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Ann Thorac Surg 2003;75:1366-1371
© 2003 The Society of Thoracic Surgeons

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Presidential address

A partnership in courage

^a Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, Chicago, Illinois, USA
^b Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

^* Address reprint requests to Dr Mavroudis, Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, M/C #22, 2300 Children’s Plaza, Chicago, IL 60614-3394, USA.
e-mail: cmavroudis{at}childrensmemorial.org

Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.

	Introduction

Top Introduction Courage as a virtue Interrelated courage Self-evaluation, peer review,... Acknowledgments References

 
In these days of fast travel and changing venues it is no surprise that a kid born in Greece and raised in Jersey City would grow up to live in Chicago and become President of the Southern Thoracic Surgical Association. Such developments are, of course, not new. Past Presidents Kit Arom and Francis Robicsek are excellent examples of our meritocracy and melting pot philosophy. A choice, not a birthright, has brought us all together; and it was a choice, not an obligation, to build on the founding principles of this Association. If we have had fun along the way, so much the better. I only hope that I have given as much to this Association as I have received.

It is my great fortune and privilege to have been chosen to serve as President of the Southern Thoracic Surgical Association (STSA). I have always treasured my now 19-year membership in the STSA and the warm friendships that have been fostered over the years. Ours is a special organization that nurtures and promotes its younger members, honors its seniors, and creates a unique atmosphere of camaraderie and mutual respect. To be President of this Association is my greatest professional honor—one that I will always cherish as a gift from my esteemed colleagues.

	Courage as a virtue

Top Introduction Courage as a virtue Interrelated courage Self-evaluation, peer review,... Acknowledgments References

 
The subject of my talk is courage. One definition of courage is an individual’s selfless pursuit of a moral good while risking personal harm, injury, or death. We know of various forms of courage, which have many modifying adjectives and synonyms. Adjectives have included intellectual, moral, corporeal, steadfast, intrepid, heroic, and extraordinary; synonyms have included fortitude, daring, bravery, and valor, among others. Physicians have been known to display many forms of courage by virtue of their basic human behavior, intellectual fortitude, and resolve while taking care of their patients. Physicians who performed pioneering operations, female physicians who prevailed despite institutional and personal barriers, and physicians who care for patients with infectious diseases are all exemplars of courage.

Courage has been regarded as a key element of the virtuous life since the time of the ancients [1]. Plato believed that the cardinal virtues of prudence, temperance, and courage work together to produce justice. For Plato, the unity of virtues means that the good or moral person exhibits all the virtues. In the Republic, Plato describes the good city and by analogy, the good person. The good person would endure through whatever hardships necessary in order to achieve justice. This is the virtue of courage. Plato’s view of courage drew heavily on a military understanding and his commentaries suggest that courage could exist in otherwise evil persons. However, for Plato true courage was tempered by reason; rash and bestial acts, especially if undertaken in the heat of the moment, were not courageous [2].

Aristotle [3] did not believe that courage could be found in an evil person. Unlike Plato, Aristotle thought that courage was the premier virtue from which all other virtues sprang. Feelings such as anger, fear, or envy are innate in human nature and have no moral characteristics. They simply are. Virtues are moral qualities that can be acquired from the person’s trained response to feelings. Aristotle states, "What is trained is something which, by being changed repeatedly in a certain way by guidance which is not innate, is eventually capable of acting that way." For Aristotle, the individual who is trained to act courageously will also choose a virtuous life in all respects. All the virtues required control of extreme feelings. Courage was the mean between rashness and cowardice and was a temperate and reasoned response. Courage was a voluntary act because it required choosing how to act; "the coward, the rash man and the brave man are concerned with the same object[s] but act differently toward them." The main qualities of courage were the overcoming of fear and the ability to endure. "When one forgets their fear and acts on their timing and endures the suffering they are courageous ... a courageous human forgets his pain, personal comfort, and endures for a better end."

Loewy [4], who examines the concepts of fear, duty, and courage in a medical setting, pointed out that fear does not always oppose duty. Fear of censure, of losing prestige, and of losing one’s own self-esteem may be powerful forces propelling one toward action. The intern wakes up in the middle of the night to care for a patient not just because he or she ought to get up, but also for fear of what will happen if he or she does not get up. It may, in fact, take more courage to stay in bed than to get up and see the patient!

Galen, personal physician to Marcus Aurelius, is reputed to have fled from the plague in Rome in 180 AD despite the anger of his emperor [5]. Galen found it necessary to give an elaborate series of excuses explaining his failure to return, and historians today still argue whether his behavior was defensible. Eighteen hundred years is a long time to bear a charge of cowardice; he might have done better to return to Rome! The physician, after all, does not desert his patient; to deserve honor, the physician must act honorably.

