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The Complete Cardiothoracic Surgeon: Qualities of Excellence
The Complete Cardiothoracic Surgeon: Qualities of Excellence
© 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 PRESIDENTIAL ADDRESS MILLER 3
2004;78:2– 8 QUALITIES OF EXCELLENCE
stated, “I ask you to recall your own personal Mentors residency programs and determining the number of
and how your lives would have been less fulfilling residents at each institution. Depending on its current
without them. I ask you, to whom do the students of status, a program is reviewed at one, three, or five-year
today turn? From whom do they seek wisdom, guidance, intervals. The possible actions of the RRC are as follows:
and insight? Who teaches them patience, perseverance, It can approve a program for a review at three or five
and practice?” [3]. years, or the review may be deferred; it may recommend
As Richard E. Clark in his Presidential Address to the probation or closing a program. The RRC ensures that
Southern Thoracic Surgical Association so eloquently accredited programs provide a resident the appropriately
stated, “As we age singularly and collectively, we have defined educational experience to be a proficient thoracic
forgotten the importance of the hero in our lives. Heroes surgeon.
are our beacons in the downpours and in the fog. Heroes The Thoracic Surgery Directors Association was
enrich us and inspire us to persevere and help us feel founded in 1978. Its purpose is to ensure quality teaching
that our lives are worthwhile” [4]. and an appropriate learning environment. It also main-
Such has been the presence of heroes in my life and tains a list of board requirements and informs program
training. The names Kirkland, Clagett, McGoon, Hatcher, directors of any changes in requirements for certifi-
and Guyton, have already been mentioned but there cation by the American Board of Thoracic Surgery. In
have also been others. Doctor Penfield Favor and Dr. Hal addition, the TSDA is responsible for the thoracic core
Urschel have helped me tremendously along the way. curriculum, the residency-matching program, and resi-
They have been beacons of light and have provided dent education.
mentorship and friendship. For the collegiality and It is the single purpose of each individual governing
friendship of Dr. Peter Pairolero, Dr. William Baumgart- component to prepare individuals to practice cardiotho-
ner, Dr. Timothy Gardner, Dr. Fred Crawford, and Dr. racic surgery in a manner that is safe, effective, and
Douglas Mathisen, I will always be grateful. accomplished without forgetting the human needs of
We as teachers must not only instruct, but also serve as their patients. Having had the opportunity to be a mem-
examples for our residents. In our role as teachers and ber of two of these three governing organizations, the
mentors, we must have thorough knowledge of the American Board of Thoracic Surgery and the Residency
governance of cardiothoracic surgical education. The Review Committee, I can report to you that each strives
governing bodies of cardiothoracic surgical education to perform the function with which it is vested and to
are, The American Board of Thoracic Surgery (ABTS), look after the best interests of the cardiothoracic surgical
The Residency Review Committee for Thoracic Surgery resident. It has been indeed an honor and a privilege for
(RRC), and The Thoracic Surgery Directors Association me to have served as a member of these two boards and
(TSDA). Each of these governing bodies has the resident their committees.
