In the demanding field of digestive surgery, excellence is not just a goal but a necessity. By integrating the profound insights of Charlie Munger on cognitive biases with the motivational principles of Zig Ziglar, surgeons can achieve superior performance and enhance patient care. This comprehensive guide offers actionable recommendations and illustrative examples tailored to the unique challenges of digestive surgery, ensuring that every decision is informed, balanced, and patient-centered. Charlie Munger is a renowned investor and philosopher known for his ability to identify and avoid judgment errors, often rooted in cognitive biases. For a digestive surgeon, understanding and mitigating these biases can significantly enhance clinical decision-making and performance. This summary outlines Munger’s 25 biases and provides specific examples and recommendations for surgical practice.

The 25 Cognitive Biases

1. Reward and Punishment Super-Response Tendency
   • Example: Opting for procedures with higher financial incentives despite less lucrative alternatives being more appropriate for the patient.
   • Recommendation: Always evaluate the long-term benefits for the patient over immediate rewards.
2. Liking/Loving Tendency
   • Example: Ignoring a team member’s faults because you like them, compromising care quality.
   • Recommendation: Maintain objective and impartial evaluations of all team members’ performance.
3. Disliking/Hating Tendency
   • Example: Dismissing valuable suggestions from colleagues due to personal dislike.
   • Recommendation: Prioritize the efficacy of suggestions and patient safety, regardless of who proposes them.
4. Doubt-Avoidance Tendency
   • Example: Sticking to familiar procedures and avoiding new techniques with better outcomes due to fear of the unknown.
   • Recommendation: Stay updated with best practices and be willing to explore new, evidence-based approaches.
5. Inconsistency-Avoidance Tendency
   • Example: Persisting with outdated surgical techniques to remain consistent with past practices.
   • Recommendation: Regularly review clinical guidelines and adapt as necessary.
6. Curiosity Tendency
   • Example: Spending excessive time researching rare conditions not relevant to daily practice.
   • Recommendation: Focus on continuous updates in areas directly related to daily clinical work.
7. Kantian Fairness Tendency
   • Example: Treating all cases identically without considering individual patient needs.
   • Recommendation: Personalize care to meet the unique needs of each patient.
8. Envy/Jealousy Tendency
   • Example: Allowing jealousy of colleagues’ success to affect the work environment.
   • Recommendation: Focus on personal and collaborative professional development, celebrating others’ successes.
9. Reciprocity Tendency
   • Example: Rewarding personal favors with clinical decisions, like preferences for shifts or cases.
   • Recommendation: Maintain professionalism and base decisions on clinical and ethical criteria.
10. Simple, Pain-Avoiding Psychological Denial
    • Example: Avoiding discussions about poor prognoses to evade emotional discomfort.
    • Recommendation: Address all clinical situations honestly and sensitively, providing appropriate support.
11. Excessive Self-Regard Tendency
    • Example: Overestimating personal skills and refusing assistance or second opinions.
    • Recommendation: Recognize personal limitations and seek collaboration when necessary.
12. Over-Optimism Tendency
    • Example: Underestimating surgical risks and failing to prepare patients for potential complications.
    • Recommendation: Conduct comprehensive risk assessments and communicate realistically with patients.
13. Deprival-Superreaction Tendency
    • Example: Overreacting to resource shortages impulsively.
    • Recommendation: Plan ahead and stay calm to find effective solutions.
14. Social-Proof Tendency
    • Example: Adopting practices simply because they are popular among peers without assessing their efficacy.
    • Recommendation: Base clinical decisions on robust evidence and recognized medical guidelines.
15. Contrast-Misreaction Tendency
    • Example: Underestimating a postoperative complication because it seems minor compared to a recent severe case.
    • Recommendation: Evaluate each case individually and objectively, avoiding subjective comparisons.
16. Stress-Influence Tendency
    • Example: Making hasty decisions under high-pressure situations.
    • Recommendation: Develop stress management techniques and make decisions calmly and deliberately.
17. Availability-Misweighing Tendency
    • Example: Making decisions based primarily on recent experiences instead of comprehensive historical data.
    • Recommendation: Maintain detailed records and review long-term data to inform decisions.
18. Use-It-or-Lose-It Tendency
    • Example: Assuming surgical skills remain unchanged without regular practice.
    • Recommendation: Regularly participate in training and simulations to keep skills up-to-date.
19. Drug-Misinfluence Tendency
    • Example: Underestimating the effects of postoperative analgesics.
    • Recommendation: Carefully monitor medication use and adjust as needed.
20. Senescence-Misinfluence Tendency
    • Example: Resisting learning new surgical techniques due to age.
    • Recommendation: Engage in continuous medical education and remain open to innovation.
21. Authority-Misinfluence Tendency
    • Example: Blindly following a senior colleague’s outdated practices.
    • Recommendation: Question and validate all practices against current evidence and standards.
22. Twaddle Tendency
    • Example: Engaging in irrelevant discussions during surgical planning.
    • Recommendation: Focus on relevant, evidence-based information.
23. Reason-Respecting Tendency
    • Example: Failing to explain the rationale behind surgical decisions to patients.
    • Recommendation: Always provide clear, logical explanations to patients and their families.
24. Lollapalooza Tendency
    • Example: Multiple biases leading to a major error in patient care.
    • Recommendation: Be vigilant about recognizing and mitigating multiple biases simultaneously.
25. Tendency to Overweight Recent Information
    • Example: Giving undue importance to the most recent piece of information received.
    • Recommendation: Balance recent information with a thorough review of all relevant data.

