SURGERY, A NOBLE PROFESSION
Surgery is, indeed, one of the noblest of professions. Here is how Dictionary defines the word noble: 1) possessing outstanding qualities such as eminence, dignity; 2) having power of transmitting by inheritance; 3) indicating superiority or commanding excellence of mind, character, or high ideals or morals. These three attributes befit the profession of surgery. Over centuries, the surgical profession has set the standards of ethical and humane practice. Surgeons have made magnificent contributions in education, clinical care, and science. Their landmark accomplishments in surgical science and innovations in operative technique have revolutionized surgical care, saved countless lives, and significantly improved longevity and the quality of human life. Generations of surgeons have developed their craft and passed it on to succeeding generations, as they have to me and to each one of you, to take into the future.
Beyond its scientific and technical contributions, surgery is uniquely fulfilling as a profession. It has disciplined itself over the centuries and dedicated its practice to the best welfare of all human beings. In return, it has been accorded the respect of society, of other professions, and of policy makers. Its conservative stance has served it well and has been the reason for its constancy and consistency. At the beginning of the 21st century, however, profound changes are taking place at all levels and at a dizzying pace, providing both challenges and opportunities to the surgical profession. These changes are occurring on a global level, on the national level, in science and technology, in healthcare, and in surgical education and practice.
To retain its leadership position in innovation and its attractiveness as a career choice for students, surgery must evolve with the times. It is my belief that surgery needs to introduce changes to create new priorities in clinical practice, education, and research; to increase the morale and prestige of surgeons; and to preserve general surgery as a profession. I am reminded of a Chinese aphorism that says, “You cannot prevent the birds of unhappiness from flying over your head, but you can prevent them from building a nest in your hair.”
ADVANCES IN SCIENCE
The coalescence of major advances in science and technology made the end of the 20th century unique in human history. Notable among the achievements are the development of microchips and miniaturization, which fueled the explosion in information technology. The structure of the human genome is nearly completely elucidated, ushering in the genomic era in which genetic information will be used to predict, on an individual basis, susceptibility to disease and responsiveness to drug therapy. The field of nanotechnology allows scientists to work at a resolution of less than one nanometer, the size of the atom. By comparison, the DNA molecule is 2.5 nanometers.
In the last 50 years, biomedical research became increasingly reductionist, turning physiologists and anatomists into molecular biologists. As a result, two basic science fields—integrative physiology and gross anatomy—now have a lower standing in medical education and surgical science than they once did. Surgery and surgical departments can and possibly should claim these fields, but the window of opportunity is narrow. Research is now moving back from discipline-based reductionist science to multidisciplinary science of complexity, in which biomedical scientists work side by side with engineers, mathematicians, and bioinformatists. The ability of high-speed computers to quickly process tens of millions of pieces of data now allows for data-driven rather than hypothesis-based research. This collaboration among different disciplines has already been successful.
TRANSFORMATION OF HEALTHCARE SYSTEM
During the past 75 years, we have seen the entire healthcare system undergo a profound transformation. In the 1930s and for a considerable period thereafter, medical practice was fee-for-service, the doctor–patient relationship was strong, and the physician perceived himself or herself as being responsible nearly exclusively to his or her individual patients. The texture of medical practice started to change when the federal government became involved in the provision of healthcare in 1965. The committee on “Crossing the Quality Chasm” identified six key attributes of the 21st-century healthcare system. It must be:
- Safe, avoiding injuries to patients;
- Effective, providing services based on scientific knowledge;
- Patient-oriented, respectful of and responsive to individual patients’ needs, values, and preferences;
- Timely, reducing waits, eliminating harmful delays for both care receiver and caregiver;
- Efficient, avoiding wasted equipment, supplies, ideas, and energy;
- Equitable, providing equal care across genders, ethnicities, geographic locations, and socioeconomic strata;
No one knows at present what this 21st-century healthcare system will look like. While care in the old system was reactive, in the new system it will be proactive. The “find it, fix it” approach of the old system will be replaced by a “predict it, prevent it, and if you cannot prevent it, fix it” approach. Sporadic intervention, provided only when patients present with illness, will give way to a system in which physicians and other healthcare providers plan 1-, 5-, and 10-year care programs for each patient. Care will be more interactive, with patients taking a more important role in their own care. The technology-oriented system will become a system that provides graded intervention. Delivery systems will not be fractionated but integrated. Even more importantly, care will not be based simply on experience and clinical impression but on evidence of proven outcome measures. If the old system was cost-insensitive, the new system will be cost-sensitive.