as its central core and theme. The functions of each From Halsted’s establishment of the Pyramidal Resi-
individual component of the governance are as follows: dency System at Johns Hopkins in 1899, as highlighted in
The ABTS is responsible for testing and certification, the the presidential addresses of Drs. Bender and Murray, to
RRC evaluates residency programs for accreditation, and the rectangular system recommended by Churchill at the
the TSDA is responsible for resident instruction, core Massachusetts General Hospital, residency training has
curriculum, and education. Each component is a neces- come a long way [1, 5–7]. Many of you here today went
sary governing body to develop the best thoracic surgery through the Halsted Pyramidal System at Hopkins or
resident possible. Let us now look at each individual Vanderbilt. Churchill was on target when he developed
component. the rectangular system, as it was a fairer test of training
The American Board of Thoracic Surgery was founded and competence [7]. Churchill emphasized that correct
in 1948 and is composed of 17 members with a term of six decisions are derived from good judgment, which is a
years each. Since its predominant purpose is testing and combination of intelligence, knowledge, experience, and
credentialing, the board is responsible for the both the the continuous critical analysis of results [7]. His resi-
oral and written exams, and the recertification exam, dency program was designed as education for uncer-
Self-Education Self-Assessment in Thoracic Surgery, the tainty, with concomitant emphasis on equanimity. John
practice review, and Continuing Medical Education. Its Whiteham described the Churchill residency: “One
17 members are drawn from the various thoracic disci- cannot become aware of alternatives without some abil-
plines. Board certification indicates that individuals have ity to tolerate uncertainty; and we cannot experience
successfully completed an approved education program, good judgment and common sense in reaching well-
and have been evaluated with an exam designed to considered conclusions and wise action unless we can
assess the knowledge, experience, and skills required to tolerate uncertainty with equanimity” [7].
provide high-quality thoracic care. I would now like to turn my attention to qualities that
The purpose of the Residency Review Committee is to I think the complete cardiothoracic surgeon in the second
oversee training programs. It is composed of six mem- millennium will be required to attain. After reading most
bers, including its chairman: two from the American of the cardiothoracic surgery Presidential Addresses for
Board of Thoracic Surgery; two from the American Col- the past 30 years, today I share with you my own
lege of Surgeons; and two from the American Medical thoughts based on 30 years of academic clinical experi-
Association. The RRC is responsible for credentialing ence. Ours is the “Apollonian Quest”, as stated by Aldo
4 PRESIDENTIAL ADDRESS MILLER Ann Thorac Surg
QUALITIES OF EXCELLENCE 2004;78:2– 8
Castanaeda [8]. “Whether or not we can achieve it is by Table 1. Qualities of a Cardiothoracic Surgeon in the Second
the aspects of circumstance, ability, determination, will, Millennium
providence, and being the beneficiaries of our mentors 1. An excellent technical surgeon with good judgment
who have instructed us so well [8].” 2. A detailed knowledge of cardiorespiratory physiology
The title of my address, “The Complete Cardiothoracic 3. An excellent teacher and have knowledge of cardiothoracic
Surgeon: Qualities of Excellence” will ring a familiar bell surgical education
to those who are students of surgical history. A variation 4. An excellent radiologist
of this theme has been used three times before. As noted 5. Have knowledge of health care economics
by Dr. Lawrence Cohn: In the Fourteenth century, the 6. Have knowledge of new surgical technology
French surgeon Guy de Chauliac wrote, “What the Sur- 7. A leader
geon Ought to Be” [9]. In 1972, Dr. Andrew Morrow 8. Be adaptable
presented “What the Cardiac Surgeon Ought to Be” [10]. 9. Have historical knowledge of the specialty
In 1999, Dr. Lawrence Cohn presented “What the Car- 10. Have a quality of persistence
diothoracic Surgeon of the 21st Century Ought to Be” [9]. 11. Should be a humanist
Using this as a paradigm, I give credit to Dr. Larry Cohn 12. Should have a hobby
for his original ideas on this topic. I have taken the 13. Should have a faith
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 surgery data bank and to the newly formed congenital
in the field of cardiothoracic surgery and teachers of the and thoracic surgery databases.
future generations of cardiothoracic surgical residents, Academic cardiothoracic surgeons are expected to
should strive to attain these qualities. demonstrate excellence in not only outcome results but
In 1790, Guy De Chauliac said the traits of a surgeon also the ability to train residents in an effective reproduc-
are that he should be learned, he should be expert, and ible technique. When I was at the Mayo Clinic in the
1960s, Dr. Dwight McGoon stated that there are 122 steps
he should be ingenious and adaptable [9]. In 1972, in his
in an aortic valve replacement from skin incision to skin
Presidential Address to the American College of Vascular
closure: “Write those down, learn them, and you will do
Surgeons, Dr. Andrew Morrow said a cardiac surgeon
well.”” Over the course of my six months with Dr.
