I will say that I am
astonished to be standing here now. Who would have thought that more
than 3 and a half decades ago, when I started my surgical journey, I
would be standing here giving a lecture established in tribute to the
first woman surgeon anyone ever spoke of to me.
The year
was 1978. I was a young medical student recently smitten by surgery, at a
very southern medical school, my University of Virginia (UVA), which I
truly love despite the fact that it was many years, if not decades,
before a woman surgery faculty member arrived on campus. I certainly
could not find one there and then. I did, however, have a wonderful
new-found mentor after my defection from pediatric genetics to surgery,
named Dr Les Rudolph. Dr Rudolph, like Dr Jonasson, was a pioneer in the
field of transplantation surgery, and was one of few surgical faculty
at UVA who, despite my place near the top of the class, had embraced my
ambition to pursue surgery these 35 years ago. (I might add that several
others have now claimed a mysterious role in my decision…somehow I
missed that input at the time!). At one of our meetings, he told me that
he thought I should know that women—at least somewhere else—had become
surgeons and had, in fact, risen to be leaders in my now newly intended
future field of practice. He told me in one breath of the 2 he knew–and
whom I must meet: Dr Olga Jonasson and Dr Katherine Anderson.
I
trust both names are familiar to all in this room, but for those who do
not know the name of Dr Katherine Anderson, she is a marvelous
pioneering leader in pediatric surgery and just 9 years ago, was the
first woman to be president of the American College of Surgeons. With Dr
Rudolph's help, I found Dr Anderson, the first woman surgeon I ever
met, long before Dr Jonasson, meeting her in my home town of Washington
DC, first as a medical student and then as a resident, and she
subsequently became a lifelong mentor and friend.
However,
it took me much longer to meet Dr Jonasson—in fact, it was close to 17
years before I personally met her enough to say more than a simple
awe-struck “hello” to her. I will never forget the first real
conversation I had with Dr Jonasson; it was during one of those days
spent in a hotel room examining at times trembling young surgeons. We
were, of course, giving the American Board of Surgery (ABS) certifying
examination, the “old format exam,” a good bit more free form than
today's version. I was there as a novice associate examiner and she as
the consummate, very experienced director. I was, like virtually all
younger surgeons who would have found themselves in my situation with Dr
Jonasson that day, shall we say, “concerned” at the prospect of
spending the day with her. I can assure you I felt as much on the
examinee’s seat as our candidates did that morning. At the time, from my
youthful perspective, this concern was entirely justifiable for Dr
Jonasson was one of the most highly respected leaders in American
surgery, and while there were only “rumors,” she wasn’t known for being
warm and fuzzy. I was also mindful of Dr Rudolph’s long-ago advice to
meet her, and I didn't want to disappoint him.
Dr
Jonasson, by then, was even more legendary than when Dr Rudolph had
first mentioned her name. In my mind, as a young woman surgeon
excessively focused on firsts, she was particularly famous for her
recent service as the first woman to chair a medical school department
of surgery—at Ohio State University. By the time of this exam, she had
moved on from that job.
For those who have not yet served
as an ABS examiner, one of the simpler pleasures of this service, other
than the thrill of giving oral examinations 8 hours a day for 3 days in
a row, is the chance to meet new colleagues from around the country.
When you are young, you meet those you have long heard of, but have
never known. When you get old, you realize the younger examiners look at
you with similar curiosity. If all goes well, one chats, learns of
their practices, interests, and often families. As the day began, I
wasn't sure if Dr Jonasson thought this came with the process or not. I
watched as she began the exam. She did, of course, use the most
difficult scenarios from our books, those which I wouldn't have dreamed
of asking because I didn't have a clue where to go with them. She was
even and clear with the candidates and warm to me as her associate
examiner that morning. Evidently, I presume because I did not embarrass
myself too badly, she asked about my interests and career progress. She
expressed what I interpreted as a sense of approval.
After
a bit, I asked her about how her career had developed, as all young
women surgeons do when they happen to encounter another surgeon they
perceive to be like themselves; ie, someone with 2 X chromosomes who has
run the happy gauntlet of a surgical career before them. Although I had
no such ambition of my own at the time, I eagerly asked her about being
chair of a department of surgery. Her reply was, “Oh, those deep dark
days.” She said it not with anger but with a wistful wise smile. I was
stunned, and of course silenced. How could this dynamic, surgical icon
have ever had a dark day in surgery? She was the epitome of surgical
success, a master surgeon revered by her patients and beloved by her
residents; ask anyone who trained under her mindful gaze. She was an
accomplished scientist and clinical innovator, at the cutting edge of a
new surgical discipline, and a potent force in American surgical policy.
