Editor’s note: The following is an edited version of the Olga M. Jonasson, MD, Lecture that Dr. Scott-Conner delivered at Clinical Congress 2019 in San Francisco, CA. The presentation has been modified to conform with Bulletin style.
Clinicians are beset by numerous stressors, and it seems that we surgeons, because of our active and direct involvement in patient care, are stuck in the “pain point” between our patients and the system. For our own well-being, we need to recapture the joy of surgery. By taking care of ourselves and each other, we also will take better care of our patients.
What do I know of these stresses, after a lifetime in the cloisters of academia? My own academic career took me from New York, NY, where I attended medical school and trained, to three predominately rural states: West Virginia, Mississippi, and Iowa. I stay in contact with former residents in both academic and private practice and with surgeons in mostly rural practice around my area. I also am an avid follower of the American College of Surgeons (ACS) Communities. Reading those daily digests, the sense of unhappiness and frustration engulfing many of my surgical colleagues is striking. This misery stands in stark contrast to the sense of joy and vocation that called many of us to surgery. And let me add that we in academia also experience and must respond to these pressures.
Sources of stress
Some of the challenges include the following: drastically declining reimbursement, the rapid pace of technological innovation, increasing specialization within general surgery, closure of small hospitals, consolidation of hospital systems, conversion to employed status for many in private practice, threat of litigation, what I call “weaponized” peer review, dysfunctional electronic health records, closed networks, and many others. Some topics that made the list of “Hot Threads” on the ACS Communities in 2019 are as follows: “Why is general surgery dead?” “Hospitals and ageism,” and “While inflation has increased, reimbursement has been pitiful.” Other threads included vigorous discussions of surprise medical billing legislation, Medicare for all, threats to private practice, and activity after clinical retirement. This list just scratches the surface.
How do these issues affect us, and what tactics can we use to circumvent them? Changes are needed at the global (that is, national and international) level and the local level (that is, within our own individual medical communities). We also need to take action individually, to allow ourselves to experience and project joy—the joy that drew us to this amazing vocation in the first place.
Danielle Ofri, MD, an attending physician at Bellevue Hospital, New York, recently published an editorial in the New York Times with the inflammatory title, “The business of health care depends on exploiting doctors and nurses.”1 “One resource seems infinite and free: the professionalism of caregivers,” she wrote. The editorial leads off with a familiar scenario: “You are at your daughter’s recital and you get a call that your elderly patient’s son needs to talk to you urgently.” And another: “Your patient’s MRI [magnetic resonance imaging] isn’t covered, and the only option is for you to call the insurance company and argue it out.” She goes on to describe how “one additional task after another is piled onto the clinical staff members, who can’t—and won’t—say no.”
An assault on our moral fiber
The result of these challenges is an epidemic of burnout. In a recent survey of ACS Governors, more than 50 percent of the respondents reported experiencing burnout at some point in their career.2 A previous survey of the ACS membership in 2008 yielded similar results.
The problem with the term burnout is that it seems to imply that if we were just stronger, smarter, better, we wouldn’t burn out. As a surgeon, I don’t like the term.
Freudenberger defined burnout in 1975 as “a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from excessive demands on energy, strength, or resources in the workplace.” Key symptoms include a feeling of emotional exhaustion and a tendency to treat colleagues or patients as objects.3 If you do a PubMed search on “burnout,” you will find innumerable references documenting burnout in various clinician populations around the world. Burnout is now the most accepted term used to describe clinician distress in an inherently dysfunctional system.
The problem with the term burnout is that it seems to imply that if we were just stronger, smarter, better, we wouldn’t burn out. As a surgeon, I don’t like the term. What burns out? A defective light bulb. A candle guttering to its end. We’d like to think that surgeons do not burn out. Yet the very nature of our work and our ethos in today’s environment predisposes us to the condition. We take on tough cases and expect excellent outcomes. We suffer, find workarounds, and continue to advocate for our patients until the burden becomes unendurable. The very dedication and perfectionism upon which we surgeons pride ourselves may render us more susceptible. Failure to recognize the symptoms, to name the problem, leads to delayed intervention.
It is crucial to recognize that burnout is a symptom of a problem in the workplace, not a weakness of the clinician. Burnout and disruptive behavior are on a continuum; when too much pressure has accumulated over time, the clinician erupts. At the breaking point, surgeons may consider early retirement or become clinically depressed. Suicide can be an extreme consequence.