Even so, limits and guidelines differentiate self-confidence from self-righteousness, calculated risk from foolhardiness, and morality from immorality when the result of the action will never be found out. Let me provide some examples of these distinctions. A surgeon can take a risk for a patient if he or she has scientific evidence that might lead to a successful outcome (self-confidence), but should not take the risk if the only basis for action is bravado (self-righteousness). The lifeguard will willingly jump into a stormy ocean to rescue a drowning person knowing that the chances of success are better than even (calculated risk), but may not jump in if a surface oil-slick fire will surely prove fatal (foolhardiness). An attacking marine will take a prisoner of war when not in the best interests of the mission (morality) instead of killing the surrendered in the guise of self-defense to pursue the mission more effectively (immorality). As with most judgments of human nature, gray areas exist that warrant definitions, assessment of circumstances, and weighing of options.

	Interrelated courage

Top Introduction Courage as a virtue Interrelated courage Self-evaluation, peer review,... Acknowledgments References

 
The type of courage that I want to address is that courage that exists between the surgeon, a patient, and the patient’s family; I call this interrelated courage. This is the type of courage that drives surgeons to perform new and avant garde operations and the kind of courage that patients exhibit when they agree to the risks of the new technology, new techniques, and new medications.

I have been haunted by this concept of interrelated courage since I began running with my pump technician, John Keller, at the University of Louisville in 1981. John is a wounded decorated marine veteran from the Vietnam War. We talked about courage and the types of feelings that drive people to risk their person, reputation, and vision in the face of a sea of adversity to achieve a noble cause, a new treatment, or a virtuous principal. Much has been written about this metaphysical concept. For my part, I always felt comfortable running with John. Our conversations were easy. I had the belief and confidence that he would stand with me and I with him had we encountered any problems. I thought then, did I engender the same response from my patients? Did they have the same confidence and trust in me that I had in John?

These thoughts led to an interesting academic journey that documented the deeds of four Navy surgeons, each of whom removed a live, embedded, highly explosive device from the body of a wounded soldier during the Vietnam War. For this display of intellectual and corporeal courage, they were awarded the Navy Cross for extraordinary heroism [6].

Figure 1 is a roentgenogram of a live unexploded mortar shell that pierced the shoulder of South Vietnamese Army Regular PFC Nguyen Van Luong, and became embedded along his chest wall with the firing pin millimeters away from his iliac crest. In a calculated and intrepid feat of courage, US Navy Captain Harry H. Dinsmore performed the extraction operation by removing the live mortar shell with the assistance of Petty Officer John Lyons, who instructed Dr Dinsmore in how to handle the firing pin. As Chief of Surgery of the Da Nang Naval Hospital with the First Marine Division, Dinsmore could have assigned the operation to another surgeon but, "It’s a job you can’t give to anybody else," he said [6].

View larger version (119K): [in this window] [in a new window]   Fig 1. A roentgenogram of a live unexploded mortar shell that pierced the shoulder of a South Vietnamese Army Regular PFC Nguyen Van Luong. (Life, October 14, 1966, pp 89A–100.)

Lieutenant James Back, US Navy Medical Corps, attended to many South Vietnamese children during his tour of duty. My wife Martha and I visited Lexington, Kentucky, the home of his surviving mother, Mrs Rose Back, who told us his chilling story. Back was awarded the Navy Cross for removing an undetonated highly explosive fuse of a B-40 rocket from a wounded marine. He died 6 years later due to abdominal carcinomatosis, presumably as a result of exposure to the defoliant, Agent Orange, which was used in Vietnam at the time.

Figure 2 is a roentgenogram of a live, undetonated grenade embedded in a wounded marine that Lt Commander David H. Lewis encountered during his duty call. He had 4 days left before his tour of duty was over and he could go home to his wife and two children. His commanding officer, Captain Jim Lay, informed Lewis that he would assign the case to another surgeon because of the proximity to Lewis’s discharge. Lewis refused and scheduled the operation as he had intended. He told me that he did not start to worry until his colleagues typed and crossed him for 4 U of blood and prepared an operating room for him in the event of a catastrophe. The extraction went well, the patient and the surgeon both survived.

View larger version (91K): [in this window] [in a new window]   Fig 2. A roentgenogram of a live, undetonated, grenade from a launcher, which was embedded in a wounded marine that Lt Commander David H. Lewis encountered during his duty call. (Reprinted from Mavroudis C, Surgery; 1991;110:896–902 [6], with permission.)