Just as Charlie Munger highlights the importance of avoiding cognitive biases for effective decision-making, Zig Ziglar teaches us the significance of attitude and continuous improvement. For a digestive surgeon, applying these principles can transform clinical practice, leading to exceptional performance and superior patient care. Zig Ziglar said, “You don’t have to be great to start, but you have to start to be great.” Every step taken towards overcoming cognitive biases and adopting evidence-based practices is a step towards excellence. By recognizing and mitigating these 25 cognitive biases, you position yourself for an assistive performance that not only treats but truly cares for patients.

Recommendations from Zig Ziglar for Digestive Surgeons

1. Believe in Yourself: “If you can dream it, you can achieve it.” Trust in your ability to learn and grow continually.
2. Set Clear Goals: “A goal properly set is halfway reached.” Define clear objectives to enhance your skills and knowledge.
3. Maintain a Positive Attitude: “Your attitude, not your aptitude, will determine your altitude.” Face challenges with a positive and resilient mindset.
4. Learn from Every Experience: “Failure is an event, not a person.” Use every situation, good or bad, as a learning opportunity.
5. Serve Others with Excellence: “You can have everything in life you want if you will just help enough other people get what they want.” Focus on patient well-being in all decisions.

By integrating Munger’s lessons and Ziglar’s motivational wisdom, you will not only become a better surgeon but also an inspiring leader and a true advocate for excellence in medicine. Remember always: “Success is doing the best we can with what we have.” Keep evolving, seeking knowledge, and above all, serving your patients with dedication and compassion. Together, let’s transform the practice of digestive surgery, one step at a time, towards the excellence our patients deserve.

Aplicando Princípios Filosóficos na Prática Cirúrgica

O campo da cirurgia, especialmente no tratamento das doenças do aparelho digestivo, exige não apenas habilidades técnicas refinadas, mas também resiliência emocional e ética sólida. A prática cirúrgica, por sua natureza, envolve decisões difíceis, momentos de pressão extrema e desafios inesperados. Nesse contexto, os princípios do estoicismo, filosofia praticada por pensadores como Sêneca, Epicteto e o imperador Marco Aurélio, oferecem ferramentas valiosas para que o cirurgião enfrente a complexidade emocional e ética de sua profissão.

Neste artigo, direcionado a estudantes de medicina, residentes de cirurgia geral e pós-graduandos em cirurgia do aparelho digestivo, vamos explorar como os princípios estoicos podem ser aplicados à prática cirúrgica, promovendo não apenas a eficiência técnica, mas também a excelência ética. Abordaremos as virtudes estoicas que podem moldar o comportamento de um cirurgião, aprimorando sua capacidade de lidar com adversidades e tomar decisões sábias no centro cirúrgico.

1. Aceitação das Limitações: “Primum non nocere” em Ação

O princípio estoico de aceitar o que não pode ser mudado é fundamental para o cirurgião. Em um procedimento cirúrgico, o inesperado pode surgir a qualquer momento. O estoicismo ensina que devemos focar no que está sob nosso controle – nossas ações e reações – e aceitar com serenidade aquilo que foge ao nosso alcance, como complicações imprevistas ou resultados adversos. Essa atitude fortalece o cirurgião, permitindo-lhe manter a calma e a clareza mental em situações críticas.