The National Academy of Medicine just released Taking Action Against Clinician Burnout—A Systems Approach to Professional Well-Being.4 But we don’t need just a systems approach. We need systemwide change and individual strategies to develop the resilience to survive these assaults.
I prefer the term “moral injury” to describe the distress many of us are feeling. Moral injury is a term that initially was used to describe some of the symptoms of soldiers returning from the Vietnam War who had a constellation of symptoms that appeared to relate to threats to a soldier’s moral fiber, rather than threats to their own life (as in classic post-traumatic stress disorder).5 Wendy Dean, in a recent editorial, described it in the medical environment as resulting from “the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.”6
Here are some examples of distress often experienced in health care: A patient needs an operation, but the insurance company won’t cover it. A patient needs a medication but can’t afford it (and the insurer won’t cover it). You request a specific instrument—maybe just a stapler or a suture—and are told to use something else, something that someone somewhere has judged to be “equivalent” because the hospital has a contract with the manufacturer.
To paraphrase Dean and others, surgeons are smart, tough, durable, and resourceful. If we could have “MacGyvered” ourselves out of this situation by working harder, smarter, or differently, we would have done it. In fact, our constant efforts to MacGyver our way out of a bind and to get our patients the care they need may have led to our evolving burden of moral injury—the continued erosion of our moral fiber. Think of a rope, fraying against the sharp surface of the edge of a rocky cliff, strand by strand parting, until it breaks.
Another concept that applies to surgeons is that of the “second victim.” Whenever a complication, a medical error, or a death occurs, the first victim is the patient. The “second victim,” often forgotten, is the surgeon who feels responsible for the event.7,8
Remember the old saying that every surgeon carries a graveyard around in his or her head? When the complication or death is the result of a medical error, or a liability suit has been filed, the surgeon’s suffering intensifies; hence, the term “second victim.” Because we intervene so directly and decisively in the lives of our patients—that is, we are uniquely privileged and allowed to inflict the controlled trauma of an operation—the inherent imperfections of our own art and the deep sense of personal responsibility inculcated in us by our mentors returns to haunt us.
Responding to the assaults
Both the system and the surgeon need to combat these assaults. At the systemic level, we need tort reform and a more rational system for compensating victims of errors. At the individual level, we must support each other when such an event occurs. Too often the “second victim” retreats into a kind of self-imposed isolation at a time when both collegial and institutional support are needed.
Added to these burdens are individual stressors, such as student debt, care for children and elderly parents, and plans for retirement. Many of these encumbrances disproportionately fall upon women because of our natural role as caregivers.9
But what about joy? How can we recapture that sense in our own lives as surgeons? I have told you that I will talk about three spheres of action:
- Individual action—actions or strategies we can all incorporate
- Local action—actions at the hospital staff, county, or state level
- Global action—actions that our professional societies, including the ACS and the American Medical Association (AMA), are undertaking and must expand on our behalf
First, let’s acknowledge that what we do is miraculous and should give us joy. When I retired from clinical practice, I sought a way to communicate the joys and challenges of surgical practice to the lay public and began studying narrative medicine. What is narrative medicine? You can think of it as the intersection between the humanities and medical practice, as well as a set of tools that facilitate incorporation of the humanities into medical training.10
I recently led a narrative medicine session for a group of pediatrics residents. I used a format that incorporates three elements: close reading of a short piece of literature, a period of quiet reflective writing (that is, writing in response to a prompt), and then time to share what is written. Sharing is completely voluntary. No preparation is required, and no homework is assigned. All this work is done in slightly less than an hour.
For this session, I used Suite X of the William Carlos Williams poem “January Morning,” which begins, “The young doctor is dancing with happiness in the sparkling wind, alone at the prow of the ferry!” The stanza concludes with just one more sentence. The entire piece is two sentences, each ending with an exclamation point.
We discussed this poem for approximately 15 minutes, speculating about the setting, the source of the doctor’s happiness, and so on. Where was he going on the ferry? Perhaps to meet a loved one. Maybe to a new job. Possibly on vacation. Why dancing? Why a doctor? Why alone?