What about their patients? To be sure they had no rational choice; they had to have confidence in the surgeon. The situation, however, does not underestimate the courage that it took to voluntarily lie down and entrust their lives to the skill and courage of a human they did not even know who had, himself, to find the self-reliance and self-discipline to keep them both alive. The greater form of courage is between them, an interrelated courage. In a larger sense, the relationship between surgeon and patient becomes the synergistic outcome of courage. Their fates are interlinked. The surgeon’s courage gives the patient hope and allows the patient to trust. The patient’s faith lends the surgeon courage. This is especially true in the case of new operations and procedures when the outcome is uncertain. The surgeon draws on the patient’s courage for emotional support and ethical legitimacy [7]. One wonders how our experiences with our patients approach the idea that both surgeon and patient display interrelated courage.

Shelp [8], a noted medical ethicist, wrote about the place of courage in the physician–patient relationship. He pointed out that the desired virtues of the physician, compassion and competence, meld with the desired virtues of the patient, gratitude and compliance, to form the framework within which the physician and the patient will interact. Each is faced with unknowns such as the nature of the operative procedure, progression of the disease, and uncertainty of the outcome, which will require from them a collective courage and fortitude. This interrelated courage will no doubt require endurance, trust, and moral conviction. It is the element of uncertainty that distinguishes courage from confidence. We do not always know whether the desired goal will be worth the risk and suffering that must be borne to achieve it.

Courage is not foolhardiness. A competent surgeon may come to a point during an operation that he or she has not encountered before. A difficult choice may be necessary, a choice that will require the courage to choose between options without knowing the outcome for certain. However, what if a recent report had detailed just this situation and the surgeon did not know of the publication? To act in ignorance when there is a reasonable expectation that one should have known the available literature on the subject is not heroic; it is a betrayal of a patient’s trust and faith in us.

In our rapidly changing field, we oftentimes show courage when performing an operation that involves both uncertainty and risk. If the operation is successful, much of this courage is transferred to our patients who now will live with the uncertainty of the long-term result and the management of the disease process for the rest of their lives.

I remember the case of a newborn boy who underwent cardiac transplantation in the early days of neonatal transplantation. Figure 3 is a picture of the graft just before the implant. Although the operation took some courage to perform, in the years that followed it was our patient and his parents who found the courage and fortitude to continue with his life, to take the obligatory medications, and to assume the burden of the knowledge of his uncertain future. Would his new heart grow? Would rejection be a lifelong problem? Nobody then knew the answers to these questions. Every time I saw this patient, I felt more of the balance of our interrelated courage shift to him and his parents. Ten years after performing his heart transplant I gave the eulogy at his funeral; as I spoke I felt how the balance of our joint courage had shifted entirely to him. I walked away that day thinking of how modern medicine had failed this boy, how slow the progress in cardiac transplantation has been, and how our patients and we need courage to work and live at the limits of medical competence and knowledge.

View larger version (143K): [in this window] [in a new window]   Fig 3. Picture of an infant donor heart just before implantation into a child with hypoplastic left heart syndrome in 1984.

View larger version (11K): [in this window] [in a new window]   Fig 4. A graph inversely relating courage and knowledge.

Or consider the courage that it took to perform the early Rashkind procedure in desperately sick infants. No one dared give them much anesthesia beyond a mouthful of alcohol. Lecompte [10], in his excellent report on the history of surgical repair of transposition of the great arteries, joked that when this method was imported from Great Britain into France they modified the technique so that the cognac was shared between the child and the operators, so great was the anxiety involved. Leave it to our French comrades to celebrate interrelated courage with an interrelated aperitif! Be that as it may, these pioneers kept performing these operations. They learned from their failures. They transformed their activities from an area of uncertainty to an area of confidence through knowledge.

	Self-evaluation, peer review, and quality assurance

Top Introduction Courage as a virtue Interrelated courage Self-evaluation, peer review,... Acknowledgments References

 
When the synergism between surgeons and patients results in unexpected poor outcomes, a rupture of trust becomes evident. In Bristol, Great Britain, a governmental review of the surgical results of congenital heart surgery outcomes revealed a larger than expected mortality for repair of transposition by arterial switch and repair of atrioventricular canal [11]. At the root of the problem was that the surgeons were underachieving without knowing it. But although the mortality figures were indeed high, the inquiry, without appropriate peer review or scientific analysis, involved shoddy data entry and gross inaccuracies, which heightened the situation in the press [12]. Moreover, the crux of the blame was placed on the shoulders of the surgeons without regard to the performance of the associated health care team—the anesthesiologists, cardiologists, and intensivists. This debacle resulted in the patient’s misplaced confidence in trust and the surgeon’s misplaced confidence in his abilities. The patients felt that their trust in their surgeons was violated because the surgeons, in their view, were not competent. A similar incident occurred in Denver, where a journalist’s inappropriate use and interpretation of database outcome reports resulted in significant consternation within the medical center without comprehensive peer review and implementation of corrective measures [13].