“O que está no meu poder é como reajo ao que acontece. O resto está fora do meu controle.” – Marco Aurélio

2. A Virtude da Perseverança em Meio às Adversidades

A cirurgia, especialmente nas doenças do aparelho digestivo, frequentemente envolve longos procedimentos, altos níveis de complexidade e a necessidade de ajustes rápidos. O estoicismo valoriza a perseverança diante de dificuldades, uma virtude essencial para o cirurgião que deve persistir no cuidado dos pacientes, mesmo em cenários complicados. A capacidade de continuar com foco e determinação, mesmo em circunstâncias adversas, é o que distingue o cirurgião estoico.

“A adversidade é uma oportunidade para a virtude.” – Marco Aurélio

3. Disciplina e Autocontrole no Centro Cirúrgico

O autocontrole é uma das virtudes centrais do estoicismo, e no campo cirúrgico, é vital que o cirurgião mantenha o controle emocional durante procedimentos complexos. O estoicismo nos ensina a não sermos controlados por emoções passageiras, como medo ou frustração, mas sim a agir com racionalidade. No centro cirúrgico, isso se traduz em decisões conscientes e calculadas, que priorizam o bem-estar do paciente, mantendo a objetividade diante de situações estressantes.

“Não é o que acontece, mas como você reage que importa.” – Marco Aurélio

4. Justiça e a Importância de Tratar Todos os Pacientes com Equidade

Para o cirurgião, a justiça, outro pilar estoico, é essencial. Todo paciente, independentemente de sua condição socioeconômica, deve receber o mesmo nível de cuidado e atenção. A prática cirúrgica ética requer que o cirurgião trate cada paciente com equidade, aplicando os princípios da medicina de maneira justa, sem preconceitos ou favoritismos. O cirurgião estoico vê em cada paciente uma oportunidade de exercer a sua profissão com justiça e integridade.

“A justiça consiste em fazer o que é correto, não o que é popular.” – Marco Aurélio

5. Coragem e Resiliência na Tomada de Decisões Difíceis

A cirurgia muitas vezes exige coragem para tomar decisões difíceis, especialmente em situações de risco à vida do paciente. A filosofia estoica valoriza a coragem como uma virtude indispensável. Para o cirurgião, isso significa enfrentar com firmeza e clareza os dilemas éticos e clínicos, mesmo quando há incertezas. A coragem estoica permite que o cirurgião aja com confiança e serenidade, tomando decisões informadas e moralmente corretas, mesmo em momentos críticos.

“A coragem é a dignidade sob pressão.” – Marco Aurélio

Conclusão

A prática cirúrgica é muito mais do que um conjunto de habilidades técnicas; é uma arte que exige um equilíbrio entre conhecimento, ética e resiliência emocional. Ao adotar os princípios estoicos, o cirurgião pode enfrentar os desafios diários com serenidade, perseverança e justiça, sempre em busca do bem maior para seus pacientes. O estoicismo oferece uma base filosófica robusta para lidar com as pressões da vida cirúrgica, fortalecendo o profissional em sua jornada por excelência técnica e moral.

“A felicidade de sua vida depende da qualidade de seus pensamentos.” – Marco Aurélio

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Promoting a Positive OR Environment: Manners and Etiquette

Maintaining a respectful and collaborative atmosphere in the operating room (OR) is crucial for effective teamwork and patient safety. The author outlines key manners and etiquette that contribute to a positive OR environment:

1. Politeness: Being courteous and considerate in interactions with colleagues fosters a harmonious atmosphere.
2. Respect: Treating everyone in the OR with respect, regardless of their role or position, is essential for teamwork.
3. Humility: Remaining humble helps create a collaborative environment where everyone’s input is valued.
4. Learning Names: Taking the time to learn and use the names of all team members enhances personal connections.
5. Offering Help: Anticipating needs and offering assistance without being asked demonstrates a proactive and cooperative attitude.
6. Asking for Help: Being willing to seek assistance when needed promotes a culture of mutual support.
7. Expressing Gratitude: Thanking colleagues for their contributions acknowledges their efforts and encourages teamwork.
8. Patient-Centered Focus: Keeping the patient at the center of all actions emphasizes the ultimate goal of providing quality care.

