PRESIDENTIAL ADDRESS

The Complete Cardiothoracic Surgeon: Qualities of

Excellence
Joseph I. Miller, Jr, MD
General Thoracic Surgery, The Emory Clinic, Emory University School of Medicine, Atlanta, Georgia

A s I stand before you this morning, we have already

presented the past and present of the Southern
Thoracic Surgical Association from the historical aspects,
spouse’s perspective, and summaries of the important
general thoracic, adult cardiac, and pediatric surgical
papers presented before this association. My thoughts for
this address spanned a broad spectrum of potential
topics, but ultimately my remarks had to reflect my
observations on the practice of cardiothoracic surgery
based on 30 years of professional academic experience.
Harvey Bender stated that presidential addresses tend
to be one of three types [1]: (1) The first type is a scientific
paper based on an area of his or her special interests and
one that frequently stresses clinical outcomes in the
management of a disease process; (2) the second type is
historical, one that reviews and documents important
turning points in the development of the specialty and
emphasizes the important roles played by previous lead-
ers in the field; (3) the third type is philosophical, and I
think mine best fits into that category.
I feel that we have to look at the preservation of the
specialty of cardiothoracic surgery and the qualities that
the complete cardiothoracic surgeon will need to learn
and acquire as we move into the second millennium.
Preservation of the specialty and pursuit of qualities of
excellence in cardiothoracic surgery (CTS) are what will
sustain not only the Southern Thoracic Surgical Associ-
ation, but also our specialty as a whole.
In my opinion, the specialty has never been held in As we look at our role in training cardiothoracic sur-
higher esteem by other specialties or by the public. In gery residents, we should remember precepts from our
most institutions, the department or division of cardio- Hippocratic Oath: “I will look upon him who shall have
thoracic surgery sets the standard that all of the other taught me this Art even as one of my parents — I will
impart this Art by precept, by lecture and by every mode
departments follow: in economics, local and national
of teaching— to disciples bound by covenant and oath,
involvement, publications, and level of expertise. When I
according to the law of medicine.” [2].
look at the 16 members of our section who are present at
Reflecting on our role as teacher, Dr. David Faxon,
division meetings, I am amazed at the extraordinary immediate past president of The American College of
collection of talent gathered under the leadership of Dr. Cardiology, expressed it well: “In our profession we are
Robert Guyton. sometimes called to be teachers and sometimes to be
As I approached this address, my thoughts focused on students. In some cases we have the answers that others
two universal aspects of our specialty: One, the training seek; at other times we seek answers from those who may
of cardiothoracic surgery residents and two, the pursuit be more experienced and wiser than we. Each of us has
of qualities that will result in strengthening our specialty. faced pivotal moments in our lives and in our careers
when we have sought answers, guidance, and inspiration
Presented at the Fiftieth Annual Meeting of the Southern Thoracic from the same sources again and again, and have been
Surgical Association, Bonita Springs, FL, Nov 13–15, 2003. provided with direction, to clarity and a renewed sense of
Address reprint requests to Dr Miller, General Thoracic Surgery, Emory
purpose. These people assume the mantle of ‘Mentors’
University School of Medicine, 1365 Clifton Rd, NE, Building A–A2206, for us and without them we may not have been able to
Atlanta, GA 30322; e-mail: jmille6331@aol.com. achieve our loftiest goals and ideals” [3]. Faxon further

© 2004 by The Society of Thoracic Surgeons Ann Thorac Surg 2004;78:2– 8 • 0003-4975/04/$30.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2004.02.013
Ann Thorac Surg
2004;78:2– 8
stated, “I ask you to recall your own personal Mentors
and how your lives would have been less fulfilling
without them. I ask you, to whom do the students of
today turn? From whom do they seek wisdom, guidance,
and insight? Who teaches them patience, perseverance,
and practice?” [3].
As Richard E. Clark in his Presidential Address to the
Southern Thoracic Surgical Association so eloquently
stated, “As we age singularly and collectively, we have
forgotten the importance of the hero in our lives. Heroes
are our beacons in the downpours and in the fog. Heroes
enrich us and inspire us to persevere and help us feel
that our lives are worthwhile” [4].
Such has been the presence of heroes in my life and
training. The names Kirkland, Clagett, McGoon, Hatcher,
and Guyton, have already been mentioned but there
have also been others. Doctor Penfield Favor and Dr. Hal
Urschel have helped me tremendously along the way.
They have been beacons of light and have provided
mentorship and friendship. For the collegiality and
friendship of Dr. Peter Pairolero, Dr. William Baumgart-
ner, Dr. Timothy Gardner, Dr. Fred Crawford, and Dr.