Then I gave them the writing prompt, “Write about a time when you felt like dancing with happiness.” Some wrote of the hospital environment, but most wrote about profound personal experiences, such as the birth of a child. Some shared what they had written. At the conclusion of the hour, one resident said, “We don’t talk about joy enough.” Think about that— we don’t talk about joy enough.
It seems to me surgeons have two sources of joy—our personal lives and our professional ones. Within the hospital environment, we find joy in what we do for patients and in the exercise of our skill.
It seems to me surgeons have two sources of joy—our personal lives and our professional ones. Within the hospital environment, we find joy in what we do for patients and in the exercise of our skill. A surgeon whom I respect greatly put it this way in a recent e-mail: “It’s the great results that are joyful, whether a cosmetic surgery or a lifesaving one. Seeing the patients’ results is a joy for me.”
ACS Past-President Carlos A. Pellegrini, MD, FACS, FRCS(Hon), FRCSI(Hon), FRCSEd(Hon), in his keynote speech to the New York Surgical Society, invoked the Japanese concept of “ikigai”—an intersection of four conditions: what you love doing, what you are good at doing, what the world needs, and what you can be paid to do.11 For surgeons, the superimposition of these four factors places us in that fortunate zone. Most of us went into surgery because we loved it—loved the art and science and the difference that we could make in the lives of our patients. Most of us are really good at it, the world definitely needs surgeons, and we get paid for it. When all four intersect, all is well. When one of the four is missing; so, too, is the satisfaction.
I recently asked a pediatric surgery colleague what operation he most enjoys doing. He told me that he gets the most satisfaction from doing a simple pyloromyotomy for hypertrophic pyloric stenosis. The improvement is dramatic, immediate, and life-changing for both the small patient and the family. Everyone is happy.
I became curious, so I queried our General Surgery ACS Community members, asking, “What is your absolutely favorite operation? And, if you have time, why?” It was a totally unscientific survey. I primed the pump by confessing that I had always loved to drain pus. I was amazed by the results. Some surgeons wrote of delicate or technically demanding operations, such as a Whipple or a parathyroidectomy or carotid endarterectomy. Several wrote eloquently of their satisfaction with life-changing operations, particularly for patients who had no other recourse. These were not necessarily dramatic “saves,” but rather operations that made a significant difference in a patient’s life. One described incorporating a panniculectomy into an incisional hernia repair, thus giving the patient a bonus. Another described repairing a scrotal hernia that “went down to the knees” on a global outreach mission and the satisfaction of seeing the man walk away, unencumbered, afterward.
Right colon resection through a transverse incision was an unexpected favorite that, when I thought about it, made a great deal of sense. Appendectomy—both open and laparoscopic—was near the top of the list, both because of technical satisfaction and the life-changing element. Several surgeons agreed that draining pus, especially perirectal abscesses, was highly satisfying. Some mentioned that their favorite operation was whatever they were doing at the time. One surgeon cited the pleasure of helping residents do their first case.
And when someone posted the need to keep the focus on the patient, not self, many agreed.
Recommendations for recapturing the joy of surgery
This comment leads directly to my first recommendation: Focus on the patient, not on yourself. In the early 1900s, Sir Berkeley Moynihan, KCMG, CB, FRCS, of Leeds, U.K., said, “The most important person present at an operation is the patient. This is a truth not everywhere and always remembered.”12 One of Dr. Jonasson’s former trainees said, “She taught me how to be a doctor first, a doctor who put patients first…. She taught us to be uncompromising.”13
Focus on the patient, not on yourself…. A corollary of this is the admonition to focus on task, not self.
A corollary of this lesson is the admonition to focus on task, not self. This simple advice was given, year after year, to our surgical residents by our program director at the University of Iowa, William “John” Sharp, MD, FACS. This focus helps us avoid endless rumination about how much we wish we could get a cup of coffee, get home on time, grab a bite to eat, or even fit in a quick pit stop. I’ve invoked it myself during long nights on trauma call.
Don’t lose sight of the miraculous—the unexpected save or the everyday things we take for granted. Cultivate a quality of mindfulness.
A hospital chaplain who was allowed to observe a kidney transplant later told me that urine started to come out of the ureter as soon as the blood vessels were attached. She told me that the surgeon said, “Look, it is making pee!” She said that she felt she was standing upon sacred ground.
