Editor’s note: The following is adapted from the Olga M. Jonasson Lecture that the author delivered at the virtual Clinical Congress 2021. It has been edited and modified to conform with Bulletin style. The American College of Surgeons (ACS) Women in Surgery Committee sponsors this lecture annually to honor the memory of Dr. Jonasson, the first woman chair of a department of surgery.
I am so pleased and honored to give the Olga Jonasson Lecture at the ACS virtual Clinical Congress 2021. I’ve chosen the topic Grit in Spite of Adversity in the Pursuit of Excellence. This subject is in line with our Clinical Congress and the theme selected by 2020–2021 ACS President J. Wayne Meredith, MD, FACS, MCCM: Resilience and the Pursuit of Excellence.
Grit is the intangible resilience demonstrated by underrepresented minorities who function in the majority culture. That’s my definition of grit.
I first met Dr. Jonasson at an ACS course on clinical trials that she was leading. It was thus quite fitting that I was asked to give this lecture. I successfully ran a phase I and phase II investigator-initiated trial, followed by two phase II trials that I will discuss later. Her leadership has led to my success.
Comments on My Journey
“How did you get here?”
“What makes you different from anyone else?”
“You don’t think you’re so special, do you?”
“Just because you are a Black woman, don’t think you will be granted any favors!”
These are some of the comments I’ve heard thousands of times in my lifetime. Imagine how they would make one feel. Imagine how one could become a surgeon hearing these words over and over again.
We all know the training of a surgeon can be brutal, exhausting, and all-consuming, but why can’t anyone who has the drive, intelligence, and manual dexterity become a surgeon? In fact, women should be better surgeons, right? Because our hands are a little smaller, are a little more dexterous, why would it be harder for a woman to become a surgeon? Why would it be harder for a Black woman to become a surgeon? How challenging is it to become a pediatric surgeon—a pediatric surgical oncologist who pioneered a procedure in children? What’s the big deal? Just train like everyone else, get the best scores on the exams, take the best care of patients, and voilà—you’re a pediatric surgeon.
Today, I would like to share with you the journey that I have taken to becoming a Black woman surgeon in this country. I think the concept of grit may help us explain it.
What Is Grit?
Psychologist Angela Lee Duckworth, PhD, is a classic case of someone who understands the concept of grit. (See her TED talk about grit.)
Persistence + Perseverance = Grit
Grit is the intangible resilience demonstrated by underrepresented minorities who function in the majority culture. That’s my definition of grit. I think a Black female surgeon personifies grit. Many people have sought to define grit, and it looks very different to different people, but as a minority female in a majority environment, persistence and perseverance equals grit. I would like to share with you a number of examples in my life of how the intangible skills of persistence and perseverance have propelled me through my career.
Let’s go back to elementary school. At that time, I was in a majority culture in that everyone at the school was Black. All of the students, all the teachers, the entire neighborhood was composed of Black policemen, firemen, physicians, lawyers, and the school was walking distance from my home. I not only skipped a grade and was younger than all my classmates, but also I clearly demonstrated confidence and clarity. My intelligence was verified daily by my scores on standardized exams, being the best in the school and the best in the class, and constantly being asked to demonstrate math, science, or reading skills in the classroom. I had complete confidence and knew I would succeed.
Middle school and high school were quite a contrast. I lived in Los Angeles, CA, where we were bused to the middle school in a predominantly White neighborhood. At the middle school, most of the students were White. I didn’t even recognize the food they ate. For example, I was introduced to a round bread-like food that looked like a donut and was told it was a bagel. I also was told I didn’t belong there. The teachers initially refused to put me in advanced placement (AP) classes. My mother had to fight for me to get honors courses; when she explained that I was gifted and talented, the teachers and school administrators seemed apprehensive. When she explained that her daughter had been identified as someone who could succeed, she was met with a confused look. People didn’t say that I was likely to get an Ivy League education. In fact, the counselors and students all said, “You probably don’t need to go to an Ivy League school. You won’t make it there. You just don’t have what it takes.”