Douglas Mathisen, I will always be grateful.
We as teachers must not only instruct, but also serve as
examples for our residents. In our role as teachers and
mentors, we must have thorough knowledge of the
governance of cardiothoracic surgical education. The
governing bodies of cardiothoracic surgical education
are, The American Board of Thoracic Surgery (ABTS),
The Residency Review Committee for Thoracic Surgery
(RRC), and The Thoracic Surgery Directors Association
(TSDA). Each of these governing bodies has the resident
as its central core and theme. The functions of each
individual component of the governance are as follows:
The ABTS is responsible for testing and certification, the
RRC evaluates residency programs for accreditation, and
the TSDA is responsible for resident instruction, core
curriculum, and education. Each component is a neces-
sary governing body to develop the best thoracic surgery
resident possible. Let us now look at each individual
component.
The American Board of Thoracic Surgery was founded
in 1948 and is composed of 17 members with a term of six
years each. Since its predominant purpose is testing and
credentialing, the board is responsible for the both the
oral and written exams, and the recertification exam,
Self-Education Self-Assessment in Thoracic Surgery, the
practice review, and Continuing Medical Education. Its
17 members are drawn from the various thoracic disci-
plines. Board certification indicates that individuals have
successfully completed an approved education program,
and have been evaluated with an exam designed to
assess the knowledge, experience, and skills required to
provide high-quality thoracic care.
The purpose of the Residency Review Committee is to
oversee training programs. It is composed of six mem-
bers, including its chairman: two from the American
Board of Thoracic Surgery; two from the American Col-
lege of Surgeons; and two from the American Medical
Association. The RRC is responsible for credentialing
PRESIDENTIAL ADDRESS MILLER 3
QUALITIES OF EXCELLENCE
residency programs and determining the number of
residents at each institution. Depending on its current
status, a program is reviewed at one, three, or five-year
intervals. The possible actions of the RRC are as follows:
It can approve a program for a review at three or five
years, or the review may be deferred; it may recommend
probation or closing a program. The RRC ensures that
accredited programs provide a resident the appropriately
defined educational experience to be a proficient thoracic
surgeon.
The Thoracic Surgery Directors Association was
founded in 1978. Its purpose is to ensure quality teaching
and an appropriate learning environment. It also main-
tains a list of board requirements and informs program
directors of any changes in requirements for certifi-
cation by the American Board of Thoracic Surgery. In
addition, the TSDA is responsible for the thoracic core
curriculum, the residency-matching program, and resi-
dent education.
It is the single purpose of each individual governing
component to prepare individuals to practice cardiotho-
racic surgery in a manner that is safe, effective, and
accomplished without forgetting the human needs of
their patients. Having had the opportunity to be a mem-
ber of two of these three governing organizations, the
American Board of Thoracic Surgery and the Residency
Review Committee, I can report to you that each strives
to perform the function with which it is vested and to
look after the best interests of the cardiothoracic surgical
resident. It has been indeed an honor and a privilege for
me to have served as a member of these two boards and
their committees.
From Halsted’s establishment of the Pyramidal Resi-
dency System at Johns Hopkins in 1899, as highlighted in
the presidential addresses of Drs. Bender and Murray, to
the rectangular system recommended by Churchill at the
Massachusetts General Hospital, residency training has
come a long way [1, 5–7]. Many of you here today went
through the Halsted Pyramidal System at Hopkins or
Vanderbilt. Churchill was on target when he developed
the rectangular system, as it was a fairer test of training
and competence [7]. Churchill emphasized that correct
decisions are derived from good judgment, which is a
combination of intelligence, knowledge, experience, and
the continuous critical analysis of results [7]. His resi-
dency program was designed as education for uncer-
tainty, with concomitant emphasis on equanimity. John
Whiteham described the Churchill residency: “One
cannot become aware of alternatives without some abil-
ity to tolerate uncertainty; and we cannot experience
good judgment and common sense in reaching well-
considered conclusions and wise action unless we can
tolerate uncertainty with equanimity” [7].
I would now like to turn my attention to qualities that
I think the complete cardiothoracic surgeon in the second
millennium will be required to attain. After reading most
of the cardiothoracic surgery Presidential Addresses for
the past 30 years, today I share with you my own
thoughts based on 30 years of academic clinical experi-
ence. Ours is the “Apollonian Quest”, as stated by Aldo
4 PRESIDENTIAL ADDRESS MILLER
QUALITIES OF EXCELLENCE
Castanaeda [8]. “Whether or not we can achieve it is by
the aspects of circumstance, ability, determination, will,
providence, and being the beneficiaries of our mentors
who have instructed us so well [8].”