ought to be a physiologist, a cardiologist, an investigator,
McGoon, I attempted to get them all down one-by-one in
a skeptic, an expert surgeon, a competent surgeon, an
a small spiral notebook. Ultimately, at the completion of
anatomist, have a hobby, and have a sense of business.
my rotation, he was willing to sit down and go through
In his 1999 Presidential Address presented to the
those steps with me. We should train residents in an
American Association of Thoracic Surgeons, Dr. Larry
effective reproducible technique, and the order in which
Cohn listed a number of qualities that the cardiothoracic
we conduct a particular operation should be essentially
surgeon of the 21st Century should strive to attain [9]. He
the same in all cases. If our residents learn a standardized
stated that they should include the following: (1) an technique to approach a specific procedure, then they
excellent surgeon; (2) a physiologist; (3) an excellent can learn the exceptions to the rule and do well. Equally
teacher; (4) knowledge of health care economics; (5) important to the technical performance of the procedure
versed in digital technology; (6) knowledge of new sur- is the judgment used in determining the type of opera-
gical technology; (7) a leader; (8) adaptable; (9) be persis- tion to be done. It is my feeling that there is no substitute
tent; (10) sense of history of the specialty, and (11) a for excellent judgment. As long as one has excellent
humanist. judgment, the hands will follow and technical excellence
With Dr. Cohn’s permission, I have expounded on his will be achieved. As a part of judgment, we must know
ideas and added my own personal thoughts to his list. our own capabilities and how to measure our results.
The qualities of a complete cardiothoracic surgeon in the We need to know not only our own ability to achieve a
second millennium are as listed in Table 1. given technical result, but also our limitations, and we
must never fail to ask for help in those cases in which we
Qualities of the Complete Cardiothoracic Surgeon feel that someone could help us improve the outcome for
1. THE FIRST QUALITY OF A COMPLETE CARDIOTHORACIC SURGEON our patient. Above all else, we must have absolute
IS THAT OF BEING AN EXCELLENT SURGEON. There is no substi- integrity and honesty in the operating room both with
tute for technical excellence. Ultimately our ability as ourselves and with our residents. William Shakespeare
surgeons will be determined by how effectively we per- said in Hamlet: “To thine own self be true, then thou
form surgical procedures as measured by the standard of cannot be false to any human.” As a trainee of cardio-
our fellow cardiothoracic surgeons, our professional col- thoracic residents, the manner that the senior surgeon
leagues, and our trainees. In whatever our work environ- displays in selecting patients for operation and his con-
ment, be it in the private sector or academic sector, we as duct of the operative procedure itself are the all-
practitioners of the highest art must be the best technical important tools in the training of young, future cardio-
surgeons that we can be and assure that our trainees thoracic surgeons.