There are many reasons for the declining interest in general surgery, some of which parallel reasons for the drop in medical school applicants in general. One problem specific to surgery is that medical students are given less and less exposure to surgery, due to the shortening of required surgical rotations. Most important, however, is their perception that the life of the surgical resident is stressful, the work hours too long, and the time for personal and family needs inadequate. The workload of the surgical resident over the years has increased significantly both in amount and intensity, without concomitant increase in the number of residents and at a time when hospitals have significantly reduced the support personnel on the surgical ward and in the operating rooms. Students graduating with debts close to $100,000 simply find the years of training in surgery too long, followed by uncertain practice income after graduation.
From several recent studies, lifestyle is the critical and most pressing issue in surgical residency. Some studies have also shown that the best students tend to select specialties that provide controllable lifestyles, such as radiology, dermatology, and ophthalmology. We have a problem not only in the declining number of students applying for surgical training but also in the declining quality of those who do apply. In a preliminary survey of 153 responding general surgery programs, we found that attrition (i.e., categorical residents leaving the training programs) occurred at a rate of 13% to 19% in the last 5 years. In 2001, 46% of those leaving general surgery training programs cited lifestyle as the major reason.
Unless these trends are reversed, general surgery as a specialty is threatened, and a future shortage of general surgeons is inevitable. I know that the Council of the American Surgical Association is most concerned about the crisis in general surgery. We must do a better job of communicating to students and residents that the practice of surgery is as rewarding as ever and full of opportunities in this new era. Innovations in minimal access and computer-assisted surgery and simulation technology provide exciting new possibilities in surgical training. We must also look very carefully at the demands of surgical residency and improve the life of residents without compromising their surgical experience. Unless we deal with work hours and quality of life issues, we are likely to see continuing decline in the interest of medical students in surgical training.
In conclusion, the noble profession of surgery must rise to meet numerous challenges as the world in which it operates continues to undergo profound change. These challenges represent opportunities for the profession to develop an international perspective and a global outreach and to address the growing needs of an aging population undergoing major demographic and workforce shifts. The leadership of American surgery has a unique role to play in the formulation of a new healthcare system for the 21st century. This task will require commitment to quality of care and patient safety, and it will depend on harnessing the trust and support of the American public. Advances in science and technology—particularly in minimal access surgery, robotics, and simulation technology—provide unprecedented opportunity for surgeons to continue to make landmark contributions that will improve surgical care and the human condition. I believe it is also crucially important that we train surgeon-scientists who will keep surgery at the cutting edge in the genomic and bioinformatics era. Ours is a noble profession imbued with eminence, dignity, high ideals, and ethical values. It has a rich and proud heritage… and I quote, “The highest intellects, like the tops of mountains, are the first to catch and reflect the dawn.”
Source: Lecture from Haile T. Debas, MD (UCSF School of Medicine, San Francisco, California) Presented at the 122nd Annual Meeting of the American Surgical Association, April 25, 2002, The Homestead, Hot Springs, Virginia.