The title of my address, “The Complete Cardiothoracic
Surgeon: Qualities of Excellence” will ring a familiar bell
to those who are students of surgical history. A variation
of this theme has been used three times before. As noted
by Dr. Lawrence Cohn: In the Fourteenth century, the
French surgeon Guy de Chauliac wrote, “What the Sur-
geon Ought to Be” [9]. In 1972, Dr. Andrew Morrow
presented “What the Cardiac Surgeon Ought to Be” [10].
In 1999, Dr. Lawrence Cohn presented “What the Car-
diothoracic Surgeon of the 21st Century Ought to Be” [9].
Using this as a paradigm, I give credit to Dr. Larry Cohn
for his original ideas on this topic. I have taken the
opportunity to expand this to what I think the “The
Complete Cardiothoracic Surgeon Should Be and Asso-
ciated Qualities of Excellence.” I think that we, as leaders
in the field of cardiothoracic surgery and teachers of the
future generations of cardiothoracic surgical residents,
should strive to attain these qualities.
In 1790, Guy De Chauliac said the traits of a surgeon
are that he should be learned, he should be expert, and
he should be ingenious and adaptable [9]. In 1972, in his
Presidential Address to the American College of Vascular
Surgeons, Dr. Andrew Morrow said a cardiac surgeon
ought to be a physiologist, a cardiologist, an investigator,
a skeptic, an expert surgeon, a competent surgeon, an
anatomist, have a hobby, and have a sense of business.
In his 1999 Presidential Address presented to the
American Association of Thoracic Surgeons, Dr. Larry
Cohn listed a number of qualities that the cardiothoracic
surgeon of the 21st Century should strive to attain [9]. He
stated that they should include the following: (1) an
excellent surgeon; (2) a physiologist; (3) an excellent
teacher; (4) knowledge of health care economics; (5)
versed in digital technology; (6) knowledge of new sur-
gical technology; (7) a leader; (8) adaptable; (9) be persis-
tent; (10) sense of history of the specialty, and (11) a
humanist.
With Dr. Cohn’s permission, I have expounded on his
ideas and added my own personal thoughts to his list.
The qualities of a complete cardiothoracic surgeon in the
second millennium are as listed in Table 1.
Qualities of the Complete Cardiothoracic Surgeon
1. THE FIRST QUALITY OF A COMPLETE CARDIOTHORACIC SURGEON
IS THAT OF BEING AN EXCELLENT SURGEON. There is no substi-
tute for technical excellence. Ultimately our ability as
surgeons will be determined by how effectively we per-
form surgical procedures as measured by the standard of
our fellow cardiothoracic surgeons, our professional col-
leagues, and our trainees. In whatever our work environ-
ment, be it in the private sector or academic sector, we as
practitioners of the highest art must be the best technical
surgeons that we can be and assure that our trainees
develop to be the best that they can be. Additionally, our
results will be compared to the data in the cardiothoracic
Ann Thorac Surg
2004;78:2– 8
Table 1. Qualities of a Cardiothoracic Surgeon in the Second
Millennium
1. An excellent technical surgeon with good judgment
2. A detailed knowledge of cardiorespiratory physiology
3. An excellent teacher and have knowledge of cardiothoracic
surgical education
4. An excellent radiologist
5. Have knowledge of health care economics
6. Have knowledge of new surgical technology
7. A leader
8. Be adaptable
9. Have historical knowledge of the specialty
10. Have a quality of persistence
11. Should be a humanist
12. Should have a hobby
13. Should have a faith
surgery data bank and to the newly formed congenital
and thoracic surgery databases.
Academic cardiothoracic surgeons are expected to
demonstrate excellence in not only outcome results but
also the ability to train residents in an effective reproduc-
ible technique. When I was at the Mayo Clinic in the
1960s, Dr. Dwight McGoon stated that there are 122 steps
in an aortic valve replacement from skin incision to skin
closure: “Write those down, learn them, and you will do
well.”” Over the course of my six months with Dr.
McGoon, I attempted to get them all down one-by-one in
a small spiral notebook. Ultimately, at the completion of
my rotation, he was willing to sit down and go through
those steps with me. We should train residents in an
effective reproducible technique, and the order in which
we conduct a particular operation should be essentially
the same in all cases. If our residents learn a standardized
technique to approach a specific procedure, then they
can learn the exceptions to the rule and do well. Equally
important to the technical performance of the procedure
is the judgment used in determining the type of opera-
tion to be done. It is my feeling that there is no substitute
for excellent judgment. As long as one has excellent
judgment, the hands will follow and technical excellence
will be achieved. As a part of judgment, we must know
our own capabilities and how to measure our results.