How could she have had a period of “deep dark days” in her surgical
career, particularly in what would have seemed to be a most satisfying
time?
I was disappointed, in fact fearful, that my own
aspirations for a satisfying career in academic surgery could have been
misguided. I was quite dismayed that such a powerful figure could have
had such a bad time of it. Fortunately, for Dr Jonasson, the good news
is that despite those years—and I have no idea what she really meant and
I can assure you I did not explore it any further that day—she clearly
regrouped, rebounded, and refocused her mission and once again found
bliss in her career. Dr Jonasson resumed her relentless crusade for the
cause of all things right that were presently wrong in surgery. She was a
magnificent force. For the years after that exam, Dr Jonasson was a
wonderful adoptive, available mentor to me in my career. Somehow, she
took me on in her “worthy women” crusade.
But, I've
thought about this exchange many times over the years, times when I've
been happy and fulfilled in my career, and at times when I start to feel
that slow burn of dissatisfaction. It happens in all professions no
doubt, but for us surgeons, whose careers certainly can be consuming,
and for which we have made so many sacrifices, willingly yes, but
sacrifices nonetheless, a ripple in the positive energy field of our
work is particularly unsettling.
I'm going to talk to you
about finding insights into the highs and lows, primarily the emotional
elements, of a surgical career. I propose to you that during our
decades in this wonderful profession, from training to the waning years,
you need a game plan to recognize the misery of spirit, which at times
will creep into your career. And, you need a strategy to restore
yourself when it does. I hate to tell you, but primary prevention of
these downs is not available, so start building your resucistation plan
now. I would like to give you some tools that I have often found useful,
to help you with those “deep dark” moments. Fortunately, I believe
these simplest of tools are available to all of us. I propose to you
that keeping a living memory of 2 valuable senses: a sense of purpose,
and even better, a sense of place, will serve you well.
Burnout
is a well-documented and reasonably hot topic these days in surgery.
Analyses derived from surveys a few years ago of some 800 fellows of the
American College of Surgeons, performed by Drs Balch and Freischlag and
colleagues, have yielded numerous publications about how “burnt out” we
are. So burnt out, at times, that we deliver less than compassionate
and effective care, unnecessarily place blame on ourselves, and lose the
ability to enjoy the essential elements of surgery that called us to
surgery in the first place.1
Burn out and stress make us quit surgery, retire early, behave badly
with our colleagues and families, divorce, abuse alcohol and other
substances, and even place us in a high risk group for suicide. I know, I
lost a dear colleague, a brilliant young surgeon, to suicide just a few
months ago. Although burnout can hardly have been the sole cause, the
stress of the extraordinary expectations we impose in our highly fueled
lives may fail to allow us to seek badly needed help. When it comes to
burnout, these are the findings—the facts—of how we view our sense of
well-being. I must say, my initial response to these papers was, “Good
heavens! How did this happen?”
Contrast this reported
reality with the fact that we surgeons often pride ourselves on being
members of a magnificent profession, a rare group of physicians who get
to do what few others can, apply our knowledge and skills, hard-earned
over many, many years of training, to cure people of dreadful diseases;
to rescue them from critical injury; and to mend failing parts by using
our knowledge coupled with our hands and our tools. Name another
profession so privileged in mission. And, given our exceptional
preparation, we are a particularly confident group; we do need to be,
for many reasons.
First, of course, we ask our patients
to allow us to care for them in ways that are unique and that demand
absolute trust. We ask them to climb on a table, to go soundly to sleep,
surrounded by strangers who will then care for them while we enter
their bodies through incisions and portals, with the hope of improving
health. We don't get good do-overs; we know our best opportunity is the
first. If you are a surgeon, you had best convey a sense of confidence
to that patient—in the vast majority of times, well-founded confidence, I
believe, for that's what our patients expect and deserve.