Atualmente, o conhecimento da anatomia se junta a um universo de outros conhecimentos que, não menos importantes, vão se somando e contribuindo de forma muito rápida para o desenvolvimento científico, para a melhoria da qualidade de vida e para a maior longevidade do ser humano. A anatomia e a medicina são ciências distintas, porém não há como separar a história de ambas. Estão ligadas intimamente e por muito tempo sendo que, na antiguidade, foram tratadas como uma só história. Ana, em partes; tome, cortar. O termo anatomia, de origem grega, significa “cortar em partes”. Antigamente referia-se ao ato de explorar as estruturas do corpo humano por uso de instrumentos cortantes como anatomizar, hoje substituído pela palavra dissecar. E foi a dissecção de cadáveres humanos que serviu como método de estudo para o entendimento da estrutura e função do corpo humano durante vários séculos. Devido ao incessante trabalho de centenas de anatomistas dedicados ao aprendizado e evolução do conhecimento acerca do corpo humano, e suas de funções, é que hoje nós, estudantes, podemos aprender e familiarizar com os termos anatômicos utilizados para designar cada estrutura dessa engenhosa “máquina” que é o ser humano. Grande parte dos termos que compõe a linguagem anatômica é de procedência grega ou latina. Latim era a língua do império romano, época em que o interesse nas descrições científicas foi cultivado. No passado, a anatomia humana era acadêmica, ciência puramente descritiva, interessada principalmente em identificar e dar nomes às estruturas do corpo. Embora a dissecção e descrição formem a base da anatomia, a importância desta, hoje, está em sua abordagem funcional e nas aplicações clínicas, de forma a entender o desempenho físico e a saúde do corpo.
After the first major hepatic resection, a left hepatic resection, carried out in 1888 by Carl Langenbuch, it took another 20 years before the first right hepatectomy was described by Walter Wendel in 1911. Three years before, in 1908, Hogarth Pringle provided the first description of a technique of vascular control, the portal triad clamping, nowadays known as the Pringle maneuver. Liver surgery has progressed rapidly since then. Modern surgical concepts and techniques, together with advances in anesthesiological care, intensive care medicine, perioperative imaging, and interventional radiology, together with multimodal oncological concepts, have resulted in fundamental changes. Perioperative outcome has improved significantly, and even major hepatic resections can be performed with morbidity and mortality rates of less than 45% and 4% respectively in highvolume liver surgery centers. Many liver surgeries performed routinely in specialized centers today were considered to be high-risk or nonresectable by most surgeons less than 1–2 decades ago.Interestingly, operative blood loss remains the most important predictor of postoperative morbidity and mortality, and therefore vascular control remains one of the most important aspects in liver surgery.
“Bleeding control is achieved by vascular control and optimized and careful parenchymal transection during liver surgery, and these two concepts are cross-linked.”
First described by Pringle in 1908, it has proven effective in decreasing haemorrhage during the resection of the liver tissue. It is frequently used, and it consists in temporarily occluding the hepatic artery and the portal vein, thus limiting the flow of blood into the liver, although this also results in an increased venous pressure in the mesenteric territory. Hemodynamic repercussion during the PM is rare because it only diminishes the venous return in 15% of cases. The cardiovascular system slightly increases the systemic vascular resistance as a compensatory response, thereby limiting the drop in the arterial pressure. Through the administration of crystalloids, it is possible to maintain hemodynamic stability.
In the 1990s, the PM was used continuously for 45 min and even up to an hour because the depth of the potential damage that could occur due to hepatic ischemia was not yet known. During the PM, the lack of oxygen affects all liver cells, especially Kupffer cells which represent the largest fixed macrophage mass. When these cells are deprived of oxygen, they are an endless source of production of the tumour necrosis factor (TNF) and interleukins 1, 6, 8 and 10. IL 6 has been described as the cytokine that best correlates to postoperative complications. In order to mitigate the effects of continuous PM, intermittent clamping of the portal pedicle has been developed. This consists of occluding the pedicle for 15 min, removing the clamps for 5 min, and then starting the manoeuvre again. This intermittent passage of the hepatic tissue through ischemia and reperfusion shows the development of hepatic tolerance to the lack of oxygen with decreased cell damage. Greater ischemic tolerance to this intermittent manoeuvre increases the total time it can be used.
Surgery is a profession defined by its authority to cure by means of bodily invasion. The brutality and risks of opening a living person’s body have long been apparent, the benefits only slowly and haltingly worked out. Nonetheless, over the past two centuries, surgery has become radically more effective, and its violence substantially reduced — changes that have proved central to the development of mankind’s abilities to heal the sick.
Consider, for instance, amputation of the leg.
