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Ann Thorac Surg 2001;71:S14-S18
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, University of Texas Southwestern Medical School, Baylor University Medical Center, Dallas, Texas, USA
Address reprint requests to Dr Urschel, 3600 Gaston Ave, Suite 1201, Dallas, TX 75246
e-mail: urschell{at}airmail.net
Presented at the Women in Thoracic Surgery Symposium, Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31, 2000.
Why are we here? Because of the:
Joy of surgery
The magic stuff
The grail that once moved every doctor in this room
To become a surgeon
Even now beckons through the jading mist
Of tedium and time—
Strip away the corrupting dullness
Look fresh at the most splendiferous
Of all professions
Clement A. Hiebert, MD
Presidential Address to the New England Surgical Society
What is wrong with this picture (Fig 1)? Here is one female General Thoracic Surgeon amidst "murderers’ row." Leslie Kohman, MD, founder of the Women in Thoracic Surgery in 1986, was the first woman elected to the Residency Review Committee for Thoracic Surgery. A similar situation existed on the American Board of Thoracic Surgery when Carolyn E. Reed, MD, became the first woman elected to the Board. These landmark firsts usher in an era that is long overdue and I think genuinely appreciated by all members of the Thoracic Surgical "Guild," as well as our patients.
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Florence Nightingale in the Crimea, and subsequently Great Britain, established a school of nursing, a monumental step, which for years has contributed significantly, in partnership with thoracic surgeons, to medical advances and the care of patients [7]. Although American medical schools were slow to accept women, Johns Hopkins ironically admitted women into its medical school in 1893, almost 80 years before the first woman was to enter their undergraduate university in 1970. Gertrude Stein studied in the School of Medicine at Johns Hopkins from 1897 to 1901 and made significant literary contributions to the role of women in medicine and surgery [8]. Interestingly enough, Harvard Medical School voted to accept women in 1901 but did not take their first female student until 1946 [9].
In the 1930s, a common operation at the Massachusetts General Hospital, after a massive pulmonary embolus, was the Trendelenberg operation. The intern would sit with the patient in the operating room until the blood pressure fell to 0, then they would "split the sternum" and try and remove the pulmonary artery clot. None of the procedures was successful but they provoked John Gibbon, MD, under the direction of Drs Churchill, Linton, and Cope in the laboratory, to develop a heart-lung machine "for support" while the pulmonary blood clot could be removed. A young female PhD assisted Dr Gibbon in the endeavor (Fig 2). She eventually married him and became the first perfusionist operating the heart-lung machine for the first successful open-heart surgery (Fig 3). The first heart-lung machine was developed at the Rockefeller Institute in 1930 by Alexis Carrel and Charles Lindbergh, but it could not be used clinically because heparin was not available until Gordon Murray’s discovery in 1940.
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Carolyn E. Reed, MD, has beautifully chronicled women’s contributions to general thoracic surgery for the postgraduate course at this meeting. Rather than review her presentation in detail, which will be published, I would like to discuss several observations that illustrate women General Thoracic Surgeons’ capabilities, qualities, and frustrations, bringing them to this long overdue opportunity. Their endeavors have been somewhat like Sisyphus rolling the stone uphill day after day.
The Helen Taussig story about conceiving and motivating the creation of a systemic-to-pulmonary shunt for cyanotic infants is well known. However, the rejection of her idea by Robert Gross is not. Doctor Taussig told the following story:
In the mid-1930s, I first realized that an infant with pulmonary atresia died as the ductus underwent obliteration and that cyanotic infants with severe pulmonary stenosis became markedly worse as the ductus closed off. This observation led me to believe that keeping the ductus arteriosus open would help these infants. My first research efforts were directed toward preventing the normal obliteration of the ductus. I had not progressed very far with this problem when Dr Robert Gross showed that in a patient with persistent patency of the ductus arteriosus it was possible surgically to ligate the ductus and restore the circulation to normal. Not being a surgeon, the thought immediately occurred to me that if it were possible to ligate a ductus, it should be possible to build a ductus.
In 1939, I visited Dr Gross. He had told the story of our interview to many interns; therefore I feel free to tell it here. I asked him if he could build a ductus. He replied he has built many ductuses. When I quietly said I thought it would be a great help to a cyanotic child, he was not in the least interested. So, I returned to Baltimore to wait for a more propitious time.