Second,
in regard to confidence, although with good preparation these days,
aided by incredible imaging and diagnostics that limit our “surprises”
compared to the days of old, we nonetheless occasionally will encounter a
truly unexpected finding in the operating room. Or, perhaps even more
challenging; we will, on occasion, need to mend an error created by our
own hand. When that happens, we need to regroup, to recall out of our
experience and knowledge tool-base, the wisdom to make the correct
observations and decisions to execute an appropriate new plan right then
and there. Outside of that critical environment of the operating room,
like all other physicians (those cognitive types!), we would have the
luxury of reanalyzing, getting more data, regrouping, and making a new
plan; but in the operating room, we have a more limited set of options
to progress and we need to make and move on with decisions, often with
incomplete datasets that will lead, we hope, to the best result. That
takes not only knowledge and skill, it takes confidence. Confidence to
make best possible decisions, confidence to call a colleague if needed,
and confidence to move forward with the hope of making a decision that
will end in a good result for our patient.
And there is
one other domain in which confidence matters. Our results, for the most
part, show. We lose blood, our operations take variable amounts of time,
our patients hurt and sometimes have complications, some preventable,
some not. But nonetheless, our results, good and bad, do show. Sometimes
our operations simply fail, or errors result in injury or worse,
painful not only to our patients but to their families, and of course to
us, the personally responsible surgeon, a surgeon who has harmed a
patient. If these moments don't hurt you, if you can easily dismiss such
events without careful review and self-awareness, I'm worried about
you. And I hope we have few in our profession who do not suffer, for the
needed period, when bad things happen. But in the end, assuming you
really did do your best at the time to remedy the processes that led to
that bad result, you need to get back on that horse and ride again. You
need to ensure that your confidence to practice your craft is
appropriately intact. For after all, a trained surgeon is a valuable
resource to our society.
So we are a confident, proud,
happy group, right? Well, on balance, yes. But this expectation for
satisfaction can betray us. When we get unhappy in our careers, we are
in some core manner breaking our covenant with our profession to be
confident, proud, and happy. It hurts. I expect a pastor or priest who
faces a challenge in faith may feel a similar loneliness and sense of
loss. These moments will come to all of us, sometime or another, and we
need to be mindful and prepared to address these times. Interestingly,
relatively few surgeons in survey data or in personal comments suggest
they would have preferred another professional pathway. Our training
programs, perhaps the arduous routes we mandate, deliver to us a highly
self-selected cohort. We all really want to be surgeons. I believe a
primary passion for surgery really does exist in all of us.
We
share a group think. We think the same things are funny, we like each
other, better than we like, umm, internists. Much of this, of course, is
based in shared experience and interest; some, more innately in shared
sensibilities and priorities. Many years ago, Gerson Greenberg did a
study that evaluated how we choose our residents.2
He asked the attendings and the residents in the study to place in rank
order the qualities that they valued, a list numbering from 1 to 40
qualities. Concordance was remarkable between the 2 groups, with
compassion, honesty, and intelligence, and skill ranking at the top.
Fascinatingly, when I was entering medical school 40 years ago, those
characteristics would never have crossed my mind as being attributes of a
surgeon. I will not reveal what my preconceptions were; just suffice to
say, they were far less flattering. Of course, I had not yet met one.
Nonetheless,
as we choose our successors, it is true we select people that want to
be like us and vice versa. For my first 25 years in surgery, that meant
that the majority of surgical faculty who were picking their successors
as entering residents, had to “stretch” their perspective of “sameness”
when faced with young women who chose to enter surgery. Yes, the young
women seemed to be strangely like the young men who were applying,
smart, compassionate, honest, and ambitious, but they were “different.”
Did they really know what they were signing up for; did they really want
to be us, for a full career? Didn’t they know that there were a lot of
other options that were less “demanding” and family friendly? For years,
until we reached the famous 30% composition rule of gender schema
articulated by Virginia Valian,3
which says we can judge individuals based on their performance rather
than our pre-held unconscious biases, surgical faculty making their
resident rank lists were required to explain “why” women medical
students wanted to be surgeons. Something must be off kilter in these
young women; did they really understand what they were signing up for?
Now, long past that 30% mark at our entry points, our surgical faculty
have learned to embrace and evaluate young women and men equally as
future members of our profession. And, I believe, we will eventually get
to that equity perspective at the leadership level as well. Perhaps not
in my lifetime, but we will get there.