Talk with your patients. Find out their priorities and their concerns. We surgeons speak truth. Blunt and plainspoken to a fault, we sometimes are criticized for that. Yet who among us has not been called to the bedside of a patient and taken on the hard duty of explaining, to patient and family, that intervention is futile? The very concept of palliative care has grown from this sort of honest discussion of alternatives. When you make evening rounds, take time to sit at the bedside. Hold out your hand. Often, the patient will reach out and grasp your hand with theirs. I loved to feel those warm fingers in mine, the strength of the grasp, the human touch.
Cherish your loved ones. Take care of each other.
Reach out to colleagues and peers. Avoid isolation. Consider the nurses and other health care professionals in your hospital as colleagues; you are all working together to help patients.
Consider participating in the ACS Communities. Users have described these online discussions as a kind of virtual surgeons’ lounge, where problems of all sorts—clinical and administrative—can be shared, and triumphs celebrated. Remember the “second victim.” Reach out to colleagues who may have been affected by medical error or death. Don’t retreat into a cocoon if you are the one so affected.
Make time for your spiritual life, whatever that may be. Something as simple as making a list at the end of the day of things for which you are grateful can lift your mood. Cultivate compassion and maintain a sense of humor. Develop resilience, the quality that is often cited as an antidote to burnout.
Take time to teach. When we teach, we nurture our own souls, as well as those of our students. The very word “doctor” derived from the Latin word for teacher. If you are in an academic position, then teaching is an integral part of your tripartite mission. Herand Abcarian, MD, FACS, said of Dr. Jonasson that her main strength “was her infectious enthusiasm that the students and residents got from her…. She made them all wish they were surgeons. It was just a remarkable thing.”14
You don’t have to be an academic surgeon to make teaching part of your daily routine. Teaching is like watering a garden—both the garden and the gardener are nurtured. Teach everyone around you. Of course, educate your patients and their families, but also teach the nurses, the aides, the nurse anesthetists. Share your knowledge in little moments of enlightenment. And be prepared to listen and to learn yourself. Collegial conversation with physicians in other specialties educates both.
Seek opportunities to educate the lay public. Whether it is through Stop the Bleed® training, a few words about breast cancer at halftime during a “think pink” women’s basketball game, or a course on surgical anatomy for senior citizens, get the word out.
If you are near a medical school, volunteer to help in simulation labs, or to teach an Advanced Trauma Operative Management® course or an Advanced Trauma Life Support® course, or to lead other formal activities. If you are not close to a medical school, you are probably rural, so consider allowing a medical student to shadow you as part of a rural elective.
Consider surgical volunteerism. Learn about Operation Giving Back.
Develop new skills
Be prepared to periodically reinvent yourself and to see these reinventions as opportunities to explore new terrain. I tell our trainees and students that you will need to expand their skills about every five years or so. The necessity for reinvention may come from within—as your practice changes or as a result of technical innovation in your area of practice.
Technical innovation can be explosive and cataclysmic, or it can be evolutionary. I, and most older general surgeons, have experienced both. In 1987, the first laparoscopic cholecystectomy was performed, and in 1989, the first series of cases was published. The world of general surgery underwent a seismic change. Until then, laparoscopy had been primarily a gynecologist’s tool that a small number of visionary surgeons used for diagnostic purposes. Cholecystectomy was, and is, one of the most common operations general surgeons perform. It was done through a big incision. The new operation came into widespread use without the benefit of institutional review boards or randomized clinical trials. We learned a lot from that experience and do things better now.
Every general surgeon in practice had to decide whether to adopt the new technique. Some took this opportunity to retire. But the early adopters and their students rapidly developed the instruments, techniques, and applications that we are still using today. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) stepped into the breach and developed training programs and materials.
How do you learn new skills? You build upon old skills, you fall back upon transferrable skills, you read everything you can, and you take every advantage of the training opportunities national organizations offer.
How do you learn new skills? You build upon old skills, you fall back upon transferrable skills, you read everything you can, and you take every advantage of the training opportunities national organizations such as SAGES, the ACS, and the American Society of Breast Surgeons (ASBrS) offer. You seek mentors and proctors. When I was learning how to do laparoscopic cholecystectomy, my proctor was a supremely skilled gynecologist who was facile in performing difficult laparoscopic pelvic dissections for infertility.