Helen Taussig, 1975
2nd Henry Ford Hospital
International Symposium on Cardiac Surgery
On our way to place the first American woman on the summit of Mount Everest in 1987 with Dick Bass, our expedition stopped at the highest hospital in the world at Kunda, Nepal. It was run by a female Thoracic Surgeon from New Zealand who was caring for 15 teenagers with tuberculosis empyema (Fig 4).
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Bernadine Healy is a hero of mine (Fig 5). Her insight, extreme intelligence, vision, and clarity of expression has provided leadership not only for women, but for men, too. As one of the few female Presidents of the American Heart Association and the first female Director of the National Institutes of Health, she has instigated initiatives in all aspects of women’s health, directing more than a billion dollars into the previously inadequate research for these problems. She was the Dean of Ohio State’s Medical School and is now the Director of the American Red Cross.
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Attributes of a Great Surgeon:
Maturity in judgement
Dexterity of hand
Devotion in teaching
Serenity in crisis.
Sir Richard Sweet
Ashley Montague, since the late 1940s, had carefully documented the natural superiority of women [11]. Recently, just before his death, he uncovered even further anthropological and medical data supporting without question, the strength, power, and durability of females when compared with males. His course at Princeton University entitled "Human Nature" is legend, and included the special qualities common to the female species and critical to medicine and thoracic surgery.
I think when any of us, particularly women, elect a life in thoracic surgery, we must be aware of Hippocrates’ admonition:
Life is short
And the art long
The occasion instant
Experiment perilous
Decision difficult.
Our first female Resident in Dallas, Lorraine Rubis, was the ninth woman to receive Thoracic Board Certification in 1979 (Fig 6). Lorraine’s upbeat attitude, constant enthusiasm, indefatigability, superb surgical judgment, and technical skill represented the "standard" for an excellent resident. Her talent for writing music and playing the piano, as well as her strength of commitment and persistence, presented a formidable obstacle for the "redneck Texas male." One time after a difficult case, she and I went to the Dallas Petroleum Club in our scrub suits and coats for lunch. As we were reading the menu the maitre d’ informed me that women were not allowed to eat at the Petroleum Club. Since I did not think of Lorraine particularly as female or different from any other good surgeon, we made a short but successful stand and completed our meal—establishing another "Rubis first." A Rubis-like statement might echo William Lloyd Garrison:
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I will not equivocate—
I will not excuse
I will not retreat a single inch;
And I will be heard!
The struggle of women in the field of thoracic surgery reminds me of the motto and book title, Quest for the Best, of my long time friend and traveling colleague, Stanley Marcus, founder of the Nieman Marcus department store, Phi Beta Kappa, and member of the Board of Overseers at Harvard University. Our lives should be a constant search for excellence in all we do [12–14].
Surgery is the most martial and masculine of medical specialties. The combat with death is carried out in the operating room, where the intrepid surgeon challenges the forces of destruction and disease. What, then, if the surgeon is a woman?
Joan Cassell [15]
The Woman in the Surgeon’s Body
Interestingly, Alexis De Tocqueville, after travelling throughout America in 1840 and describing democracy, commented: "If I were asked ... to what the singular property the growing strength of America ought mainly to be attributed, I should reply: To the superiority of their women."
Swanee Hunt, the daughter of H.L. Hunt, the "Billionaire" oilman from Dallas, was recently appointed the Director of the Women & Public Policy at the John F. Kennedy School of Government at Harvard University. While she was Ambassador to Austria, the outstanding female leaders (including surgeons, lawyers, and teachers) from Bosnia asked for her assistance in reaching a peaceful settlement in their country where the men have fought for more than a thousand years without compunction. Swanee, with these women, was a primary force in resolving a peaceful settlement in Bosnia. Her staff spoke to the spouses’ postgraduate program at The Society for Thoracic Surgeons Annual Meeting 2000, recounting the "Women Waging Peace" policy initiative. They defined 62 conflicts, chose 10 of the more severe conflicts, and selected 5 women from each side of those 10 conflicts. These women were brought to the John F. Kennedy School of Government at Harvard University for a period of discussion and further development of conflict resolution skills. The effort was extremely successful. In addition, the Women & Public Policy Program addresses the 30 million women per year that are currently "trafficked sexually" in the world, representing another challenge.