develop to be the best that they can be. Additionally, our Andrew Morrow pointed out in his Presidential
results will be compared to the data in the cardiothoracic Address that the attributes of an expert surgeon include
Ann Thorac Surg PRESIDENTIAL ADDRESS MILLER 5
2004;78:2– 8 QUALITIES OF EXCELLENCE
the wisdom of selecting patients for surgery and the Table 2. Issues in Healthcare Economics
conduct of the operative procedure [10]. Morrow stated:
1. There is more competition for market share
“A surgeon and only the surgeon should make the all
2. There are more sophisticated and experienced purchases of
important final decision as to whether a patient is a service
candidate for an operation and, if so, what procedure is 3. There is greater emphasis on cost and service
the most appropriate.” He reminded us of one of the 4. There is overcapacity in facilities and personnel
most poignant statements of Blalock, “The fact that a 5. There are changes in the method of providing service,
patient is going to die does not necessarily mean that he marketing, pricing, and research
should be operated upon” [10]. Judgment is almost as 6. There are falling profits
important as the technical ability to carry out the proce- 7. Probably equally important, there is a decrease in
dure itself. subsidization of all areas of cardiothoracic surgery
robotics, lasers and photo chemicals, transplantation im- [9]. As Friar Roger Bacon stated in his Opus Magnus of the
munology, gene therapy, molecular markers, oncologic 13th century: “The four stumbling blocks to grasping the
principles, and the new and emerging field of digital truth are: one, the pattern set by our elders; two, longstand-
technology and how it impacts all of cardiothoracic ing custom; three, the popular belief, therefore it should be
surgery. Robotic surgery is now becoming a mainstay in held; and four, the hiding of our own ignorance by making
several institutions in our country, and the utilization of a display of our apparent knowledge. Every human is
robotics in the performance of minimally invasive proce- involved in these things in every walk of life, in every
dures is crossing all aspects of our field from minimally occupation, and they arrive at the same conclusions by their
invasive valve replacement to total robotic valve replace- worst arguments” [15].
ment and to the performance of minimally invasive As J. Cassell in 1987 pointed out, “Surgeons are rarely
thoracic procedures as well. In addition, the ability to allowed the luxury of second thoughts. At the operating
destroy certain tumors by photodynamic therapy with table, the surgeon must manifest decisiveness, certitude,
laser ablation is now practiced in many medical centers. control; emergencies must be resolved, unexpected find-
The future with gene therapy, both in cardiac disease and ings anticipated, and the advantages exploited” [16].
oncologic therapy for lung cancer, is in the forefront of
many laboratory investigations. Emerging digital tech- 9. THE COMPLETE CARDIOTHORACIC SURGEON MUST HAVE A
nology is affecting all of medicine, and one has to learn KNOWLEDGE OF THE HISTORY OF CARDIOTHORACIC SURGERY.
this in-depth knowledge or be left behind. Wangensteen stated that: “If all problems in medicine
could be taught with special emphasis on a historical
7. THE COMPLETE CARDIOTHORACIC SURGEON OF THE SECOND MIL- approach, every physician would be better prepared to
LENNIUM MUST BE A LEADER. The complete cardiothoracic cope with future problems” [17]. Celsius stated in the 4th
surgeon must be a leader in the local healthcare environ- century that there are three ways to treat a patient: “Diet,
ment; he must be a leader in the training of residents; he medicine, and surgery, but only surgery works” [18].
should strive to be a leader in national specialty organi- Wangensteen further stated in 1975, “May the spirit of
zations; in essence, he becomes a renaissance human or inquiry, the love of learning, and appreciation of the
Thomas Moore’s “A human for all seasons.” He is an History of Medicine create in our medical schools an
individual that others will want to emulate. Leadership intellectual atmosphere that will heighten greater medi-
involves taking responsibility to direct the action of cine’s commitment and accountability in its service to
others and taking responsibility and accountability for humanity” [19]. Wangensteen stated in his address con-
both successes and failures. In his excellent book, Lead- cerning the education of surgeons in 1940: “The past
ership Secrets of Attila the Hun, Wes Roberts points out that never returns, but the character of the future can be
“You must have a passion to succeed, a passion that determined in part by what is done in the present” [19].
drives you to prepare yourself and your colleagues to Thomas Jefferson, in stating the qualities of the ideal
excel. By their actions, not words, do leaders establish the physician said that we as physicians should be inquisi-
morale and integrity of their subordinates, and by the tive; we should have a concern for people; we should be
ability to make timely and difficult decisions” [12]. He intelligent; and we should believe in the scientific
points out that “Leadership Effectiveness ⫽ Results ⫻ method [20]. A thorough knowledge of the history of the
Personal Qualities.” [12]. Kouzes and Posner stated, “The specialty and of individual disease processes will make
first milestone on a journey to leadership credibility is the complete cardiothoracic surgeon a better teacher,
clarity of personal values” [12]. Dr. William J. Mayo said, give him or her a greater understanding of the condition,
“Integrity is the basis of trust. Trust is a bonding of and enable him or her to take advantage of previous
caring, and when the prognosis for trust is poor, the research.
