnect between our students and our faculty. Students want information, and they want early interaction with, and exposure to, surgeons. They want role models. Unless departments of surgery start to speak up and show up in the preclinical years and confront the stereotypes that besiege them, our students will continue to accept the mirage that portrays surgery as an undesirable career.

We are rife with opportunities to begin to make more meaningful differences to the lives of our students and residents. All you need to do is look at the evaluation forms completed by learners and you will see the chinks in the armor. Surgeons are among the most competitive individuals I know. How does it make you feel to know that students say the following?

"Surgeons provide horrible mentoring-they are disrespectful of patients, disrespectful of students, and disrespectful of colleagues." "My experience on surgery was characterized by inhumane expectations of time commitment in and out of hospital; a breakdown in relationships, no sex drive, I began to hate learning, and lost compassion for patients."

"The world of surgery is a toxic emotional environment-this does not create healers, it creates cynical, selfcentered, divorced, wounded, jerks." "I felt like I was in the way of them getting as much done as possible given the time constraints they were under. I never felt like I had an opportunity to discuss my patients and when I did I never knew if I was presenting too much or too little."

Dr. Kathy Liscum [7] wrote an eloquent article in FOCUS several years back entitled, "Your life as a surgeon: What message are you sending?" In it she stated, "We are responsible for the general professional education of our learners. In addition to modeling competent clinical practice, compassionate patient care, and professional interpersonal communication we must find a way to send a message of balance. If we want to be positive role models it is incumbent on us to find ways to relay this message to our students and our residents." Faculty protest, "we don't have time to teach and we don't get paid to teach." To that I reply, "Do you have time to think?" Just think out loud. Thinking out loud is teaching, it's acknowledging the fact that you know that students don't know what is going on. Ask them about what they think they're seeing. Ask them why they think something is occurring. And you know what? Students will walk away feeling you have taught them and feeling that they have learned something. Finish your sentences. Telling a student she did a good job is nice, but it's not telling her what she did correctly or incorrectly. You did a good job of . . . you did a good job at . . . . When you do that, students will walk away feeling they received feedback about their performance.

Give them goals. Tell them you are going to be asking them about something relevant to their patient. This will help guide their learning efforts and will let them know that you are holding them accountable. Give students specific tasks to complete so they understand their important role in the functioning of the team.

I have been an educator in the field of surgery for nearly 23 years, but it has been a part of me all my life. As the daughter of a surgeon and an elementary school teacher, I have witnessed the sacrifices you and your families have made. I have felt the angst as you have had to tell your child you couldn't make it to his or her game because you had a patient in critical need of your attention. And I have seen the frustration as you have called your spouse stating that you will be late . . . again. I have surveyed your spouses and know what they think of your careers and your lives.

As presented by my colleague Dr. Lillian Kao [8] at last year's meeting, two thirds of your spouses wish you worked less, and half felt that you would be happier if you did. Half do not feel that you adequately contribute to household responsibilities or childcare, but nearly 70% feel that you do make an effort. They want you to be more involved in decision making and they want to be more involved in decisions that will affect your family. They worry about your stressors and they worry about the effect it has on you and your family. Finally, your spouses are proud of what you do and are willing to accept the additional demands placed upon them because you truly love what you do and because you strive to make a difference.

I have worked in an inner-city hospital, a community hospital, a community-based medical school, and now a university medical center. I have been an enthusiastically welcomed, and at times, grudgingly accepted member of the club. I have been offered a bird's eye view of the life of a surgeon and what I have witnessed is your humanity-your will to make a difference. I have the best job in the world, and so do you. Every day we get to work with students and residents who possess the best and brightest minds in the world, but, more importantly, we get to work with individuals who care . . . they want to help people heal. They are willing to delay immediate gratification, to sacrifice time with family and friends, and to incur huge debt loads because they want to make a difference in the lives of others. My challenge to you is to remember: remember what it was like and dare to care. Dare to be that individual who mentored you in your quest to be a surgeon.

Professional distance is important in helping us maintain our objectivity about student performance but, to tell you the truth, I think that is where it should end. I have never had a student cross the stage at graduation or communicate with me years later, when they are well into their careers, and complain "you know, you cared too much and that was a problem." As a high school student I was a devotee of Dr. Leo Buscaglia. Dubbed the "Professor of Love" at the University of Southern California, his lectures were frequently carried on PBS. And as a dramatic, albeit not terribly tortured teenager, I found hope and insight in his thoughts. One of his more memorable quotes was as fol-lows: "too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around."

The definitive Oxford English Dictionary defines a hero as "a (person) who exhibits extraordinary bravery, firmness, fortitude, or greatness of soul, in any course of action, or in connection with any pursuit, work, or enterprise; a (person) admired and venerated for his achievements and noble qualities." That's a wonderful definition, and who am I to argue with the "Oxford English Dictionary?" But to me a hero is someone who silently challenges others to follow in their footsteps by inspiring them to reach beyond their limits and seek the best in not only themselves, but also in others. Sharon Salzberg [9] , author of "Faith: Trusting Your Own Deepest Experience," told a story about her yoga instructor, who, in demonstrating a pose, lost his balance. When he asked her classmates what had just happened to him, all tried to provide justification for what he had just done. When he asked her, "what just happened?" She stated, "to be honest, I think you fell." "You're right," he replied, "I fell. Then I started over. That's good yoga." The author stated that the incident was one of his best lessons, it was about honoring the role of intention. If we fall, we don't need self-recrimination or blame or anger, we need a reawakening of our intention and a willingness to recommit, to be whole-hearted once again. I think that we have fallen in surgery. Many surgeons in academic surgery have stopped reaching out because they are frustrated by the demands of clinical activities and the regulations that encumber their practices. They are withdrawing from, and in some cases lashing out at, the very things they cite that they love most about being in academics: teaching medical students and residents.

I am tempted to list my personal heroes and how they came to be on my list, but the fact of the matter is that my list would mean little to anyone but me. Instead, I urge each of you to take a moment and reminisce through your personal hall of honor and remember what qualities these individuals possessed. I am grateful to my heroes. Some are new, some are unexpected, many have long held that special role in my life, and all are greatly appreciated. My heroes exist in this room. They are colleagues who have become among my dearest friends, they are the students and residents whose lives I have been privileged to be a part of, and they are the voices of my family and friends who have made me believe that I am limited only by my desire and my imagination.

And so, members of the ASE, I thank you for the honor and the opportunity of serving this amazing organization on its 25th anniversary. I have been embraced by members of the ASE and the Association of Program Directors in Surgery and have been afforded opportunities I never dreamed possible. I will forever be grateful to the members of both organizations for their support and confidence. I am living proof that the collaboration between these organizations makes a wonderful difference. This has been an organization of dreams and opportunities for me and I thank you.

It's time for heroes, again: or were they ever gone? Presented at the Annual Meeting of the Indiana Council for the Social Studies

Plain Speaking: An Oral Autobiography of Harry Truman

Married to Their Careers

Preclinical students: who are surgeons?

Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship

Your life as a surgeon: what message are you sending?

Perceptions and predictors of surgeon satisfaction: a survey of spouses of academic surgeons

Trusting Your Own Deepest Experience