Avoiding Disruptive Behavior:

• Rude, disruptive, or disrespectful behavior is not tolerated.
• Avoid yelling, making sarcastic comments, or engaging in inappropriate jokes.
• Refrain from gossiping or denigrating others.
• When playing music, be considerate of others’ preferences, and turn it off during critical times like the initial time-out.

Social Media Etiquette in the OR:

• Stay professional when using social media in the OR.
• Avoid checking Facebook or Instagram during surgery.
• Exercise caution when posting online, as anything posted can be captured and spread.
• Refrain from posting identifiable patient information.

Effective Communication and Surgical Pause:

• Ongoing effective communication among the surgical team is crucial.
• Emphasizes the importance of the surgical pause or “time-out” to establish a shared mental model.
• Recommends using a structured checklist, such as the World Health Organization Surgical Safety Checklist, during the surgical pause.
• Highlights the checklist’s positive impact on reducing mortality, complications, and hospital length of stay.
• Encourages active engagement of all team members during the checklist process.

Customizing the Checklist:

• The surgical safety checklist can be modified by hospitals or services to include relevant items specific to their patient population.
• Designated leaders should review and discuss each item, ensuring that all team members are introduced and empowered to speak up if they identify potential safety concerns.
• Customization may include a debriefing section at the end of the case to address additional items relevant to the team’s specific practices.

In summary, promoting positive manners and etiquette, avoiding disruptive behavior, and utilizing effective communication tools contribute to a culture of safety and collaboration in the OR. The surgical safety checklist serves as a valuable tool when implemented with commitment and engagement from all team members.

Embora “Ortodoxia” seja uma obra filosófica e teológica escrita por G.K. Chesterton, suas ideias podem ter algumas aplicações interessantes e reflexivas no cotidiano da cirurgia. Claro que a relação direta pode não ser evidente, mas certos princípios filosóficos podem fornecer perspectivas valiosas para os cirurgiões. Aqui estão algumas maneiras pelas quais as ideias de “Ortodoxia” podem ser aplicadas no contexto cirúrgico:

1. Valorizar o pensamento paradoxal: A cirurgia é uma disciplina complexa e muitas vezes ambígua, onde os médicos devem tomar decisões cruciais em situações desafiadoras. Valorizar o pensamento paradoxal pode ajudar os cirurgiões a considerar opções diversas e até opostas antes de tomar decisões importantes.
2. Reconhecimento da complexidade humana: Chesterton destaca a importância de compreender a natureza complexa da realidade. No contexto cirúrgico, isso se traduz em tratar cada paciente como um indivíduo único, com suas próprias circunstâncias médicas, emocionais e sociais. Isso pode ajudar os cirurgiões a abordar cada caso com uma mente aberta e livre de preconceitos.
3. Equilíbrio entre tradição e inovação: Assim como Chesterton valoriza a tradição cultural, os cirurgiões podem se beneficiar de uma abordagem equilibrada entre as técnicas tradicionais e as inovações médicas. Combinar o conhecimento estabelecido com as mais recentes pesquisas e tecnologias pode levar a melhores resultados para os pacientes.
4. Enfrentar a incerteza: A cirurgia pode ser imprevisível, e os resultados nem sempre são garantidos. A ortodoxia de Chesterton nos encoraja a aceitar a incerteza e a enfrentar os desafios com coragem e confiança. Essa mentalidade pode nos ajudar a enfrentar situações complicadas e se adaptar a cenários imprevistos.
5. Importância da ética e moralidade: Chesterton enfatiza a importância da moralidade e da virtude. Na cirurgia, esses princípios são essenciais para garantir a melhor qualidade de atendimento ao paciente, respeitando sempre a dignidade e os direitos humanos.
6. Valorizar a imaginação: A imaginação é uma parte essencial do trabalho cirúrgico, permitindo aos médicos visualizar procedimentos, simular situações e pensar em soluções criativas. A capacidade de imaginar possibilidades pode ajudar os cirurgiões a planejar cuidadosamente cada intervenção.

Embora “Ortodoxia” não tenha sido escrito com o objetivo específico de se aplicar à cirurgia, as ideias e princípios contidos na obra podem inspirar uma reflexão mais profunda e nos guiar de forma mais consciente, sensível e equilibrada.