We need to know not only our own ability to achieve a
given technical result, but also our limitations, and we
must never fail to ask for help in those cases in which we
feel that someone could help us improve the outcome for
our patient. Above all else, we must have absolute
integrity and honesty in the operating room both with
ourselves and with our residents. William Shakespeare
said in Hamlet: “To thine own self be true, then thou
cannot be false to any human.” As a trainee of cardio-
thoracic residents, the manner that the senior surgeon
displays in selecting patients for operation and his con-
duct of the operative procedure itself are the all-
important tools in the training of young, future cardio-
thoracic surgeons.
Andrew Morrow pointed out in his Presidential
Address that the attributes of an expert surgeon include
Ann Thorac Surg
2004;78:2– 8
the wisdom of selecting patients for surgery and the
conduct of the operative procedure [10]. Morrow stated:
“A surgeon and only the surgeon should make the all
important final decision as to whether a patient is a
candidate for an operation and, if so, what procedure is
the most appropriate.” He reminded us of one of the
most poignant statements of Blalock, “The fact that a
patient is going to die does not necessarily mean that he
should be operated upon” [10]. Judgment is almost as
important as the technical ability to carry out the proce-
dure itself.
2. THE COMPLETE CARDIOTHORACIC SURGEON OF THE SECOND MIL-
LENNIUM MUST HAVE A DETAILED KNOWLEDGE OF CARDIORESPIRA-
TORY PHYSIOLOGY. First, he should have a knowledge of
pulmonary physiology as it relates to pulmonary function
testing. (Note: The term “He” as used in the manuscript is
not gender specific and refers to he or she depending
upon whether the surgeon is a male or female. It is not
meant to refer to the male gender specifically.) The
complete cardiothoracic surgeon must have an in-depth
knowledge of the extent and limits of pulmonary resect-
ability based upon four levels of pulmonary screening.
He should be able to interpret the routine pulmonary
function studies. He should know their significance and
when pulmonary exercise testing is indicated and how to
interpret the results of MVO2 (maximum oxygen con-
sumption), exercise oximetry, and the limits of the six-
minute walk study. In addition, he should know when
pulmonary rehabilitation is indicated and when it may be
useful in the preparation of the marginal resection can-
didate. The second large area of knowledge of which the
cardiothoracic surgeon should be aware is the interpre-
tation and application of the results of cardiac testing. He
should have thorough knowledge of transesophageal
echocardiography, cardiac catheterization data, and the
ability to interpret coronary angiography.
3. THE COMPLETE CARDIOTHORACIC SURGEON MUST ALSO BE AN
EXCELLENT TEACHER AND HAVE A KNOWLEDGE OF CARDIOTHO-
RACIC SURGICAL EDUCATION. He must instruct and inspire
our thoracic surgery residents to seek further knowledge,
to raise questions, and to share information as well as
provide them the opportunity to write and participate in
surgical research. He should inspire in them the concept
that a cardiothoracic surgeon is “a surgeon and some-
thing more.” In addition, he must have an in-depth
knowledge of cardiothoracic surgical education as ef-
fected by The American Board of Thoracic Surgery, the
Residents Review Committee, and The Thoracic Surgical
Directors Association.
4. THE COMPLETE CARDIOTHORACIC SURGEON MUST BE AN EXCEL-
LENT RADIOLOGIST. Today’s cardiothoracic surgeon must
have the ability to interpret three-dimensional knowl-
edge from an anatomic, physiologic, and radiographic
viewpoint. His or her knowledge of anatomy and surgery
teach them, based on experience, what is possible and
what is not possible to accomplish. It is a sinequanon
that the surgeon never knows for sure what can be
PRESIDENTIAL ADDRESS MILLER 5
QUALITIES OF EXCELLENCE
Table 2. Issues in Healthcare Economics
1. There is more competition for market share
2. There are more sophisticated and experienced purchases of
service
3. There is greater emphasis on cost and service
4. There is overcapacity in facilities and personnel
5. There are changes in the method of providing service,
marketing, pricing, and research
6. There are falling profits
7. Probably equally important, there is a decrease in
subsidization of all areas of cardiothoracic surgery
accomplished until he or she is at the operating table. An
almost impossible-looking CT scan of an advanced
stage IIIA or IIIB lung cancer with invasion in the
mediastinum may appear unresectable, but when one is
there it may be possible to resect part of the atrial and/or
cava wall and excise the tumor. Only the surgeon has the
ability to interpret anatomic, physiologic, and radio-
graphic data because of his unique experience in all three
modalities.