The procedure had long been recognized as lifesaving, in particular for compound fractures and other wounds prone to sepsis, and at the same time horrific. Before the discovery of anesthesia, orderlies pinned the patient down while an assistant exerted pressure on the femoral artery or applied a tourniquet on the upper thigh.
Surgeons using the circular method proceeded through the limb in layers, taking a long curved knife in a circle through the skin first, then, a few inches higher up, through the muscle, and finally, with the assistant retracting the muscle to expose the bone a few inches higher still, taking an amputation saw smoothly through the bone so as not to leave splintered protrusions. Surgeons using the flap method, popularized by the British surgeon Robert Liston, stabbed through the skin and muscle close to the bone and cut swiftly through at an oblique angle on one side so as to leave a flap covering the stump.
The limits of patients’ tolerance for pain forced surgeons to choose slashing speed over precision. With either the flap method or the circular method, amputation could be accomplished in less than a minute, though the subsequent ligation of the severed blood vessels and suturing of the muscle and skin over the stump sometimes required 20 or 30 minutes when performed by less experienced surgeons.
No matter how swiftly the amputation was performed, however, the suffering that patients experienced was terrible. Few were able to put it into words. Among those who did was Professor George Wilson. In 1843, he underwent a Syme amputation — ankle disarticulation — performed by the great surgeon James Syme himself. Four years later, when opponents of anesthetic agents attempted to dismiss them as “needless luxuries,” Wilson felt obliged to pen a description of his experience:
“The horror of great darkness, and the sense of desertion by God and man, bordering close on despair, which swept through my mind and overwhelmed my heart, I can never forget, however gladly I would do so. During the operation, in spite of the pain it occasioned, my senses were preternaturally acute, as I have been told they generally are in patients in such circumstances. I still recall with unwelcome vividness the spreading out of the instruments: the twisting of the tourniquet: the first incision: the fingering of the sawed bone: the sponge pressed on the flap: the tying of the blood-vessels: the stitching of the skin: the bloody dismembered limb lying on the floor.”
It would take a little while for surgeons to discover that the use of anesthesia allowed them time to be meticulous. Despite the advantages of anesthesia, Liston, like many other surgeons, proceeded in his usual lightning-quick and bloody way. Spectators in the operating-theater gallery would still get out their pocket watches to time him. The butler’s operation, for instance, took an astonishing 25 seconds from incision to wound closure. (Liston operated so fast that he once accidentally amputated an assistant’s fingers along with a patient’s leg, according to Hollingham. The patient and the assistant both died of sepsis, and a spectator reportedly died of shock, resulting in the only known procedure with a 300% mortality.)
Life as a Surgeon
Surgical careers begin long before one is known as a surgeon. Medicine in general, and surgery in particular, is competitive from the start. As the competition begins, in college or earlier, students are confronted with choices of doing what interests them and what they may truly enjoy vs doing what is required to get to the next step. It is easy to get caught up in the routine of what is required and to lose track of why one wanted to become a doctor, much less a surgeon, in the first place. The professions of medicine and surgery are vocations that require extensive knowledge and skill. They also require a high level of discretion and trustworthiness. The social contract between the medical profession and the public holds professionals to very high standards of competence and moral responsibility. Tom Krizek goes on to explain that a profession is a declaration of a way of life ‘‘in which expert knowledge is used not primarily for personal gain, but for the benefit of those who need that knowledge.’’
For physicians, part of professionalism requires that when confronted with a choice between what is good for the physician and what is good for the patient, they choose the latter. This occurs and is expected sometimes to the detriment of personal good and that of physicians’ families. Tom Krizek even goes so far as to question whether surgery is an ‘‘impairing profession.’’ This forces one to consider the anticipated lifestyle. In sorting this out, it is neither an ethical breach nor a sign of weakness to allocate high priority to families and to personal well-being. When trying to explain why surgery may be an impairing profession, Krizek expands with a cynical description of the selection process. Medical schools seek applicants with high intelligence; responsible behavior; a studious, hard-working nature; a logical and scientific approach to life and academics; and concern for living creatures. He goes further to explain that in addition to these characteristics, medical schools also look for intensity and drive, but are often unable to make distinctions among those who are too intense, have too much drive, or are too ingratiating.