But, returning to
how we surgeons self-select, it is fun to examine how this extends even
to surgical specialty styles. We all know that colorectal surgeons are
funny and irreverent, plastic and reconstructive surgeons are a bit more
intense and refined and always lovely; pediatric surgeons are a pretty
serious group although they wear funny neckties and hats; trauma
surgeons get bored really quickly if the Injury Severity Score starts to
drop; surgical oncologists can be pretty excessively cognitive;
transplant surgeons are wacko, but you've got to love them for their
passion beyond belief; and cardiac surgeons think they are deities,
which is a good thing given the frequency with which they have patients
with deadly problems.
Personally, I was destined to
become a pediatric geneticist, already considering pediatric
residencies, until my last medical school rotation, having put that
dreaded surgical requirement off to the end. Then, I met my first
surgeons and made my first trips to the operating room. That was the end
of genetics. Group think, shared sensibility, like attracts like: done.
Gender never crossed my mind, despite the fact I had never met a woman
surgeon at the time.
We surgeons have the same core
values and principles (with a capital P), in caring for our patients. We
believe in patient primacy, we believe in seeing our patients though
their entire course of care, from illness until health, and indeed at
times until death. We can make decisions. We understand that most bad
things happen at night or at some other inopportune moment and that we
will unwaveringly respond despite our fatigue and inconvenience. We get a
real buzz out of doing our work in the operating room. Thankfully there
are still many young people who want to be us, even as each generation
refines what that means. We share certain core principles, values, and
styles and we all fundamentally relish surgery.
Here's a
fun example. At surgical meetings these days, I always stop in at a
video session. When I started in this business, the video sessions were
full-scale production movies that were shown at night once a year at the
annual Clinical Congress. These were amazing movies of heroic cases
performed by the masters. It was excellent theater. But now, of course,
these sessions are ubiquitous and everyone can create and share their
handy work, and they do so beautifully and willingly. When I go to a
movie session, however, I go only in part to watch the surgery. I really
go to watch the surgeons. Go inside the dark room. These rooms are
intensely quiet. Surgeons watching surgery are silent. We barely
breathe. No one chatters. No one dozes off. No one answers emails. The
entire audience is watching, intently and silently. I really enjoy that
total focused silence. It always reminds me that we, we surgeons, all
really like this stuff. We hang together with this common passion.
That's an up.
For those of us who are surgical educators,
and actually all surgeons are educators, I don't mean to dismiss those
who educate their patients, families, staff, and colleagues on a daily
basis, but those of us who are charged with raising that next
generation, we get to see our trainees embrace and develop these same
passions. A young surgeon is almost as much fun as a new puppy;
everything is exciting, unpredictable, and to be explored. But, raising a
surgeon takes a lot more work than raising a puppy. But what a reward
to see them mature into responsible, ethical,
ready-to-be-delivered-to-our-communities surgeons and ready to join the
ranks of our profession as life-long members. That is fun. For you
educators, take note, even though it may seem daunting at times, that's
another up. So why is it that a surgical career is not always full of
bliss? I suppose we could make a long list of irritants. There are many
reasons, the most obvious being that in addition to providing a valued
and essential professional service to our patients, surgery is also a
job, a means to support ourselves and our families. We get paid to do
this stuff.
The current business of being a surgeon is
personally taxing, often capricious, frequently infuriating. What are we
supposed to do about that? I suppose we could all buy hospitals and
make sure we kept them full of our patients, but I doubt that would add
to our fundamental satisfaction, even though it could fatten our
wallets. As much as we would all love to say that we can restore the old
times, the glory days of (dare I say excessive) reimbursement and
privileged practice, a return to that time is not in our stars. Our
professional societies, no matter how large the political action
committee war chests, are not going to be able to deliver us,
unmodified, from this current transformation now upon us in health care.
I simply don't think surgeons are going to make more money, regardless
of how much harder we work. However, with any luck, and the abundant
hard work of many volunteer surgeons and our organizations, I believe we
will be able to craft a new order that will be fair and tolerable in
supporting both our purpose as surgeons and offering a return on
investment of our energies that is equitable and satisfying. This one is
a down we need to turn into an up. If your bliss is in trying to
influence new systems and policies, get involved to the extent you wish;
influence as you can, choose the deliverables that will add value to
your patients and your career, but remember, this is a long and winding
road with no clear common destination. This is not a job for every one
of us, but I am grateful to those who choose it.
Next
problem, our careers are long, 30, 40, 50 years; I've even seen 70-year
careers by notable surgeons in Texas! What we need to know and do is
changing so rapidly that our heads can spin. How do we keep up, much
less at the top of our game? Do we throw in the towel and just keep
doing things the way we always have? This is a looming, constant,
threatening down, but we can turn this into an up, I think.