Another example of how my self-confidence had eroded is from my AP chemistry class. I had a good friend who sat next to me. We had been given an unknown powder that we were asked to identify. We had to do several experiments throughout the semester and determine what it was. At the end of the semester, we wrote down on an index card our conclusion. I was confident in what I had written and put my name on the back of the index card. My friend, however, looked over at my card and said, “Hmm. I don’t think that’s the right answer. You’ve got the wrong answer. You’ve got to change it quickly. The teacher’s coming up the aisle to collect the cards.” And because I didn’t have that self-confidence, because I had been told for several years over and over that I couldn’t do it, I thought, “Maybe she’s right. Maybe I don’t know the right answer.” And I changed it. Turns out it was the correct answer, and I was right after all.
I then went on to college and medical school. I did, in fact, make it to the Ivy League school and the Ivy League medical school. I was quite excited about being accepted into medical school, as it had been my lifetime goal.
We had a histology class and each of us was given a microscope, which was on our desk. It was the same microscope every day with our name printed in front. One morning, I went into the class—which I loved because we got to look at cells under the microscope and describe tissues, and I really liked that type of learning—and in the place where my name should have been was a sticker with a racial slur. I was hurt. I was crestfallen, and I didn’t really know what to do. I looked over at my classmate—the only other Black female in the class. She said, “We’ll go to the dean. We will try to get it settled.” Of course, nothing really ensued, and we never identified the vandal, but that individual most likely is still a physician today.
Residency and Mentorship
When I went on to residency, I was thrilled. Residency was a wonderful experience, and the complements of intelligence and my demeanor were paying off. I was finally going to be a surgeon. I was so excited.
I was accepted to a program at the University of California (UC) Davis East Bay under the tutelage of ACS Past-President Claude Organ Jr., MD, FACS. He was the second Black male President of the College. Dr. Organ even received honorary fellowship in the Association of Women Surgeons, quite apropos to this talk. He was the consummate mentor and an outstanding chair of surgery. He gave me continued guidance and supported my pursuit of being a pediatric surgeon. His support of women surgeons was obvious and practiced daily. My success is a result of his support and gentle nudging. He was always telling me I could do anything I wanted to do. He never really said I might be the first Black female pediatric surgeon. All he told me was to be a good resident, and he would help me get there. He was an incredible mentor and sponsor.
I want to describe for you an incident that I had when I was an intern that gave me pause and started to make me think maybe I was not quite the decision-maker I thought I was. I was managing a Swan-Ganz catheter in an older female in the surgical intensive care unit. She was quite ill. My job was to float the catheter. Many readers may not even know what that was, but it was routine at the time. I was quite proud of myself because I had successfully placed the catheter, moving swiftly, and I was able to access her internal jugular vein and get the catheter inserted quickly. I inflated the balloon successfully and got pressures adequately. I then handed it over to the nurse. At this stage in my career, I was excited that I didn’t have to call the chief resident—that I could do it on my own.
Several hours later, soon after the nurse had inflated the balloon, a code blue was called. When I went to the bedside, I thought that probably the pulmonary artery had ruptured. However, no one listened to me when the code occurred. My chief resident came. I said, “I think she just ruptured a pulmonary artery.” She called the cardiovascular surgical team and brushed me off, saying, “No, no, no, that’s not what’s going on. It’s probably a pulmonary embolism. Don’t worry about it.” That incident allowed me to see myself and know that I could make decisions. I just needed more confidence.
Here is where the grit started. I started to build grit and persistence with every encounter in the hospital. Every single issue I encountered was something that I wanted to push through because I desperately wanted to graduate and become a surgeon—a pediatric surgeon.
Another example of where I had to use my grit is when I sought consent from a patient. I was so excited when I walked into the room as a third-year resident. I was going to assist on an aortobifemoral bypass. I had read about the procedure and knew exactly what I needed to do.
I walked into the double room, where the patient was a White female approximately 80 years old. She was close to the window, so I had to pass by another individual to get to her. I quietly leaned over and said hello and walked in front of her bed. Before I could introduce myself, she said, “Oh sweetie, the trash is right over there for you to take out.” The smile quickly left my face, and my heart sank. I had on a white coat and thought I was appropriately dressed in scrubs. I even had a badge with my name on it. I didn’t know what to say. I wanted my patient to have confidence in me as a surgeon. However, I didn’t know how to allay her fears that someone that she thought was coming to take out the trash would actually do her operation.