chances for a good outcome diminish. Trust and caring
are almost synonymous” [13]. Now, more than ever, we 10. THE COMPLETE CARDIOTHORACIC SURGEON SHOULD DEVELOP,
must use our leadership ability and skills to broaden our TO THE BEST OF HIS ABILITY, THE QUALITY OF BEING PERSISTENT-
scope and think in terms of healthcare problems at both . Persistence is perhaps the most important personal
the local and national levels. quality that a complete cardiothoracic surgeon can de-
In summary, Winston Churchill, in 1951, said of the velop. It is often the key to a successful outcome. As Cohn
ability to lead: “I can practice in an honorary fashion the pointed out, many times we have experienced success in
arts of surgery and medicine . . . being temperamentally a very difficult operation by simply adhering to our game
inclined to precision and a sharp edge, it might be plan in the operating room, no matter what the obstacles
thought that I should choose the surgeon’s role” [14]. [9]. Gustav Mahler stated: “For success, nothing in the
world can take the place of persistence; talent alone will
8. THE COMPLETE CARDIOTHORACIC SURGEON MUST BE ADAPT- not be successful because nothing is more common than
ABLE. The complete cardiothoracic surgeon must be adapt- the unsuccessful human with talent. Education alone will
able to change. He must consider new ideas and he should not be successful because the world is full of educated
never fail to keep an open mind. Larry Cohn stated: “The fools. Persistence and determination are alone omnipo-
most successful thoracic surgeons are, by their very nature, tent” [15]. “It is the ability to keep on going and trying
adaptable because they deal with new predicaments every through the valleys in the late night hour in the operating
day in the operating room, in the ward, and in the clinic” room when success often comes and a successful out-
Ann Thorac Surg PRESIDENTIAL ADDRESS MILLER 7
2004;78:2– 8 QUALITIES OF EXCELLENCE
Table 3. Humanism and Surgery sustain his interest besides the core of medicine; other-
wise, he will become stale and introspective as he be-
Content of Surgery (4 Compartments):
comes older. Doctor Richard E. Clark, in his Presidential
1. Technology ⫽ handicraft
Address in 1989 entitled “Who, Hobbies and Heroes,”
2. Humanism ⫽ safe application of science to human needs
points out the necessity of hobbies in our life [4]. He
3. Science ⫽ observation and experimentation
quotes from Dr. William Osler: “No human is really
4. Empiricism ⫽ common sense
happy or safe without a hobby, and it makes precious
Churchill [7]. little difference what the outside interest might be . . .
anything will do as long as he straddles a hobby and
come for the patient results” [9]. For the surgeon who is rides it hard.” He quotes from Sir Isaac Newton: “Young
persistent and has expert knowledge and technique, man, get a hobby; preferably two; one for indoors and
rarely is there an adverse outcome. one for out.” Any complete cardiothoracic surgeon needs
some interest outside the field of medicine. It does not
11. THE COMPLETE CARDIOTHORACIC SURGEON MUST ALSO BE A matter the hobby or interest. It may be photography,
HUMANIST. Dwight McGoon, in his Presidential Address literature, or golf, but there is something that each of us
to the AATS in 1984 said: “All efforts in research, educa- needs: a diversion outside of the laboratory and operat-
tion, administration, writing, editing, and long hours of ing theater.
intensive labor at the operating table have inherent and
13. THE ELEMENT OF FAITH . Regardless of our religious back-
transcendent value only in one respect . . . as an unselfish
expression by skilled and dedicated surgeons of a concern ground, there is something of “faith” that lies embedded
for the welfare of needful human beings” [21]. We must within the inner nature and soul of us all. Jeremiah 6:16
remember that our patients are our primary concern and it says, “Thus saith the Lord, ”stand ye in the ways, and see,
is for them we have dedicated the long years of training. We and ask for the old paths, where is the good way, and
must never lose our compassion for the patient. As Aldo walk therein, and ye shall find rest for your souls.