Laparoscopic cholecystectomy required acquisition of a completely new skill set. Most changes have been less cataclysmic. A more typical example might be the continued evolution of breast surgery. For those of us who trained in the late 1970s, lumpectomy, image-guided biopsy, sentinel lymph node biopsy, and nipple-sparing mastectomy replaced the modified radical mastectomy we learned to do. But these skills were an extension of those techniques already learned.
General surgeons who have taken trauma call and used ultrasound for focused abdominal sonography for trauma exams or to facilitate line placement are well-positioned to add breast ultrasound to their repertoire. A basic ultrasound course taken online through the ACS, coupled with hands-on courses at the ASBrS and a case log, allows one to attain certification.
My point is, just as suturing and knot-tying are transferrable skills, so are facility with ultrasound, the Seldinger technique, and other fundamental techniques, which makes accommodating evolutionary change in our practice a bit easier.
Our surgical societies, with the ACS leading the way, are providing and must continue to provide training opportunities for surgeons who change practice patterns, who move into a different practice and need new skills, or who wish to bring new techniques to their community. We need to be nimble, to anticipate and produce high-quality educational offerings that facilitate skills acquisition by moving, as we do during a difficult dissection, from known to unknown.
Don’t forget that part of change requires you as a surgeon to keep current on multidisciplinary management. Neoadjuvant therapy to downstage malignancy and permit less mutilating surgery has drastically changed our approach to cancer at a variety of sites. Accurate risk assessment allows better patient counseling.
Seek additional education in management, leadership, teaching, and other “nonmedical” issues. Take advantage of short courses at national meetings. Distance learning and online courses are available to augment your knowledge in almost any area. I was fortunate to have evening courses at Millsaps College just a couple of blocks away and partners willing to let me out on time when I decided to get a master of business administration degree. Now, low-residency programs are available at many big-name schools. Consider your tuition to be an investment in your own future.
Cherish diversity and each other. View your individual differences as sources of strength, rather than weakness. We recently celebrated the first all-woman astronaut space walk. You might ask, why did it take so long, and why is it remarkable? Consider biologic diversity in the context of space travel.
In 2013, the National Aeronautics and Space Administration (NASA) asked the Institute of Medicine to impanel a committee to look at ethical issues surrounding the human exploration of space. The committee explored a couple of fundamental issues: First, what should NASA do if a mission exceeded allowable exposure parameters? What was the ethical way to proceed? The deep space environment is hostile, and for many health sequelae, you can almost think in terms of dose-response curves—the longer an astronaut is exposed, the more likely it is that a health problem will develop.
To make this concept concrete, consider the issue of radiation exposure. What if assignment to a mission would result in an astronaut exceeding approved exposure standards? Radiation happens to be easier to quantitate and has established standards. The second question was how to incorporate fairness. If women, for example, were more susceptible to a given exposure than men, should they be excluded from the mission? I served on a committee that wrote a report defining an ethically solid approach that incorporated fairness.15
I learned a lot from this experience—most importantly, there is no perfect, invulnerable astronaut. Women are typically smaller than men and may endure isolation and confinement better. They also appear to be less susceptible to the retinal changes associated with microgravity.
Spacesuits no longer come in just one size, and an astronaut no longer needs to be chosen to fit the suit. Sure, NASA had to scramble to come up with two of the right size, and that’s embarrassing, but the point is that the system was able to accommodate.
There is strength in diversity.
With respect to changes that must occur at the institutional level, I would urge you to seek leadership opportunities by becoming involved in the various committees of your hospital. Reinvigorate meetings of your county medical society—at the very least, it allows collegial interaction with other specialists, and at the best it provides an avenue to advocate for legislative and systemic change. Become active in the surgical section of the AMA.
Similarly, participate in your state chapter of the ACS. It can provide a wonderful forum for networking, sharing views, and advocating for change.
The ACS provides ample opportunities at the national level as well. Simply by attending the Clinical Congress and sitting in a lecture hall, and, more importantly, talking with your peers from other parts of the U.S. and even the rest of the world, you are influencing the future and helping your own career.16
In July, the College introduced ACS THRIVE (Transforming Healthcare Resources to Increase Value and Efficiency)—a joint initiative with Harvard Business School.17 Here is a new initiative, looking for energetic, qualified, and interested surgeons. It is a chance to get involved and become part of the solution at the national level.