Another example of how grit can propel you occurred when I was a fellow. And you’ll see that after both of these instances, one needs to take a step back, take a deep breath but not completely get out of sorts because we are still responsible for patient care. I was doing a fellowship in a southern city and was pulled over by a traffic cop. I either ran through a stop sign or had done something else wrong—I actually can’t remember what I did—but I was given a traffic ticket.
When you’re a fellow, as many of you know, you’ve already completed residency, you’re already board certified, and you’re just excited about what you do. But it is a stressful environment. You’re now expected to know everything about being a surgeon, but you know nothing about your particular specialty. So, I studied endlessly. I prepared for every operation, and it was tiring but enjoyable.
One night, about 31 days after I was pulled over by the traffic cop, there was a knock at my door at 2:00 am. I lived in a predominantly White suburb, and the knock was quite loud and disturbing. I thought perhaps the neighbor was in trouble. When I got to the front door, the police were there. They said, “Is this Andrea? Are you Andrea Hayes-Jordan?” I said, “Yes.” They said, “We have a warrant for your arrest. You haven’t paid this ticket. It’s been 31 days. If you don’t have the $438, we’re going to have to take you in.” Well, I didn’t have $438 in cash in the house at the time. I said, “If you just follow me around the corner to the ATM I’ll get it for you, and it won’t be a problem.” They didn’t like that answer, and the next thing I knew I was in the back of the squad car, handcuffed on my way to jail.
I eventually had my husband at the time pay to bail me out, but then I had to go to work the next day. I got home about 4:30 am—the same time I had to get up—so I didn’t sleep. I got to the hospital. I’m sure I had to do a complex operation, because those are the type of procedures we did, on a small baby with a tumor that was wrapped around the aorta and vena cava. What was I to do? Again, grit came in to play. You say your prayers, put your head down, and do the work you need to do to help save that patient’s life. You have to be responsible to your patients, and I never told anyone in the hospital what had happened. I didn’t want them to judge me, and I didn’t want them to think of my weaknesses. I persisted. I persisted with grit.
I will humbly say that all these examples, incidents from my life, reflect that I purposely have had indescribable grit needed to persevere.
I will humbly say that all these examples, incidents from my life, reflect that I purposely have had indescribable grit needed to persevere. Despite these incidents, and many others not mentioned, I graduated from medical school and residency, completed two fellowships, and as a postgraduate year 11, started my first job. These accomplishments happened despite the standardized test scores, despite being unsure of diagnoses, despite being unsure of myself. I managed to get through it. With a lot of mentorship and sponsorship, especially from Dr. Organ, I became the first board-certified Black female pediatric surgeon in this country. I was able to do that even after I heard from a chair of surgery at the time, when I asked why I didn’t match the first time, or the second time, or even the third time. He said, “Well, you know we just can’t take a chance on a Black woman. We can’t take a chance training a Black female.” A lot of grit, a lot of perseverance, and a lot of help have allowed me to achieve that goal. I also was the first Black woman to graduate from the UC Davis East Bay residency.
Rising to an Extreme Challenge
Continuing with the theme of being first, one task that I really wanted to complete and that I was determined to accomplish was to treat a very rare cancer, desmoplastic small round cell tumor (DSRCT) (see Figure 1). It turns out I would become the first person to do so. This operation lasts 14–20 hours, and hundreds of tumors are removed; in fact, the most that have been removed was nearly 2,000 tumors. Why did I want to do this? Why did I want to tackle something like this rare tumor? And why hadn’t it been solved before?
FIGURE 1. DSRCT
This complex tumor is composed of fibrous strands, which makes it quite difficult to treat. It has a 10% survival rate. I wanted to change the outcome of this disease. I wanted to do something different. Many people said I couldn’t do it. They said, “You know this type of disease is very rare, incurable, and there’s nothing we can do about it.” I said, “Well, maybe we can try doing something like this hyperthermic intraperitoneal chemotherapy (HIPEC) after removing all of the tumors.” My adult colleague said it would be impossible, and my pediatric colleague agreed, so I had to persevere.