Castanaeda stated in his Presidential Address: “Our spe- Certainly, in our times of inner need, we have sought
cialty is not merely an applied science and technical disci- sustenance and support through faith. In the unique
pline, it also involves an important aesthetic component, moments we share with our patients and their families,
juxtaposing art and science, and demanding, in addition, faith is there lending strength and instilling hope. There
honesty, courage, judgment, vision, compassion, and a arises within each individual, whatever his upbringing or
commitment to the pursuit of excellence“ [8]. He points out religious background, that element of faith that there is
that: “there is an unresolved paradox in which we often find something higher than we, who walks with us along the
ourselves: Our Hippocratic obligation to immerse ourselves way. As George Crile, Jr. so eloquently stated regarding
in, and at the same time, the need to distance ourselves the element of faith: “No physician, sleepless and wor-
emotionally from the struggle of human survival.” “The ried about a patient, can return to the hospital in the
privilege to participate in preserving and improving life midnight hours without feeling the importance of his
provides us with our purest professional satisfaction” [8]. faith. The dim corridor is silent; the doors are closed. At
He further states: “There is a widening gap between science the end of the corridor in the glow of the desk lamp, the
and the humanities. Often we find well-trained profession- nurse watches over those who sleep or lie lonely and wait
als who have mastered scientific facts, statistical proofs, and behind closed doors. No physician entering the hospital
surgical techniques but who lack more elusive qualities in these quiet hours can help feeling that the medical
such as respect for the dignity of human, empathy, humil- institution of which he is part is in essence religious, that
ity, and interpersonal skills” [8]. it is built on trust. No physician can fail to be proud that
Castanaeda added: “The humanities open to us the he is part of his patient’s faith” [22].
uncertainty that is our common fate as travelers and some- I would like to close with two short thoughts. Dr. Floyd
times help us to better accept the hazard of the journey. Loop stated that the qualities of the ideal surgeon are
Humanities offer us a vision that transcends our own fate scholarship, leadership, courage, and faith [23]. I would
and, very importantly, teaches us understanding” [8]. Rob- agree that these are absolutely correct. I would like to
ert Frost stated that: “Living on the horizons edge, the quote from an extremely close friend of mine, Dr. Clem-
growing age of discovery for that is where the beauty that ent A. Hiebert, now retired. In one of the most eloquent
lurks in danger, defiance, defeat, and victory lies” [21]. addresses ever given in cardiothoracic surgery, Dr.
As Dr. Hal Urschel pointed out in his Presidential Hiebert, in his 1988 Presidential Address to the New
Address to the STS in 1984 regarding humanism and England Surgical Society, pointed out the five attributes
surgery, Dr. Churchill separated surgery into four com- of surgery: one, it has a beginning and an end; two, it can
partments, which he called “The Content of Surgery” [7] be completed in a number of hours; three, it has an
(Table 3). Churchill states that: “Humanism is the safe attribute of stress to overcome; four, it has a focused
application of science to human needs” [7]. activity; and five, it has the quality of “in-chargeness”
[24]. He asked the questions: “Can we achieve fulfill-
12. THE COMPLETE CARDIOTHORACIC SURGEON SHOULD DEVELOP A ment? Is the grail beyond our reach? Are we fettered
HOBBY.The complete cardiothoracic surgeon should have forever by the mundane and the material? Can we
a hobby outside of medicine. He must have something to recapture the sense of wonder and worthwhileness in
8 PRESIDENTIAL ADDRESS MILLER Ann Thorac Surg
QUALITIES OF EXCELLENCE 2004;78:2– 8