5. THE COMPLETE CARDIOTHORACIC SURGEON MUST HAVE A DE-
TAILED KNOWLEDGE OF HEALTHCARE ECONOMICS. The complete
cardiothoracic surgeon must have a detailed knowledge
of the impact of government on thoracic surgical educa-
tion and healthcare economics. He must be willing to
grapple with economic issues and work toward their
solutions. In addition, he is required to know the eco-
nomic consequences of outcome parameters in adult
cardiac, thoracic, and congenital heart surgery. The out-
come parameters will be the standardized measure by
which all surgeons are compared. As pointed out by Dr
Robert W. Anderson of Duke University, the major issues
in healthcare economics are listed in Table 2 [11].
It is apparent that we cardiothoracic surgeons, along
with the rest of the healthcare system, must come to
some reconciliation with societal concerns to develop a
strategy to adapt and reposition ourselves to the changes
underway. If we stand back and wait, we will be lost in the
flood as the changes overtake us. Doctor Anderson goes on
to point out the principles of business as they apply in
medicine. He states the following [11]: “(1) Short-term
solutions do not sustain survival; (2) competition creates
value; (3) innovation drives quality improvements; (4) in-
centives drive innovation; and (5) our response must be
designated to improve the entire system.”
The declining subsidization of thoracic surgical educa-
tion is widely affecting all training institutions. It is
obvious that academic medical centers can only survive if
they develop an aggressive strategy to deal with these
business aspects in the medical marketplace. Anderson’s
paper should be read by all who are interested in the
specific economic aspects of our healthcare in the United
States.
6. THE COMPLETE CARDIOTHORACIC SURGEON MUST HAVE AN IN-
DEPTH KNOWLEDGE OF NEW SURGICAL TECHNOLOGY. The com-
plete cardiothoracic surgeon must have knowledge of
6 PRESIDENTIAL ADDRESS MILLER
QUALITIES OF EXCELLENCE
robotics, lasers and photo chemicals, transplantation im-
munology, gene therapy, molecular markers, oncologic
principles, and the new and emerging field of digital
technology and how it impacts all of cardiothoracic
surgery. Robotic surgery is now becoming a mainstay in
several institutions in our country, and the utilization of
robotics in the performance of minimally invasive proce-
dures is crossing all aspects of our field from minimally
invasive valve replacement to total robotic valve replace-
ment and to the performance of minimally invasive
thoracic procedures as well. In addition, the ability to
destroy certain tumors by photodynamic therapy with
laser ablation is now practiced in many medical centers.
The future with gene therapy, both in cardiac disease and
oncologic therapy for lung cancer, is in the forefront of
many laboratory investigations. Emerging digital tech-
nology is affecting all of medicine, and one has to learn
this in-depth knowledge or be left behind.
7. THE COMPLETE CARDIOTHORACIC SURGEON OF THE SECOND MIL-
LENNIUM MUST BE A LEADER. The complete cardiothoracic
surgeon must be a leader in the local healthcare environ-
ment; he must be a leader in the training of residents; he
should strive to be a leader in national specialty organi-
zations; in essence, he becomes a renaissance human or
Thomas Moore’s “A human for all seasons.” He is an
individual that others will want to emulate. Leadership
involves taking responsibility to direct the action of
others and taking responsibility and accountability for
both successes and failures. In his excellent book, Lead-
ership Secrets of Attila the Hun, Wes Roberts points out that
“You must have a passion to succeed, a passion that
drives you to prepare yourself and your colleagues to
excel. By their actions, not words, do leaders establish the
morale and integrity of their subordinates, and by the
ability to make timely and difficult decisions” [12]. He
points out that “Leadership Effectiveness ⫽ Results ⫻
Personal Qualities.” [12]. Kouzes and Posner stated, “The
first milestone on a journey to leadership credibility is
clarity of personal values” [12]. Dr. William J. Mayo said,
“Integrity is the basis of trust. Trust is a bonding of
caring, and when the prognosis for trust is poor, the
chances for a good outcome diminish. Trust and caring
are almost synonymous” [13]. Now, more than ever, we
must use our leadership ability and skills to broaden our
scope and think in terms of healthcare problems at both
the local and national levels.