When many people told me that I couldn’t do it, I had already had the experience in high school of being told I would not get into an Ivy League school and shouldn’t be in AP classes. A strong mind and thick skin was what I needed. Now, after 35 years of being told “no,” the word has less meaning. “No” simply means “not now, be patient, you’ll find a way around this obstruction.” “No, you can’t go through this way” simply means that I need to find an alternate route.
So, how did I approach this idea? I started working on it in 2002, but it wasn’t realized until 2006, after several years of applying to the institutional review board (IRB) to get approval. I did have someone in my corner: Richard Alexander, MD, FACS, who was at the National Institutes of Health (NIH) at the time. He showed me his adult protocol and said I could modify it for pediatric patients. It took several years to get the proposal through the IRB at my institution—an outstanding cancer center that was familiar with conducting clinical trials.
It was my first IRB meeting, and I expected the protocol would be shut down. The room was full of very specialized cancer physicians, all interested in doing phase I novel clinical trials. I was proposing to spend hours taking out hundreds of tumors and then putting chemotherapy in a child. I wasn’t sure this proposition would be well received, but I used what I learned in Dr. Jonasson’s course. I was, at this point, fearless.
The IRB approved the protocol in 2005 (see Figure 2). The operations were done in patients aged 12 months to 25 years old, and we were required to discuss each patient with two senior surgeons. I was quite nervous the first time we did the procedure. I didn’t know what to expect. The father had granted me permission to do the procedure on his young daughter in hopes that I could do something to help her. I wanted to be honest and say I didn’t know what the outcome would be. I did not know if she would die. He gave me his consent, and we did the first procedure in 2006. During that conversation, I had a child-life professional, two nurses, and a physician assistant present. They became my core team in producing this phase I trial. The importance of a team developing something novel is key, as this work is collective.
FIGURE 2. CURRENT MANAGEMENT OF DSRCT
Unfortunately, the first patient died four months later. I needed to decide if I was going to continue with the second patient in this phase I trial. I had been through so much and had been so persistent in pursuing my other goals that I had no doubt about this possibility. I learned that not all patients respond to this treatment, and I learned that I had to find a type of tumor that I could resect 100% and leave only microscopic disease behind. It was a learning experience, and I persisted. This idea was realized, and I was recognized in a Houston women’s magazine. I bring up the topic because, apropos to this talk, women leaders are still being highlighted for doing novel things, even today.
The second patient who had the procedure was a 5-year-old boy with DSRCT. I proposed that he enter this trial, and his mother agreed. We were able to remove all of the tumors and restore him to health. This second patient is now a successful student at Georgetown University, Washington, DC, and is getting ready to graduate.
An additional patient we enrolled in the trial was a young child who was on hospice when I first saw her. You can see on the positron emission tomography scan (Figure 3) that the patient had an enormous amount of disease. After 15 hours of surgery, we were able to eliminate all of her disease, and she is alive and well now in the eighth grade.
FIGURE 3. “INOPERABLE” TUMORS IN A YOUNG CHILD
As another example of a success in this surgery, a 22-year-old presented with this particular tumor in the pelvis. It was a very large mass, right between the bladder and the rectum. It appeared that the mass was inoperable because it was stuck to the bladder and the rectum. But I’ve learned that you can actually dissect this tumor away from the bladder and rectum and remove it successfully. I didn’t learn this in residency or fellowship. I had to teach myself how to do this procedure, but I knew it was possible because of the pathogenesis and biology of this disease.
Here’s another example of a challenging case. A 12-year-old boy was referred to me by a surgeon outside the country. At that time, this patient had an unsuccessful laparotomy. He had chemotherapy, and Figure 4 shows the smallest that the tumor got after chemotherapy. We were faced with having to do something because of the enormous mass of disease, and this was his only site of disease. He couldn’t live like this, so I offered the parents the chance of eliminating his tumor. At this point, I had about 10 years of experience and knew that this tumor could be resected. We embarked on our 16-hour operation and were able to remove this large mass en bloc and leave him without any tumor. We brought him back the next day for the HIPEC procedure. Figures 5 and 6 show the patient and the tumor after resection.