We
surgeons are the ones who have 1-shot opportunities in patient care. We
are the group who will need to define the new infrastructure needed to
ensure a surgeon can safely retool in new technologies and procedures in
non-patient–based learning and training environments. We can't repeat
the sins, the patient harms, of our recent modern history as we
prematurely disseminated laparoscopy, endovascular surgery, and more
recently, robotics, allowing our learning curves to be fully born by our
patients. We need new infrastructure: effective, efficient training
environments for hands-on learning to proficiency, policies that support
this training in the financial cost of delivering high quality surgical
care borne by all the stakeholders of surgical care delivery: the
surgeons, the hospitals where we practice, our payers, and industry. We
need to build the educational and training infrastructure to support all
of us for our 40 years in practice, to continue to improve.
I've
had the marvelous opportunity to formulate a prototype facility for
this infrastructure at my home institution in Houston; we call the place
MITIE – the Methodist Institute for Technology Innovation and
Education, a 35,000 square foot, spectacularly beautiful, magnificently
staffed, high efficiency procedural training facility coupled to a
technology and procedural research and development program. I believe
MITIE can serve as an experimental platform to start to build and
evaluate how best to develop a retooling infrastructure.
More
than 30,000 health care providers in practice, mostly surgeons, in
virtually all surgical disciplines, have come through MITIE’s doors
during these first 5 years of operation. I pinch myself each time I am
there. Now that's an up. And for those who come to learn, a surgeon
coming for a retooling experience in a new technology or procedure in a
safe environment, the experience is nearly universally a most satisfying
and professionally resuscitating event. That's another up. Never stop
learning and retooling. As a profession, our job is to ensure we keep
all boats afloat and indeed rising with the tide of quality and safety.
Although MITIE has supported many health care providers in practice, the
challenge to stay current remains a source of stress and challenge for
many surgeons with uninterruptable busy practices. Lots of work to do
here.
Another problem, particularly for that 10% to 15%
of the surgical workforce who live in administrative and other
leadership roles in their health care communities, is that these jobs we
take on are not clearly jobs about surgery. They are jobs about
managing people, working with other disciplines, business, and delivery
of health care and systems of care. Where is the surgical purpose in
these roles? It is there. It is essential work, but it is not for
everyone. Only those who relish this dialog and have the capacity to
take these missions on for the greater good should take these jobs.
These jobs are about service, not empowerment, and they are tough jobs
and are getting tougher all the time in these challenging times. These
are potential areas of bliss for some, and real downs for others. Make
sure you know where you belong before taking on one of these. And of
course we all know that having the job of a surgeon can be personally
consuming, with long hours, unpredictable schedules, broken promises to
family and friends, and no time for personal interest and relaxation.
Simply put, surgery as a job has the potential to be miserable.
So,
I contend, the key is to figure out how to keep surgery from becoming a
job. I don't care if you are a baby boomer, generation X, Y, or
millennial, you need to figure out how you are going to keep your
surgical career from becoming a job.
There is great
emphasis these days on personal wellness; life balance, personal time,
and individual sense of purpose. Many counselors, coaches, and others
propose these as strategies to improve your sense of success and
happiness. Those may be laudable goals; however, I do not believe that
these individual purposes can solely sustain you in a career as
demanding or essential as surgery. These things cannot routinely make
you happy in your career. They cannot correct a practice partner who
fundamentally differs from you. They cannot remedy a fundamentally
flawed work environment or other sore point. They cannot offer you
control of the uncontrollable aspects of your job, nor can they create
more hours in a day. These things cannot remedy your gnawing discontent
when you recognize that financial reward has become a driver of your
practice as a metric of success, to meet your own expanding needs or the
standards expected by your family or peers of success. This individual
sense of purpose cannot remind you why, the essence of why, you really
became a surgeon. What drew you to this passionate field of medicine?
I
propose that whenever you approach one of those doldrums or
dispassionate or aggravating moments that you pause and seriously try to
recall what drew you to this practice. Remember the patients you first
touched, remember your valued teachers, recall those moments in training
and the fun and formative experiences you have had. There are 2 years
of my life for which I have no recollection of life outside of the
hospital. Shocking, I suppose, and no doubt a miserable time for my
husband. But, for me as I recall, these were wonderful times. We
residents of all sorts were together, learning, taking care of patients
and each other, laughing, living. We were a vital community, a group
with a real sense of place and purpose. We certainly knew why we were
there: to become surgeons. And we shared a place to do this.