The standard advice to young surgeons starting out is, “Say no”—or, perhaps more accurately, be careful not to overextend yourself. I would urge you to “Say yes” to every opportunity you’re offered in your professional life.
Volunteer, participate, and reinvigorate yourself. The standard advice to young surgeons starting out is, “Say no”—or, perhaps more accurately, be careful not to overextend yourself. I would urge you to “Say yes” to every opportunity you’re offered in your professional life. Time appears to be fixed—there are only 24 hours in a day—but it is highly elastic. The old saying, “work expands to fill the time available” can be turned on its head, and you can find the time to do work that you love.
Don’t assume that you are too young, too old, or unqualified. If you are interested, put your name forward or have a colleague do so. If you are turned down, just do it again with another group. Remember that you may be rejected for what seems like a trivial reason—wrong specialty or wrong region of the country, for example.
I often invoke the “rule of 3s”—one out of three tries will succeed. If you succeed every time, you aren’t aiming high enough. If you never succeed, you need to reexamine your goals. But if you can succeed one out of three times, you are doing well. Rejection is part of life, not necessarily something to be feared.
Attend the ACS Leadership & Advocacy Summit in Washington, DC. Attend the didactic sessions and stay to educate your legislators on health care issues. No experience in advocacy? Never contacted your legislators? Training is provided. This conference is an easy place to start. If we do not educate our lawmakers, who will? Big Pharma, hospital associations, and liability attorneys—that’s who.
I previously mentioned the surgical section of the AMA. I’d like to briefly highlight an AMA program called STEPS Forward.18 This program comprises a series of modules to “empower teams…to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment.” One module is “Creating the organizational foundation for joy in medicine—organizational changes lead to physician satisfaction.” Note the focus: organizational changes.
Take care of yourself
Make time for wellness. Find a way to incorporate stress-relieving physical exercise in your daily routine, even if all you can do is park your car at the far end of the lot and walk briskly to and from the hospital. The University of Iowa Hospitals and Clinics, Iowa City, where I practiced until retirement and continue to teach, has miles of corridors and sky walks. I bet your hospital does, too. Follow good health habits. Find and work with a good primary care physician.
Make room in your life for the humanities and creativity. One of our hospital chaplains (not the one I mentioned previously) always carried small pieces of paper with short poems printed on them. She’d pull one out and hand it to you, saying, “Here’s a pocket poem.” How long does it take to read a pocket poem? Or to write a brief poem yourself, draw a quick sketch, or pull out your smartphone and take a photograph of rabbit tracks in the fresh snow or the sun shining through autumn leaves?
If you are in the latter half of your career, think about and prepare for retirement. Find ways to stay involved. Modify your practice, if necessary, to accommodate the inevitable changes of aging. Cultivate other interests.
If you are just starting out, take charge of your career and shape it to the form you wish it to assume. I’ve spent my entire life in academics, and it’s been a wonderful journey. I’ve trained surgeons who went on to become academic leaders and surgeons who went into small, rural practices. I’m proud of all of them. Whatever you do, devote yourself to your patients, your family, your job, and your community.
Women who have chosen surgery as their vocation are exceptionally well qualified, I believe, to cultivate the sense of joy and to pass it along to students who may be considering a career in medicine in general or in the surgical specialties. Look at the smile on Dr. Jonasson’s face in the photo on page 16. Who can doubt that this supremely competent woman surgeon loved her vocation? We were drawn to a career in surgery not because it was easy or expected, but because of our passion for the art and science. Let’s use that passion as a catalyst to change the system, our institutions, and our lives for the better.
Our interventions as surgeons forever change lives—not just those of our patients, but also their families, and sometimes we affect the very fabric of a community. We need to fight back vigorously, both individually and collectively, against the forces that would stifle our sense of wonder and reduce us to mere technicians. We stand, you stand, at the intersection between disease and wellness, offering if not cure, at least significant improvement.
The author thanks Donna Coulombe, Senior Special Projects Manager, ACS Executive Services, who graciously shared material and memories with me, and ACS Archivist Meghan Kennedy.