FIGURE 4. 12-YEAR-OLD PATIENT PRE-RESECTION
FIGURE 5. 12-YEAR-OLD PATIENT POST-RESECTION
FIGURE 6. POST-RESECTION TUMOR
An Ongoing Pursuit
This journey was a long one. I had to change the preoperative management. I had to change the intraoperative management. I had to adjust management to protect the child’s kidney from the therapy that we were delivering. I had to make significant investments to ensure this operation was safe. Remember, I was told that if one patient died, we would never be able to do this operation again. Now I’ve done more than 230 cases of cytoreductive surgery/HIPEC in pediatric, adolescent, and young adult patients. I have not had any mortality, and I have had only one patient return to the operating room. We now manage DSRCT with neoadjuvant chemotherapy (8–10 cycles), followed by HIPEC, followed by radiation, followed by chemotherapy and surveillance. We have been able to improve the survival of this disease from 10%, to 30%, to 60% in the recent era. From the thought of the first patient who died several months after the operation, from the email that I received from the third and fourth patients telling me of their success, telling me that they have reached eighth grade, telling me that they are graduating from Georgetown University—this was a demonstration of perseverance and grit.
These new discoveries generate more questions. Why are 90% of the patients male? Why am I always cutting a tumor off of seminal vesicles? Why do patients relapse outside of the abdomen? These are questions I have taken to my laboratory to study using an orthotopic xenograft model. I’m able to interrogate this model and look at the genes and hopefully, over time, create a hypothesis as to why the tumors spread. Why did the cases involve hundreds of tumors? Why did the cases occur mostly in children? In my laboratory, for the remainder of my lifetime, I hope to be able to elucidate how and why.
I hope that I was able to share with you the great rewards of research in a very difficult field of pediatric surgery. I have used my faith and grit to get me through. I love what I do. I love caring for the children whom I treat. I love making new discoveries. I love finding new genetic pathways for these tumors. I hope that everyone can be the best. It’s challenging to be a surgeon, like all of us are, and all have had to develop grit.
As Charles R. Drew, MD, FACS, past-chair, Howard University department of surgery, and the father of modern blood banking, is renowned for saying, “Excellence of performance will transcend any artificial barriers created by man.”
Clinical Congress 2021 registrants can view the Jonasson Lecture online. Login is required.
Conversation with Dr. Hayes
Editor’s note: Following is an edited version of the discussion that took place after the Olga M. Jonasson Lecture at Clinical Congress 2021. Susan Pories, MD, FACS, Chair of the American College of Surgeons Women in Surgery Committee, led the discussion with Andrea Hayes, MD, FACS, FAAP, the lecturer.
Dr. Pories: Thank you, Dr. Hayes, for a fantastic lecture. I found myself in tears after hearing your stories, and I’m sure many of the people in the audience did as well. Thank you for sharing such deeply personal experiences with us.
I want to ask you a couple of questions. I know a lot of people in the audience would have loved to be here in person, have their picture taken with you, and ask you questions afterward, but unfortunately we don’t have that capability this year. So, I’ve tried to imagine a couple of questions that the audience might have.
How do you think all of your experiences, overcoming the barriers you spoke about, can inform the next generation of surgeons? Specifically, how do you manage to keep going and stay strong when things are difficult?
Dr. Hayes: Thank you, Susan, for these questions and thanks for the opportunity to communicate with the audience. I think the experiences I shared are important in letting other surgeons—not necessarily just women surgeons, but whoever is going through situations that aren’t the easiest—know that they aren’t alone. There are a lot of other surgeons who have had to go through circumstances outside of the hospital or outside of the operating room, and they can reach out and get support and get help—not physical help, but mentorship or friendship—that can help them through those times.
I think when I was going through all that, it would have been nice to know that there was someone I could’ve reached out to and said, “Hey, guess what happened to me? Can we just talk about it for a second?” I wished I had done that. That’s really my message to all of the surgeons in the audience. Don’t feel like you’re alone. Reach out. There has got to be somebody else who has gone through something similar, and even if they haven’t, still will be there to support you.
Being a surgeon is such an important and critical role. It is more than a job having someone’s life in our hands every day, multiple times a day. It’s something that only other surgeons can really understand. I would encourage people to reach out and know that they can get through it.