The answers to these problems involve voluntary data sharing, peer review, and surgeon-led outcome analysis [14]. Over the last 10 to 15 years, the Society of Thoracic Surgeons–National Database Initiatives have demonstrated that adult, congenital, and general thoracic programs can share data on a voluntary basis and show important trends based on large populations of patients. The Northern New England Cardiovascular Disease Study Group inaugurated observation team visits between member institutions for the purpose of improving systems, efficiencies, and clinical outcomes. They succeeded in lowering overall mortality while decreasing costs [15]. This initiative, and others like it, took courage to implement and execute. Time-honored techniques were shown to be obsolete. Other techniques replaced them, resulting in improved outcomes. Oftentimes, the system could be improved. Cardiologists, nurses, perfusionists, and administrators all have a part to play. The surgeon has to have the courage to participate, have the courage to change if necessary, and be worthy of the trust that the patient has in him or her.

In our communities are men and women who have demonstrated their courage in a brave and noble manner by conditions that have been presented to them by fate. Their virtuous response, as Aristotle would say, was determined by an excellent character that was trained by family, education, and spirituality. In today’s world, surgeons are not called on to display the courage that marines showed at Iwo Jima. Nor are we asked to risk and sacrifice our lives, as did the many firemen, policemen, and other rescuers at Ground Zero and the Pentagon on September 11, 2001, when we, as a people, responded in the greatest traditions of our heritage and moral fiber. Rather, our courage is displayed in more quiet moments, during preparation, research, and endless critical review of our outcomes. Our courage is shown in our ability to humbly accept our triumphs, but more importantly to learn from and endure our failures. Our courage is necessary to earn the respect, confidence, and trust of our patients, even as we tread in areas of uncertainty.

It is no secret to the men and woman in our profession that oftentimes we need to display courage in the operating room. As previously noted, we should endeavor to decrease risk and decrease the need for courage. Uncertainty, however, always enters our theater at unexpected and difficult moments. These are the times that, through training, knowledge, and compassion, our profession has repeatedly proven the timbre and character of its members.

In the end, the synergy of interrelated courage will result in an interaction that transforms the nature of competence, compassion, compliance, and gratitude (Fig 5). We will look into the eyes of our patients and see the essence of what we do. We will sense their innocence, we will respect their courage, and we will endure with them.

View larger version (97K): [in this window] [in a new window]   Fig 5. A surgeon and his patient.

	Acknowledgments

Top Introduction Courage as a virtue Interrelated courage Self-evaluation, peer review,... Acknowledgments References

	References

Top Introduction Courage as a virtue Interrelated courage Self-evaluation, peer review,... Acknowledgments References

 

1. Pellegrino E.D., Thomasma D.C. The virtues in medical practice. New York: Oxford University Press, 1993.
2. Plato. The republic. New York: Penguin Books, 1970
3. Aristotle. The Nicomachean ethics, book III. [written 350 B.C.E.]. Ross D, trans. Oxford, England: Oxford University Press, 1980
4. Loewy E.H. Duties, fears and physicians. Soc Sci Med 1986;22:1363-1366.
5. Sheldon M. HIV and the obligation to treat. Theor Med 1990;11:201-212.[Medline]
6. Mavroudis C. Physicians and the Navy Cross: a treatise on courage. Surgery 1991;110:896-902.[Medline]
7. Fox R.C., Swazey J.P. The courage to fail: a social view of organ transplants and dialysis, 2nd ed Chicago: University of Chicago Press, 1978.
8. Shelp E.E. Courage. A neglected virtue in the patient-physician relationship. Soc Sci Med 1984;18:351-360.
9. Comte-Sponville A. A small treatise on the great virtues. New York: Henry Holt, 2001.
10. Lecompte Y. Transposition des gros vaisseux: histoire de la reparation chirurgical. Arch Pediatr 1998;2:113s-117s.
11. Bristol Royal Infirmary Inquiry. The inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary. Final report. July 2001. Available from: URL: http//www.Bristol-Inquiry.org.uk. Accessed October 28, 2002
12. Stark JF, Stark J. Performance measurement in congenital heart surgery: benefits and drawbacks. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2003;6:171–83.
13. Some heart surgery halted at Children’s: doctors sending patients elsewhere. February 28, 2001. Available from: URL: http://www.thedenverchannel.com/den/news/stories/news-51157320010228-070202.html. Accessed October 29, 2002
14. Mavroudis C., Jacobs J.P. Congenital heart disease outcome analysis: methodology and rationale. J Thorac Cardiovasc Surg 2001;123:6-7.
15. O’Connor G.T., Plume S.K., Olmstead E.M., et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA 1996;275:841-846.[Abstract/Free Full Text]

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