In summary, Winston Churchill, in 1951, said of the
ability to lead: “I can practice in an honorary fashion the
arts of surgery and medicine . . . being temperamentally
inclined to precision and a sharp edge, it might be
thought that I should choose the surgeon’s role” [14].
8. THE COMPLETE CARDIOTHORACIC SURGEON MUST BE ADAPT-
ABLE. The complete cardiothoracic surgeon must be adapt-
able to change. He must consider new ideas and he should
never fail to keep an open mind. Larry Cohn stated: “The
most successful thoracic surgeons are, by their very nature,
adaptable because they deal with new predicaments every
day in the operating room, in the ward, and in the clinic”
Ann Thorac Surg
2004;78:2– 8
[9]. As Friar Roger Bacon stated in his Opus Magnus of the
13th century: “The four stumbling blocks to grasping the
truth are: one, the pattern set by our elders; two, longstand-
ing custom; three, the popular belief, therefore it should be
held; and four, the hiding of our own ignorance by making
a display of our apparent knowledge. Every human is
involved in these things in every walk of life, in every
occupation, and they arrive at the same conclusions by their
worst arguments” [15].
As J. Cassell in 1987 pointed out, “Surgeons are rarely
allowed the luxury of second thoughts. At the operating
table, the surgeon must manifest decisiveness, certitude,
control; emergencies must be resolved, unexpected find-
ings anticipated, and the advantages exploited” [16].
9. THE COMPLETE CARDIOTHORACIC SURGEON MUST HAVE A
KNOWLEDGE OF THE HISTORY OF CARDIOTHORACIC SURGERY.
Wangensteen stated that: “If all problems in medicine
could be taught with special emphasis on a historical
approach, every physician would be better prepared to
cope with future problems” [17]. Celsius stated in the 4th
century that there are three ways to treat a patient: “Diet,
medicine, and surgery, but only surgery works” [18].
Wangensteen further stated in 1975, “May the spirit of
inquiry, the love of learning, and appreciation of the
History of Medicine create in our medical schools an
intellectual atmosphere that will heighten greater medi-
cine’s commitment and accountability in its service to
humanity” [19]. Wangensteen stated in his address con-
cerning the education of surgeons in 1940: “The past
never returns, but the character of the future can be
determined in part by what is done in the present” [19].
Thomas Jefferson, in stating the qualities of the ideal
physician said that we as physicians should be inquisi-
tive; we should have a concern for people; we should be
intelligent; and we should believe in the scientific
method [20]. A thorough knowledge of the history of the
specialty and of individual disease processes will make
the complete cardiothoracic surgeon a better teacher,
give him or her a greater understanding of the condition,
and enable him or her to take advantage of previous
research.
10. THE COMPLETE CARDIOTHORACIC SURGEON SHOULD DEVELOP,
TO THE BEST OF HIS ABILITY, THE QUALITY OF BEING PERSISTENT-
. Persistence is perhaps the most important personal
quality that a complete cardiothoracic surgeon can de-
velop. It is often the key to a successful outcome. As Cohn
pointed out, many times we have experienced success in
a very difficult operation by simply adhering to our game
plan in the operating room, no matter what the obstacles
[9]. Gustav Mahler stated: “For success, nothing in the
world can take the place of persistence; talent alone will
not be successful because nothing is more common than
the unsuccessful human with talent. Education alone will
not be successful because the world is full of educated
fools. Persistence and determination are alone omnipo-
tent” [15]. “It is the ability to keep on going and trying
through the valleys in the late night hour in the operating
room when success often comes and a successful out-
Ann Thorac Surg
2004;78:2– 8
Table 3. Humanism and Surgery
Content of Surgery (4 Compartments):
1. Technology ⫽ handicraft
2. Humanism ⫽ safe application of science to human needs
3. Science ⫽ observation and experimentation
4. Empiricism ⫽ common sense
Churchill [7].
come for the patient results” [9]. For the surgeon who is
persistent and has expert knowledge and technique,
rarely is there an adverse outcome.
11. THE COMPLETE CARDIOTHORACIC SURGEON MUST ALSO BE A
HUMANIST. Dwight McGoon, in his Presidential Address
to the AATS in 1984 said: “All efforts in research, educa-
tion, administration, writing, editing, and long hours of
intensive labor at the operating table have inherent and
transcendent value only in one respect . . . as an unselfish
expression by skilled and dedicated surgeons of a concern
for the welfare of needful human beings” [21]. We must
remember that our patients are our primary concern and it
is for them we have dedicated the long years of training. We
must never lose our compassion for the patient. As Aldo
Castanaeda stated in his Presidential Address: “Our spe-
cialty is not merely an applied science and technical disci-
pline, it also involves an important aesthetic component,
juxtaposing art and science, and demanding, in addition,
honesty, courage, judgment, vision, compassion, and a
commitment to the pursuit of excellence“ [8]. He points out
that: “there is an unresolved paradox in which we often find
ourselves: Our Hippocratic obligation to immerse ourselves
in, and at the same time, the need to distance ourselves
emotionally from the struggle of human survival.” “The
privilege to participate in preserving and improving life
provides us with our purest professional satisfaction” [8].
