First YFA Essay Contest winner: The promise of a profession lies within us

Challenges to our surgical profession are numerous. These demands include the need to adjust practices to comply with the Affordable Care Act, increased legal and regulatory requirements, new financial stresses, modifications in training requirements, and documentation of patient encounters through electronic health records.

Waning morale

These challenges have taken a personal toll on many surgeons. A 2008 survey of American College of Surgeons (ACS) members reported 40 percent of us feel burned-out, and nearly one-third screened positive for depression (n=7,905).1 More recently, a 2013 Medscape survey of 24,000 physicians in 25 medical specialties indicated that less than half (47 percent) of general surgeons agreed with the statement, “Yes, I would choose the same specialty.” This figure was a decrease from 60 percent in 2011.2 With these beliefs, how can one convey the promise of this profession to the next generation, let alone to ourselves? Where does the promise of our profession ultimately lie?

To answer these questions, I recall the advice from my research mentor, Suyu Shu, PhD, while at the Cleveland Clinic, OH: “When things are difficult and unclear, go back to fundamental principles.” Heeding this advice brought my attention to the College’s guidelines for the training of general surgeons and surgical specialists (see figure).31939 January Bulletin - Selection of applicants for graduate training for surgery

These guidelines list “character” as the first criterion of surgical trainee selection, stating, “Character embraces ethics, conscientiousness, judgment, industry, and all other elements which make up the background of a surgeon.” Most people would agree with this criterion, but there is a big gap between knowing about character and living it out. Eliminating this gap takes leadership.

Exhibiting leadership, character

Surgeons are seen as leaders. At the most basic level, patients identify us as the leader of the health care team focused on their surgical care. We are trained to efficiently gather information, analyze data, and make decisions. We are also wired to fix problems, which helps us to develop innovative approaches to address health care issues. Many of us are actively involved in finding viable solutions to the challenges facing our profession through service on local, regional, and national positions and committees. Our elected ACS leadership is actively involved with the federal government on key issues currently under deliberation.

The promise of the profession takes more than being a leader; it takes being a leader with “evidence of high character.” Indeed, we have all witnessed, experienced, or exhibited examples of poor leadership—abusive and degrading comments, disrespectful interactions, refusal to cooperate with other physicians, and arrogant behavior. A report on disruptive behavior by physicians revealed 21 percent of respondents (n=828) could directly attribute an adverse clinical outcome to a lapse in character.4 These data show what we all intuitively know—that lapses in behavior can and will negatively affect patient care.

For those of us involved in training fellows, residents, and medical students, consider the impact of our behavior on the next generation. They have to see not only how we operate, but also that our interactions with colleagues and patients, as well as our approach to challenges, are grounded in the quality of our character. This behavior includes how we hold one another accountable for lapses in character, just as we hold each other accountable for decisions that affect clinical patient care. We must have the same passion in imparting character attributes as we do for imparting surgical wisdom to our trainees.

As surgeon leaders, we need to strive to be better. I was delighted to see Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), deliver his ACS Presidential Address, The Surgeon of the Future: Anchoring Innovation and Science with Moral Values, at the 2013 Clinical Congress, in Washington, DC. Moral values and actions reflect one’s character.

Notably, the ACS holds an annual Surgeons As Leaders training course that includes character-building in its curriculum. At our institution, we have implemented a program called Leadership Lived Out that explicitly trains tomorrow’s leaders on a foundation of virtuous character traits.

Each of us has challenges that we must address. In some cases, these concerns are best addressed collectively, while other challenges can only be met on an individual basis. In all cases, each of us must face and overcome these impediments by ceaselessly striving to exude high character in all that we do. The first critical step is to examine the quality of our own character in the behavior we exhibit with our colleagues, the health care teams we lead, the trainees we mentor, and most importantly, the patients to whom we provide care. We must do so because the promise of our profession ultimately lies within each of us.


  1. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
  2. Medscape. Medscape Surgeon Compensation Report: 2012 Results. 2013. (Login required). Accessed August 25, 2014.
  3. MacEachern MT. Criteria for graduate training for surgery and a manual of graduate training for surgery: General surgery and the surgical specialties. Bull Am Coll Surg. 1939;24(1):6-11.
  4. QuantiaMD, American College of Physician Executives. Disruptive physician behavior. May 15, 2011. Accessed August 18, 2014.

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