Olga M. Jonasson, MD, FACS, and her contributions to the joy of surgery
When Olga M. Jonasson, MD, FACS, was a medical student at the University of Illinois at Chicago in the late 1950s, she told her chief, Warren Cole, MD, FACS, that she wanted to be a surgeon. He thought this idea was absurd.* Through sheer determination, hard work, and excellence, she joined the house staff at the University of Illinois, where Cook County Hospital was the prime attraction. After his initial skepticism subsided, Dr. Cole became her mentor, advising her to obtain additional training in research to prepare for an academic career. She spent a year at Walter Reed Army Hospital, Washington, DC, studying immunohistochemistry and another year at the Massachusetts General Hospital, Boston, studying transplantation immunobiology. She established a tissue-typing laboratory (initially with grant funding from the National Institutes of Health), which ultimately was used at six Chicago transplantation locations, and performed the first kidney transplantation in Illinois in 1969.
When Dr. Jonasson was named chief of surgery at Cook County Hospital in 1977, she was the first woman to hold such a position at a major medical center and considered the preeminent woman among academic surgeons in the U.S. at the time. She retained her preeminence for the rest of her life and continues to influence the course of surgery and the careers of surgeons to this day.
In 1987, Dr. Jonasson left Cook County Hospital to become the Robert M. Zollinger Professor of Surgery and Chair at The Ohio State University, the first woman to hold such a position in the U.S. During that tenure, she co-authored an editorial published in the Journal of the American Medical Association, “A pregnant surgical resident? Oh my!”† That editorial provided the first rational discussion of and description of a practical manner for accommodating the process of childbearing during surgical residency.
After Dr. Jonasson left Ohio State, she returned to Chicago and became Director of Education and Surgical Services at the ACS in 1993. Under her leadership, grants totaling more than $13 million dollars were secured to fund research studies, including one that demonstrated that the National Surgical Quality Improvement Program could be transferred from the Veterans Affairs (VA) hospital system to the more generalized environment.‡ This initiative, now run under the aegis of the ACS, has moved the peer-review process, well-intended but susceptible to individual prejudices, into a more objective realm and provided road maps to better operations and patient care.
She undertook studies of the work conditions of surgical residents and quality of care.* She was instrumental in developing the ACS Clinical Trials Methods Course in 1997, modeled after a similar course offered by the VA.§ These are only a few key initiatives that Dr. Jonasson spearheaded or facilitated during her ACS tenure.
*Husser W, Neumayer L. In Memorium: Olga Jonasson MD: Surgeon, mentor, teacher, friend. Ann Surg. 2006;244(6):839-840.
†Huang EH, Jonasson O. A pregnant surgical resident? Oh my! JAMA. 1991;265(21):2859-2860.
‡Khuri SF, Henderson WG, Daley J, et al. Successful implementation of the department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: The Patient Safety in Surgery Study. Ann Surg. 2008;248(2):329-336.
§Itani KMF. The ACS Clinical Trials Methods Course: Overview and assessment. Bull Am Coll Surg. 2011;96(8):62-65.
History of the Olga M. Jonasson, MD, Lecture
The ACS Women in Surgery Committee (WiSC), which is supported by the ACS Division of Member Services; the friends and colleagues of Dr. Jonasson; and women in surgery throughout the country established this lecture in 2007 to honor the memory of Olga M. Jonasson, MD, FACS, who died in August 2006. Dr. Jonasson was a true pioneer and trailblazer. She was a leader in academic surgery, exemplified by her becoming the first woman chair of surgery in U.S. history. She was a devoted teacher and mentor to countless numbers of surgeons, both men and women.
This lectureship is a testimony to leadership and education in surgery and a reflection of the capacity of women to reach academic pinnacles. Nominations for the lecture come from the WiSC. The following individuals have delivered the lecture at the ACS Clinical Congress:
- Ofri D. The business of health care depends on exploiting doctors and nurses. New York Times. June 8, 2019. Available at: www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html. Accessed December 6, 2019.
- Welsh DJ, Aziz HA, Paramo JC, Andreone P, Butsch DW, Smith J. The ACS Governors Survey: Burnout—a growing challenge. Bull Am Coll Surg. 2019;104(5):19-24. Available at: bulletin.facs.org/2019/06/2018-acs-governors-survey-burnouta-growing-challenge/. Accessed December 6, 2019.
- Balch CM, Shanafelt T. Combating stress and burnout in surgical practice: A review. Adv Surg. 2010;44:29-47.
- National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press; 2019. Available at: www.nap.edu/catalog/25521/taking-action-against-clinician-burnout-a-systems-approach-to-professional. Accessed December 6, 2019.
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