He further states: “There is a widening gap between science
and the humanities. Often we find well-trained profession-
als who have mastered scientific facts, statistical proofs, and
surgical techniques but who lack more elusive qualities
such as respect for the dignity of human, empathy, humil-
ity, and interpersonal skills” [8].
Castanaeda added: “The humanities open to us the
uncertainty that is our common fate as travelers and some-
times help us to better accept the hazard of the journey.
Humanities offer us a vision that transcends our own fate
and, very importantly, teaches us understanding” [8]. Rob-
ert Frost stated that: “Living on the horizons edge, the
growing age of discovery for that is where the beauty that
lurks in danger, defiance, defeat, and victory lies” [21].
As Dr. Hal Urschel pointed out in his Presidential
Address to the STS in 1984 regarding humanism and
surgery, Dr. Churchill separated surgery into four com-
partments, which he called “The Content of Surgery” [7]
(Table 3). Churchill states that: “Humanism is the safe
application of science to human needs” [7].
12. THE COMPLETE CARDIOTHORACIC SURGEON SHOULD DEVELOP A
HOBBY.The complete cardiothoracic surgeon should have
a hobby outside of medicine. He must have something to
PRESIDENTIAL ADDRESS MILLER 7
QUALITIES OF EXCELLENCE
sustain his interest besides the core of medicine; other-
wise, he will become stale and introspective as he be-
comes older. Doctor Richard E. Clark, in his Presidential
Address in 1989 entitled “Who, Hobbies and Heroes,”
points out the necessity of hobbies in our life [4]. He
quotes from Dr. William Osler: “No human is really
happy or safe without a hobby, and it makes precious
little difference what the outside interest might be . . .
anything will do as long as he straddles a hobby and
rides it hard.” He quotes from Sir Isaac Newton: “Young
man, get a hobby; preferably two; one for indoors and
one for out.” Any complete cardiothoracic surgeon needs
some interest outside the field of medicine. It does not
matter the hobby or interest. It may be photography,
literature, or golf, but there is something that each of us
needs: a diversion outside of the laboratory and operat-
ing theater.
13. THE ELEMENT OF FAITH . Regardless of our religious back-
ground, there is something of “faith” that lies embedded
within the inner nature and soul of us all. Jeremiah 6:16
says, “Thus saith the Lord, ”stand ye in the ways, and see,
and ask for the old paths, where is the good way, and
walk therein, and ye shall find rest for your souls.
Certainly, in our times of inner need, we have sought
sustenance and support through faith. In the unique
moments we share with our patients and their families,
faith is there lending strength and instilling hope. There
arises within each individual, whatever his upbringing or
religious background, that element of faith that there is
something higher than we, who walks with us along the
way. As George Crile, Jr. so eloquently stated regarding
the element of faith: “No physician, sleepless and wor-
ried about a patient, can return to the hospital in the
midnight hours without feeling the importance of his
faith. The dim corridor is silent; the doors are closed. At
the end of the corridor in the glow of the desk lamp, the
nurse watches over those who sleep or lie lonely and wait
behind closed doors. No physician entering the hospital
in these quiet hours can help feeling that the medical
institution of which he is part is in essence religious, that
it is built on trust. No physician can fail to be proud that
he is part of his patient’s faith” [22].
I would like to close with two short thoughts. Dr. Floyd
Loop stated that the qualities of the ideal surgeon are
scholarship, leadership, courage, and faith [23]. I would
agree that these are absolutely correct. I would like to
quote from an extremely close friend of mine, Dr. Clem-
ent A. Hiebert, now retired. In one of the most eloquent
addresses ever given in cardiothoracic surgery, Dr.