A
sense of place describes the essence of an environment that defines
your relationship to it. Your sense of place is dictated by the
experiences you have had within it, the thoughts and memories that you
have generated in it. It defines your human experience in a building, a
landscape, a community. A sense of place evolves with experience, with
memories, with reunions; the people in it; the intensely personal
moments you have had there; and your linkage to the purpose, activity,
and values of a place.
In those years, my group of
residents (as I expect did yours) shared vital and intense experiences,
often filled with life's greatest mysteries; unanticipated recovery,
death, unimaginable grief, and wonderful joy. I can still feel the ICU
reclining chair where I occasionally dozed for a minute or 2 in the
early hours of the morning by the bed of a patient near death, or the
trauma bays where we tried to snatch the injured from death, and of
course, our operating rooms. I can recall the shape and setting of each
and have distinct memories of times with my surgeon mentors in so many. I
can remember “accidently” transecting the esophagus rather than the
proximal stomach as Dr Tsangaris, in his very deep, gentle slow voice
said, “Barb that was a little higher than we needed… not to worry.” I
can remember turning off the ventilator of the young blind woman who
worked in our hospital as a transcriptionist and came every day to work
with her beautiful German shepherd guide dog, until the day she stumbled
off the subway platform and sustained lethal head injuries. Dr William
Knaus, the intensivist who was creating the APACHE score at the time,
comforted me while I sobbed, perhaps the only time I really cried with
overwhelming sadness during my training. I remember rounding with Dr
Kathy Anderson at Children's Hospital in DC, in the neonatal ICU, for
weeks, with a baby who would not allow her beautiful little mouth to be
used for any useful purpose, having missed the chance to learn how to
suck due to her many operations for gastroschisis. These memories are
precious. They form my sense of place and purpose.
And
over the many years I have been in practice, I have developed an equal
familiarity and comfort in the same environments in the several
hospitals I have called my professional homes. There is not an operating
room in any city around the world that I have ever entered that I did
not find in a very funny way to be a very familiar place.
I
guarantee that all the senior surgeons in this room can describe to you
the sense of place that nurtured them as they grew into surgeons during
their training and, no doubt, in an ongoing way in their subsequent
hospitals. As physicians, and especially surgeons, these are our special
places where only we can float comfortably and do our most valued and
special work. This is one of those great shared experiences, this sense
of place that hospitals and operating rooms provide, that binds surgeons
together. They remind us of our real purpose as a profession. Remember
this very valuable tool to restore your ups.
It took a
special experience to allow me to articulate the value of this sense of
place for me. It dawned during one of many trips to Europe, to my dear
France in particular. I was in Beaune, in the heart of the Burgundy
region of France, during a crisp beautiful fall; the smell of burning
vines was in the air. I stopped in one of the notable tourist
destinations in the region, the Hospice de Beaune, also known as the
Hotel-Dieu de Beaune. Beaune is very famous for its beautiful medieval
buildings with geometrically ornate colored tiled roofs. I love to
travel and marvel at the world's most beautiful and meaningful
creations; cathedrals, masterpieces of creative works, and the special
meanings they convey, and I expected one more beautiful creation this
day. Before I go much further, let me tell you the story of this place. A
story I did not know as I entered.
In 1435, the Hundred
Years War between France and England was nearing its end. One of the
victors of this war was the great Duke of Burgundy, Phillip the Good. It
turns out his chief chancellor was a certain Nicolas Rolin, an
exceedingly powerful and efficient minister. He acquired great wealth
and privilege in his ministerial duties and was known as a most
effective, but at times, less than generous administrator. After losing
his first 2 wives to disease, his third wife, Guigonne de Salins,
requested that he use his wealth to demonstrate his good will toward the
people of the region of Beaune. Together they founded the Hospice de
Beaune in 1442. Their foundation was established to serve the needs of
the destitute peasants who had been ravaged by years of war. During the
10 years after the founding of the foundation, they built a
state-of-the-art facility, L'Hotel-Dieu de Beaune, to provide health
care to the poor, elderly, sick, and disabled people of Beaune and its
region. Mind you, this was at a time when health care, such as it was,
was best provided at home with the services of a physician, for the
wealthy few, who would come to visit. The poor simply fared on their
own. To assemble such patients into hospital structures was a radical
construct.