A prática cirúrgica é uma forma de arte que exige habilidade técnica e precisão, mas vai além disso. Os cirurgiões não apenas dominam as técnicas e procedimentos, mas também são desafiados a aplicar virtudes cardinais em cada etapa do ato operatório. A diérese, exérese, hemostasia e síntese, as quatro fases cruciais da cirurgia, podem ser vistas como um reflexo das virtudes cardinais: prudência, justiça, fortaleza e temperança. Vamos explorar como essas virtudes se manifestam na rotina de um cirurgião comprometido com o bem-estar dos pacientes.

Diérese (A Prudência como Guia) : A primeira etapa da cirurgia, a diérese, é o momento em que o cirurgião realiza uma incisão precisa para acessar o local a ser tratado. A prudência, virtude da sabedoria prática, entra em cena através do domínio da anatomia. O cirurgião deve avaliar cuidadosamente cada caso, analisar os riscos e tomar decisões fundamentadas. A prudência orienta a escolha das melhores abordagens cirúrgicas, levando em consideração a saúde geral do paciente, suas necessidades individuais e o objetivo final da intervenção.

Exérese (A Justiça na Busca pelo Equilíbrio): Na fase de exérese, o cirurgião remove tecidos ou estruturas comprometidas pela doença. Aqui, a justiça desempenha um papel essencial. O cirurgião deve agir com equidade, buscando remover apenas o que é necessário, sem excessos ou negligências. A justiça implica em tratar cada paciente com equidade, respeito e imparcialidade, levando em consideração os melhores interesses do indivíduo e buscando o bem comum. É um compromisso em garantir que o procedimento cirúrgico seja realizado com integridade e sempre em benefício do paciente.

Hemostasia (A Fortaleza para Enfrentar Desafios) : Durante a fase de hemostasia, o cirurgião aplica técnicas para controlar o sangramento e garantir um campo cirúrgico claro. Nesse momento, a fortaleza se faz presente. A cirurgia pode apresentar situações imprevistas, complicações ou momentos de grande pressão. A fortaleza permite ao cirurgião manter-se firme, agir com coragem diante de adversidades e tomar decisões rápidas, mas sábias, para proteger a vida e o bem-estar do paciente. A fortaleza é a virtude que impulsiona o cirurgião a enfrentar desafios com firmeza e superar obstáculos através de uma alma inabalável, mantendo durante todo o procedimento uma determinação com o melhor prognóstico do paciente.

Síntese (A Temperança na Busca do Equilíbrio Final) : A última etapa, a síntese, envolve a restauração da integridade do tecido por meio de suturas ou outros meios. Nesse momento, a temperança se revela. A temperança é a virtude que permite ao cirurgião exercer controle e moderação, evitando excessos e buscando a harmonia. A escolha adequada do material de sutura, a técnica precisa e o cuidado meticuloso são fundamentais. A temperança assegura que a finalização do ato operatório seja feita com prudência, justiça e fortaleza, considerando o bem-estar a longo prazo do paciente.

Logo, podemos concluir que a prática da cirurgia transcende a habilidade técnica e exige o cultivo das virtudes cardinais. A prudência, a justiça, a fortaleza e a temperança tornam-se guias éticos para o cirurgião comprometido com o cuidado ao paciente. A diérese, exérese, hemostasia e síntese, cada uma refletindo uma virtude cardinal, são etapas cruciais em busca da excelência médica. Quando o cirurgião incorpora essas virtudes em sua rotina, ele se torna não apenas um técnico habilidoso, mas um verdadeiro médico que busca o bem-estar e a cura integral do paciente. A arte da cirurgia, assim, se revela não apenas como uma expressão de destreza manual, mas como uma expressão do cuidado compassivo e virtuoso que o médico oferece ao paciente.

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:

1. Safe, avoiding injuries to patients;
2. Effective, providing services based on scientific knowledge;
3. Patient-oriented, respectful of and responsive to individual patients’ needs, values, and preferences;
4. Timely, reducing waits, eliminating harmful delays for both care receiver and caregiver;
5. Efficient, avoiding wasted equipment, supplies, ideas, and energy;
6. 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.

SURGICAL PRACTICE

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.

CONCLUSIONS

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.

Complete references here