There are many ethical challenges confronting medical students. As they start, medical students often have altruistic intentions, and at the same time are concerned with financial security. The cost of medical education is significant. This can encourage graduates to choose specialty training according to what will provide them the most expedient means of repaying their debt. This can have a significant, and deleterious, impact on the health care system in that the majority of medical graduates choose to pursue specialty training, leaving a gap in the availability of primary care providers. As medical students move into their clinical training, they begin interacting with patients. One concern during this time is how medical students should respond and carry on once they believe that a mistake on their part has resulted in the injury or death of another human being. In addition, the demands of studying for tests, giving presentations, writing notes, and seeing patients can be overwhelming. The humanistic and altruistic values that medical students have when they enter medical school can be lost as they take on so much responsibility. They can start to see patient interactions as obstacles that get in the way of their other work requirements. During their clinical years, medical students decide what field they will ultimately pursue. For students to make an informed decision about a career in surgery, they need to know what surgeons do, why they do it, and how surgery differs from other branches of medicine. It is important for them to be aware of what the life of a surgeon entails and whether it is possible for them to balance a surgical career with a rewarding family life.
Beginning residents are confronted with a seemingly unbearable workload, and they experience exhaustion to the point where the patient may seem like ‘‘the enemy.’’ At the same time, they must learn how to establish strong trusting relationships with patients. For the first time, they face the challenge of accepting morbidity and death that may have resulted directly from their own actions. It is important that residents learn ways to communicate their experience to friends and family, who may not understand the details of a surgeon’s work but can provide valuable support. The mid-level resident confronts the ethical management of ascending levels of responsibility and risks, along with increasing emphasis on technical knowledge and skills. It is at this level that the surgical education process is challenged to deal with the resident who does not display the ability to gain the skills required to complete training as a surgeon. Residents at this level also must deal with the increasing level of responsibility to the more junior residents and medical students who are dependent on them as teacher, organizer, and role model. All of this increasing responsibility comes at a time when the resident must read extensively, maintain a family life, and begin to put long-range plans into practice in preparation for the last rotation into the chosen final career path. The senior surgical resident should have acquired the basics of surgical technique and patient management, accepting nearly independent responsibility for patient care. The resident at this level must efficiently and fairly coordinate the functioning team, engage in teaching activities, and work closely with all complements of the staff. As far as ethics education is concerned, residents at this stage should be able to teach leadership, teamwork, and decision-making. They should be prepared to take on the value judgments that guide the financial and political aspects of the medical and surgical practice.
The Complete Surgeon
The trained surgeon must be aware of the need to differentiate between the business incentives of medical care and doing what is right for a sick individual. As financial and professional pressures become more intense, the challenge increases to appropriately prioritize and balance the demands of patient care, family, education, teaching, and research. For example, how does the surgeon deal with the choice between attending a child’s graduation or operating on an old patient who requests him rather than an extremely well-trained associate who is on call? How many times do surgeons make poor choices with respect to the balance of family vs work commitments? Someone else can
competently care for patients, but only parents can be uniquely present in the lives of their children. Time flies, and surgeons must often remind themselves that their lives and the lives of their family members are not just a dress rehearsal.
Knowing When to Quit
A 65-year-old surgeon who maintains a full operating and office schedule, is active in community and medical organizations, and has trained most of her surgical colleagues is considering where to go next with her career. Recently, her hospital acquired the equipment to allow robotic dissection in the area where she does her most complicated procedures. She has just signed up to learn this new technology, but is beginning to reflect on the advisability of doing this. How long should she continue at this pace, and how does she know when to slow down and eventually quit operating and taking the responsibility of caring for patients? Murray Brennan summarizes the dilemma of the senior surgeon well. The senior surgeon is old enough and experienced enough to do what he does well. He yearns for the less complicated days where he works and is rewarded for his endeavors. He becomes frustrated by restrictive legislation, the tyranny of compliance, and the loss of autonomy. Now regulated, restricted, and burdened with compliance, with every medical decision questioned by an algorithm or guideline, he watches his autonomy of care be ever eroded. Frustrated at not being able to provide the care, the education, and the role model for his juniors, he abandons the challenge.