These initiatives emphasize the comment by Matthew Arnold:
If ever the world sees a time when women shall come together, purely and simply for the benefit and good of mankind, it will be a power such as the world has never known.
There are men and classes of men that stand above the common herd—the soldiers, the sailors, the shepherd, not infrequently, the artist rarely, rarer still the clergyman. The physician almost as a rule, he or she is the flower, such as it is, of our civilization and when this stage of man is done with, and only to be marveled at in history, he or she will be thought to have shared as little as any to the defects of the period and most notably established the virtues of the race.
Robert Louis Stevenson
I think the time has come that we move from The Woman in the Surgeon’s Body [15] where the female surgeon finally realized what it was about the way the male surgeons treated her ...
"They’d worked it out," she said, describing the men’s attitude toward women surgeons. "Either you’re not a woman—you’re a bear, a dog, or a lesbian. Or you’re not a surgeon—you’re no good."
Joan Cassell [15]
The Woman in the Surgeon’s Body
Another outstanding female surgeon, when asked about her female surgical role models, said she had none [16–19]. She said she learned good technical surgery first and academic research later, and thrived on male role models. She emphasized the importance of surgical technique and of academic "generosity." She chose surgery because it not only provided maximal intellectual stimulation as does internal medicine, but also allowed for active intervention—thus providing the broadest of all medical specialties [20–23].
Karen Guice, MD, has said that female surgeons need more than one mentor in surgery. One might advise for career, most likely a male. Another could mentor for "personal things," such as talking about how it is different being a woman in a male-dominated specialty. A third might be necessary for help in an academic-research career.
Changing the old order to include female thoracic surgeons requires a multiphased, aggressive intervention:
If no one lifts a finger or no one cares
Things change,
The human body grows older
Machines grow rusty
Friendships fall apart,
Foundations begin to settle
Left unattended, the dynamic of change is decline.
The trick is to convert change into a positive force
And that takes action.
Henry Cisneros
Every good and excellent thing stands moment to moment on the razor’s edge of danger and must be fought for.
Ross Perot
Pat McCormick made her reputation as the first "true" female General Thoracic Surgeon, providing an aggressive approach to pulmonary metastases and chest wall reconstruction at Memorial Sloan Kettering. Valerie Rush replaced her there and also serves as Deputy Director of the American College of Surgeons Clinical Oncology Trials. Doctor Robert Ginsberg at Memorial Sloan Kettering Cancer Center is the only Thoracic Division Director who has always had two female General Thoracic Surgeons on his staff.
Manliness, manhood, manly courage ...there was something ancient, primordial, irresistible about the challenge of this stuff, no matter what a sophisticated and rational age one might think he lived in ... A surgeon soon found he wanted to associate only with other surgeons. Who else could understand the nature of the little proposition (death) they were all dealing with?
Tom Wolfe [24]
The Right Stuff
This is as true for surgeons as it is for fighter pilots. I think we are past that and are being availed with a greater number of skilled female surgeons. In Russia it is commonplace—in America it soon will be. One of the best technical surgeons I have observed is a woman [25, 26].
Only a few of the many significant contributions to the evolution of female excellence in thoracic surgery have been discussed here today. The struggle at times seems like war. Appropriately, we should recall General Douglas MacArthur’s admonition as to the cause of failure in war. The history of failure in war can be summed up in two words: "too late."
Too late in comprehending the deadly purpose of a potential enemy;
Too late in realizing the mortal danger;
Too late in preparedness;
Too late in uniting all possible forces for resistance;
Too late in standing with one’s friends.
General Douglas MacArthur
Our days are filled with the piteous procession of women and men, begging of us clarity, for leave to be allowed to live a little longer, upon whatever terms.
The special qualities innate in women will provide the fields of medicine and thoracic surgery skill, sensitivity, caring, strength, commitment, and perseverance. These are the qualities that thoracic surgery, and indeed all of medicine, needs most.
In the struggle for balance, equality, and excellence in the care of our patients, let us not forget ...
Isn’t it strange
That princes and kings
And clowns that caper
In sawdust rings
And common people
Like you and me
Are builders for eternity?
Each is given a bag of tools
A shapeless man
A book of rules
And each must make—
Ere life has flown—
A stumbling block
Or a stepping stone.
R.L. Sharpe
References
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