When you ask what sustains me, I can’t help but mention my faith. I am a Christian, and I pray every day, all day, even during my operations, to get me through it.
Dr. Pories: What do you think we can do to improve the number of underrepresented minority surgeons, both men and women?
Dr. Hayes: I think that to improve the number of underrepresented minority surgeons among both men and women, we need to provide more models of success. If you are not actually able to see a person who looks like you doing the job that you might want to do, then you may not be able to imagine yourself in that role.
We have two responsibilities: one is to increase the pipeline by being visible even at the junior high and high school levels, and the other is to be attentive to the pipeline further down where it might be a bit weak. The level of residents, medical students, and fellows who may have gotten into medical school, or gotten into residency, or are either being let go or selected to leave certain trainings, are the people we need to support. I think those are the two ways that we should approach this issue.
As I understand it, sixth grade is when children decide whether science and math are areas they should pursue and know whether they could be a surgeon because they have seen or talked to someone or heard a podcast that motivates them. That experience is incredibly important.
The other side of me knows we do have folks in the pipeline who have dropped out or have not made it to the end of surgical residency who are underrepresented minorities. We need to be very supportive of them, and that means providing an environment in which they can succeed. We have to really watch our implicit biases and do our best to provide an environment where every surgeon, every medical student, feels that they can be successful, so they can learn like the rest of the surgeons.
Dr. Pories: I noticed that you and Dr. Jonasson both decided at a very young age that you wanted to be in medicine and be a surgeon specifically. I think I could say the same about myself. My mother told me I said the same when I was 4 years old. I think you do have to start when people are young in urging them to believe they can do whatever they want.
Dr. Hayes: Yes, absolutely. You have to be able to tell them over and over, especially those days when you question why you’re doing this work, whether you’re good at it. Those are the days you really need someone to encourage you.
Dr. Pories: Specifically, where do you suggest a young surgeon turn for advice, especially if they don’t have the right mentor in their own residency program or hospital? Sometimes there just doesn’t seem to be support locally.
Dr. Hayes: I think the place to turn if you don’t find support locally is some of our surgical societies. We have the Society of Black Academic Surgeons, Latino Surgical Society, and the Asian Surgical Association, which can help support people by providing opportunities to have conversations with the senior folks in those organizations, and even the junior folks, to get advice and help. Then they should surround themselves with members of those communities so that they have the cushion they need. You need that cushion, and everyone is going to fall at some point, so you have a soft landing. Having those relationships within surgical societies can provide that soft landing and increase the network of surgeons that they can communicate with. All institutions are different, and there may be someone at their institution who can help them, but if not, the surgical societies can help. The ACS now has a new Office of Diversity and that also would be a place to look for support.
Dr. Pories: What do you think specifically we can do in the ACS to improve things on a national level in this regard?
Dr. Hayes: I think the ACS made a big step this year in establishing the Office of Diversity, the Board of Governors Diversity Pillar, and the Regental Committee on Anti-Racism. Through the pillar and the Regents committee, I understand, we will be able to support various institutions and their development of programs by way of grants. I know a number of surgeons have great ideas about what they can do at their hospitals and their committees to support diversity, equity, and inclusion. I think the College’s support of the chapters as they embark on these tasks is critically important.
Dr. Pories: One more question: You are certainly a leader in your field of pediatric surgery. Would you leave us with one or two pearls about leadership and what we should do to become better leaders in our field?
Dr. Hayes: Wow, there are so many leaders whom I have learned from in the past who have taught me a lot of things. I think one of the things that helps me as a leader is being transparent and very real. One of my leadership styles is to be genuine. If you are having a bad day or you are upset by something that happened at home, just be open about that and say you know this probably isn’t the best day for you to talk to a colleague about something that can wait. People need to know that leaders are also vulnerable, and they’re people, and they’re not perfect. Showing your vulnerability and being transparent is one of the tips that I would give to future leaders.
The other suggestion that’s been repeated many times in seminars and that I have found helpful is to change furious to curious. In the situations where you want to be furious in the operating room or on the floor, just change those emotions into a question of how we might make this better next time. Ask, “How did this happen, and how can we change it to make it into a positive?”