Finishing with Grace
Each surgeon should continuously map a career pathway that integrates personal and professional goals with the outcome of maintaining value, balance, and personal satisfaction throughout his or her professional career. He or she should cultivate habits of personal renewal, emotional self-awareness, and connection with colleagues and support systems, and must find genuine meaning in work to combat the many challenges. Surgeons also need to set an example of good health for their patients. Maintaining these values and healthy habits is the work of a lifetime. Rothenberger describes the master surgeon as a person who not only knows when rules apply, recognizes patterns, and has the experience to know what to do, but also knows when rules do not apply, when they must be altered to fit the specifics of an individual case, and when inaction is the best course of action. Every occasion is used to learn more, to gain perspective and nuance. In surgery, this is the rare individual who puts it all together, combining the cognitive abilities, the technical skills, and the individualized decision-making needed to tailor care to a specific patient’s illness, needs, and preferences despite incomplete and conflicting data. The master surgeon has an intuitive grasp of clinical situations and recognizes potential difficulties before they become major problems. He prioritizes and focuses on real problems. He possesses insight and finds creative ways to manage unusual and complex situations. He is realistic, self-critical, and humble. He understands his limitations and is willing to seek help without hesitation. He adjusts his plans to fit the specifics of the situation. He worries about his decisions, but is emotionally stable.
A cirurgia é uma forma de terapia para as doenças que é motivada pelo CORAÇÃO, planejada na CABEÇA e executada pelas MÃOS.
Prof . Phd. Tom DeMeester
Um corpo inerte aguarda sobre a mesa
Naquele palco despido de alegria.
O artista das obras efêmeras se apresenta.
A opereta começa, ausente de melodia
E o mascarado mudo trabalha com presteza.
Sempre começa com esperança e só términa com certeza.
Se uma vida prolonga, a outra vai-se escapando.
E nem sempre do mundo o aplauso conquistando
Assim segue o artista da obra traiçoeira e conquistas passageiras.
Há muito não espera do mundo os louros da vitória
Estudar, trabalhar é sua história, e a tua maior glória
Hás de encontrar na paz do dever cumprido.
Quando a vivência teus cabelos prateando
E o teu sábio bisturi, num canto repousando
Uma vez que sua missão vai terminando
Espera do bom Deus por tudo, a ti, seja piedoso.
SOIS VÓS INSTRUMENTO DA TUA OBRA.
Following is a list of Dr. Ephraim McDowell’s personal qualities described as “C” words along with evidence corroborating each of the characteristics.
Courageous: When he agreed to attempt an operation that his teachers had stated was doomed to result in death, he, as well as his patient, showed great courage.
Compassionate: He was concerned for his patient and responded to Mrs. Crawford’s pleas for help.
Communicative: He explained to his patient the details of her condition and her chances of survival so that she could make an informed choice.
Committed: He promised his patient that if she traveled to Danville, he would do the operation. He made a commitment to her care.
Confident: He assured the patient that he would do his best, and she expressed confidence in him by traveling 60 miles by horseback to his home.
Competent: Although lacking a formal medical degree, he had served an apprenticeship in medicine for 2 years in Staunton, Virginia, and he had spent 2 years in the study of medicine at the University of Edinburgh, an excellent medical school. In addition, he had taken private lessons from John Bell, one of the best surgeons in Europe. By 1809 he was an experienced surgeon.
Carefull: Despite the fact that 2 physicians had pronounced Mrs. Crawford as pregnant, he did a careful physical examination and diagnosed that she was not pregnant but had an ovarian tumor. He also carefully planned each operative procedure with a review of the pertinent anatomic details. As a devout Presbyterian, he wrote special prayers for especially difficult cases and performed many of these operations on Sundays.
Courteous: He was humble and courteous in his dealings with others. Even when he was publicly and privately criticized after the publication of his case reports, he did not react with vitriol. The qualities of character demonstrated by Dr. Ephraim McDowell 200 years ago are still essential for surgeons today.