Hiebert, in his 1988 Presidential Address to the New
England Surgical Society, pointed out the five attributes
of surgery: one, it has a beginning and an end; two, it can
be completed in a number of hours; three, it has an
attribute of stress to overcome; four, it has a focused
activity; and five, it has the quality of “in-chargeness”
[24]. He asked the questions: “Can we achieve fulfill-
ment? Is the grail beyond our reach? Are we fettered
forever by the mundane and the material? Can we
recapture the sense of wonder and worthwhileness in
8 PRESIDENTIAL ADDRESS MILLER
QUALITIES OF EXCELLENCE
surgery?” He stated: “The only true happiness comes
from squandering ourselves for a purpose. The best-kept
secret in surgery is to find fulfillment. You must lose
yourself in something larger than the operative field. It is
then that we can achieve the fulfillment of mind, heart,
and spirit” [24].
In conclusion and as an epilogue to this Fiftieth Pres-
idential Address, I ask myself the question, would I do it
again?
Epilogue
1. I still believe the field of cardiothoracic surgery is a
grand and glorious profession. Surgery is still fun. It
is the staff of life.
2. I think we will continue to attract the best and the
brightest students as long as we educate them in the
Hippocratic saying that “Life is short— but the art is
long.”
3. Osler was correct when he said “Listen to the
salutation of the dawn for such is the staff of life.”
4. Henry Adams stated: “A teacher affects eternity; he
can never tell when his influence stops.”
5. It has been a wonderful journey.
We, as cardiothoracic surgeons, have a unique privilege
—to be caretakers of our fellow human. Let us do so as
doctors, as teachers, as mentors, and above all else, as
men and women who can make this world a better place
in which to live [3].
Ladies and gentlemen, past Presidents, members and
guests, it has been a distinct honor and privilege to serve
as the Fiftieth President of this great association. I thank
you from the bottom of my heart.
I greatly appreciate the technical assistance of Patricia Porth in
the preparation of this manuscript
References
1. Bender HW. Passion, trust, and responsibilities. Ann Thorac
Surg 1991;51:352–6.
Ann Thorac Surg
2004;78:2– 8
2. Hippocratic Oath.
3. Faxon DP. The claim of scientific discovery: the critical role
of the physician-scientist. Circulation 2002;105:1857–60.
4. Clark RE. Who, hobbies, and heroes. Ann Thorac Surg
1990;49:515–21.
5. Halsted WS. The training of the surgeon. Johns Hopkins
Hosp Bull 1904;15:267–75.
6. Murray GF. Thoracic night lights: the residency. Ann Thorac
Surg 1994;57:265–73.
7. Urschel HC Jr. Life is short and the art long, the occasion
instant, the experiment perilous, the decision difficult. Ann
Thorac Surg 1984;38:1–14.
8. Castanaeda AR. The making of a cardiothoracic surgeon: an
Appolonian quest. J Thorac Cardiovasc Surg 1994;108:806 –
12.
9. Cohn LH. What the cardiothoracic surgeon of the twenty-
first century ought to be. J Thorac Cardiovasc Surg 1999;118:
581–7.
10. Morrow AG. What the cardiac surgeon ought to be. Surgery
1972;72:819 –26.
11. Anderson RW. Cardiac surgery in the 21st century. Ann
Thorac Surg 1997;64:1574 –8.
12. Roberts W. Leadership secrets of Attila the Hun. New York:
Warren Books, 1988.
13. Mayo WJ. Inscription on statue of W. J. Mayo. Plummer
Bldg., Rochester, MN.
14. Churchill W. Never give in, The challenging words of
Winston Churchill. Kansas City, MO: Hallmark Publishers,
1967.
15. Lellehei CW. New ideas and their acceptance. J Heart Valve
Dis 1955;4(Suppl 2):106 –14.
16. Cassell J. On control, certititude, and the “paranoia” of
success. Dordrecht, NL: Reidel, 1987:231.
17. Wangensteen OH. Has medical history importance for sur-
geons? Surg Gynecol Obstet 1975;140:434 –42.
18. Majno G. The healing hand: man and sound in the ancient
world. Cambridge, MA: Harvard Univ Press, 1975:235.
19. Wangensteen OH. Has medical history importance for sur-
geons? Surg Gynecol Obst 1975;140:432–42.
20. Cohn LH. Contribution of Thomas Jefferson to American
medicine. Am J Surg 1979;138:286 –92.
21. McGoon DC. A laboratory for progress. J Thorac Cardiovasc
Surg 1984;88:157–63.
22. Crile GC Jr. The way it was. Kent, OH: Kent State Univ Press,
1992.
23. Loop FD. Thoracic and cardiovascular surgery. Presidential
address. J Thoracic Cardiovasc Surg 1998;116:683–8.
24. Hiebert CA. The worthwhileness of a career in surgery. Arch
Surg 1989;124:530 –4.