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Ann Thorac Surg 2004;77:1149-1150
© 2004 The Society of Thoracic Surgeons
In recent years, a number of substantive changes have occurred in the training and practice of medicine and surgery. The pace of change is always accelerating. As surgeons, we initially believed that we were immune to many of the evolving issues and concerns regarding resident work hours and lifestyle debates. However, now that has all changed and we find ourselves in transition, trying to balance our professional lives with personal and professional responsibilities. This essay will provide opinions on the direction that our profession is heading and why we should remain concerned and engaged.
In his 1963 presidential address to the Thirteenth Annual Student American Medical Association Convention, Dr Michael E DeBakey [1] proclaimed that "the demands of a physician's practice are so rigorous, requiring such exclusiveness on the part of the doctor that he must forego almost all other aspects of life". Four decades later, this philosophy continues to exist within organizations such as the American College of Surgeons [2] whose members pledge "to pursue the practice of general surgery with honesty and to place the welfare and the rights of [the] patient above all else... ." However, healthcare within the United States has become a multibillion-dollar industry, and it is estimated that by the year 2007, American healthcare will cost more than 2 trillion dollars and will require 20% of the gross domestic product [3]. Jones [4] pointed out that in order to function effectively in today's healthcare system we need guidelines to sustain a focus on the welfare of sick people and "to navigate in a trillion dollar industry, we need a compass: medical ethics."
As surgeons, we are being forced to justify and balance three distinct areas of responsibility encompassing ethical, moral, and personal obligations in the face of escalating patient-care requirements. It is inarguable that surgeons should be able to spend more time with their families and pursue outside interests; however, the caveat lies within the word "should" and between "the devil and the details."
Ethical obligations
Ethical decision-making involves personal sacrifice and an unwavering conscience. As surgeons, our ethical obligations transcend self-interest, personal emergency, and social, political, and economic forces. We chose surgery as a profession for a myriad of different reasons; however, by doing so, we all agreed to function in a capacity that would be beneficial and helpful to our patients.
Developing an inner ethical being requires (1) a fundamental belief and a total and permanent commitment to an ideal; and (2) full dedication to the good of others and to help people who are in need.
Moral obligations
Moral development involves personal sacrifice, effort, resolution, work, and discipline, leaving little room for incompetence, selfishness, or even legitimate personal concerns like fatigue, lack of time, or demands by the family. In his 2001 presidential address to the Western Surgical Association, Dr J David Richardson [5] reminded us that "unlike other disciplines able to rely upon alternative caregivers, surgery does not lend itself to care by proxy." One cannot discharge moral responsibility by giving it to someone else; it is nontransferable, that is, "you can delegate authority, but not responsibility" [6].
Personal obligations
Satisfying our daily personal obligations with surgical responsibilities represents one of the most difficult aspects of the surgical lifestyle, as we are often criticized for not spending enough time taking care of our families or ourselves. However, we believe the surgical profession offers a service of high significant personal value. To accomplish this goal, we must (1) reinstate the principle of "just doing what is right"; (2) work without ulterior motives; and (3) display commitment and availability with no questions asked.
Alexis Carrel [7] once wrote, "To accomplish our destiny, it is not enough to merely guard prudently against road accidents. We must also cover before nightfall the distance assigned to each of us." Winston Churchill [8] said, "It is no use saying, ‘we are doing our best.’ You have got to succeed in doing what is necessary". General Dwight D. Eisenhower [9] very eloquently stated, "We succeed only as we identify in life, or in war, or in anything else, a single overriding objective, and make all other considerations bend to that one objective."
Comment
Advocating these concepts represents a difficult challenge. It seems as though putting our patients first has become something of an archaic concept, even though, we have an ethical obligation to the patient and society to provide good care, which is referred to as the "social contract." Society moves in the direction in which needs exist, and as physicians we not only must meet the needs, but we must also preserve certain basic principles essential to the proper provision of medical care. The surgical profession must be allowed to return to its original mission and renegotiate the social contract in order to become more balanced, because as we all know, "good medical care is rarely cheap and cheap medical care is rarely good" [1].
From both theoretical and practical standpoints, surgical training and practice go beyond the realm of simple commitment and reside firmly in hard work. In observing current medical students and residents, many have noted that there is a political incorrectness to the hard work that is so necessary to fulfill the commitment. Even with the current resident work hour restrictions, the number of unfilled general surgery residency programs in the United States increased from 5 in 1997 to 41 in 2001 [10]. Prior studies have noted that lifestyle, especially a "controllable lifestyle," is a major contributing factor in specialty choice by students [10]. We are not arguing that a balance between purposeful hard work and personal responsibilities should be overlooked; however, many surgical problems demand immediate attention. We agree with Dr Richardson [5] when he stated that "lifestyle as a buzzword cannot be allowed to be a ‘cop-out’ for failure to have adequate surgeons and other physicians to meet societal needs" or eventually, our society will be "served" by a medical community that is less talented and definitely less interested in providing medical services in the tradition of its predecessors. Great care must be taken to support and refresh those aspects of American medicine that have sustained it as the most noble of vocations, that have enriched our professional lives, and that have set us apart as the steadfast protector for the interests of our patients.
In conclusion, as surgeons we continue to work through the night, long past the time when our colleagues have gone home, because that is how we have been trained. Attitudes such as this should not be changed, but rather embraced, because to our patients, we represent "hope." In the words of Stephen Paget [11], "We serve three masters: our profession, our patients, and our own people. For if a doctor's life may not be a divine vocation, then no life is a vocation, and nothing is divine."
References
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