The Hotel-Dieu de Beaune, with its exquisite
tiled roof, received its first patient in 1452, and unbelievably,
remained in continuous operation until 1971, when a new modern hospital
was built outside of town. The Hotel-Dieu de Beaune of 1452 had
remarkable structural features. It was built over a small river that
runs through the town to facilitate use of fresh clear water from
upstream. It was staffed by the Sisters of the Hospitalier, a new order
founded to care for the sick. A state-of-the-art pharmacy, surgical
instrumentation, learned physicians, and all other remarkable modern
amenities of the late Middle Ages were provided for the welfare of the
poor. It was an unprecedented concept in health care—a facility treating
poor patients with dignity and compassion using sophisticated care of
the age.
Not only was it a magnificent functional
structure, it was also adorned with glorious commissioned works of art,
the art I had intended to see that day; art that was installed in 1452
to inspire the souls of the patients and to support their emotional and
spiritual needs. To heal patients was more than to provide remedies, it
was to provide hope. After the 500-year-old hospital moved to a new site
in 1971, the old Hospice de Beaune was completely restored over the
next 25 years to the original structure of 1452. This is where my
recognition of a sense of place comes in.
On that fall
day, before I knew any of this story of the Hotel-Dieu, I walked into
the grand hall of the building looking for art. Immediately, I was
overwhelmed almost to the point of breathlessness with a sense of
familiarity. A sense that this was “a place of my profession.” The
soaring arched wooden ceiling with gargoyled timbers looked down on 2
long rows of beautifully draped hospital chambers, some 40 or more, each
with a small bed, table, and basin with rich crimson curtains placed
around for privacy, with a large open central space for the work of the
sisters. This, to me, was immediately not an artistic historical
masterpiece, although it certainly was that, with exceedingly valuable
and rare paintings and statues adorning the walls. This place was a
hospital! It was a place that served the purpose of us doctors and
nurses and, of course, our patients. I knew what had happened here, I
understood the people who worked here and the patients who lived and
died here. Though more than 500 years old, this place cried out that it
was a place of healing. To me, this recognition was so powerful, so
unexpected that I was startled. I looked at my husband and younger son
and others in the room who were marveling at the art and statues and
magnificent architecture, while I was overwhelmed with the sense of the
physicians and patients who had been treated for so many years in this
very place. I was stunned, silenced, and comforted.
This
experience catapulted me to the present and made me mindful of all the
places and shared experiences that our houses of healing have created.
It reminded me of the sense I had when I stepped into the grand foyer of
the old Charity Hospital in New Orleans, of Grady Hospital in Atlanta,
of every VA hospital lobby I have ever had the pleasure of entering, of
my now so comfortable Houston Methodist Hospital, and of oh so many
operating rooms. We, collectively, have built hospitals and clinics and
used them, but actually they become vital living structures that allow
us to serve our purpose unlike any other places. These are not just
structures with people in them doing work, they are special environments
for us and our patients where our healing is done, our compassion is
shared, patients' lives are lived and lost, and the next generation of
doctors come of age. They convey the most powerful sense of place.
Please, you must all go to Beaune someday. I want you to feel this
place.
For those of you still in training, when you get
back to your teaching hospitals, clinics, and operating rooms, I want
you to consciously look around your environment. Breathe it in; feel
that sense of place. It will sustain you when times get tough. And when
you start feeling flustered, disillusioned, and angry, think back, find
your roots, and use them as resuscitating events. Remembering these
things may well help remind you of the purpose of your life as a
surgeon. It will remind you not of your individual purpose but of our
professional purpose, which, by virtue of your choice of surgery as a
career, you have taken on as your own. Remember, we exist as surgeons
not because we want to be a surgeon, but because the people of our
society need us to know how to take care of them with our surgical
skills when they are ill.
Remember, resuscitate, breathe
deeply. Look around at the places where you practice your profession.
Reflect on shared purposes with your colleagues. Recall valuable places
and the important purpose you serve. It will keep you fresh and vital,
and reassure you that you truly did make many important, very correct,
choices in selecting your surgical career. Thank you again for the honor
of this opportunity. I am truly humbled to be here with you.
Presented at the American College of Surgeons 100th Annual Clinical Congress, San Francisco, CA, October 2014.
