Portal de Periódicos da CAPES

Identity

2010; Lippincott Williams & Wilkins; Volume: 68; Issue: 4 Linguagem: Inglês

10.1097/ta.0b013e3181d692f5

1529-8809

Gregory J. Jurkovich,

Diversity and Career in Medicine

I have been thinking about the word “identity” for a while now. It is not, perhaps, the typical focus of a presidential address to an academic surgical society. You might expect something more along the lines of a history of our organization, a comment on a major advancement in our field, a remembrance of a glorious symbolic figure of our profession, or a call to action to address some grievance, or even ruminating on the field of medicine we have chosen. Surgery is the career path we have chosen. Like most of you, I have defined myself as a surgeon and, more specifically, as a trauma surgeon. We have chosen this identity, or it may have chosen us. In some way, along the way, nature, God, and karma brought us to this place of our identity. I have my identity. You have yours. And our organization, like any other professional organization, also has its identity. This address is about the importance of identity in defining who we are, why we do what we do, how it guides our decisions, and how it comforts us in times of stress and turmoil; but it is also about how it can hold us back from trying new things or even from achieving the potential of what we could be. Professional Identity My professional identity has been bred from a mix of Catholic priests and old time medical general practitioners, transplant surgical pioneers, and the original acute care surgeons of the county hospitals. My middle name, Jerome, is in honor of Monsignor Jerome Quinn (1927–1988), a Roman Catholic priest who baptized me and befriended my family for more than 30 years. He was a well-recognized biblical scholar of his time, as was his namesake, St. Jerome of the fourth century, the patron saint of librarians and encyclopedists. St. Jerome is perhaps best remembered for the medieval story of his befriending a lion after removing a thorn from its paw. It is a bit of a stretch, but this does remind me of the way some nights on call turn out. My nickname “Jerry” is from Jerome. Dr. Ben Owens was our “family doctor” for many years. He was the classic family general practitioner from Hibbing Minnesota and the cornerstone of that community’s healthcare. He undoubtedly influenced my decision to become a physician. I also have to acknowledge the Dean of Students at the University of Minnesota Medical School, Dr. Al Sullivan, who demonstrated a nurturing belief in me and my future, and of course the influence of my father, who I seem to be more and more like every day (Fig. 1).Figure 1.: Medical school graduation.I was not always going to be a physician and certainly not a surgeon. Although my identity was tied to the sciences and my academic performance in high school, I was desperate not to be too much of a nerd, failing miserably as President-elect Peitzman has so nicely pointed out in my introduction. I grew up, as it were, in the sixties and seventies, and they were the time of rebellion, free love, psychedelic drugs, and space travel. I did none of those. Either it did not fit or I just simply missed out. I was an engineering major in college, for reasons that escape me now, and decided late on a career change to medicine. In medical school, I thought I was going to be an internist, but the influence of the surgical service of Dr. John Najarian was too strong. In residency at the University of Colorado, the pull between the cutting edge transplant world of Dr. Tom Starzl, and the county hospital, free form, take no prisoners world of the senior leader Dr. Ben Eiseman, and the young attending Dr. Gene Moore were a dynamic that further shaped my identity. These were stimulating times, creative times, and identity shaping times. I present this brief litany of my legacy, in part, not only to thank these mentors and supporters but also to acknowledge that the formation of an identity takes some time for individuals, as it does for organizations. I suspect that many of you can similarly retrace the origin of your identity, but there is more to identity than our mentors and our site or style of practice. There is our heritage, as Dr. Fabian’s presidential address last year highlighted. Our heritage does shape us, but it can also trap us into believing that we cannot change: that we must remain as we are. But this is so untrue. If this were the case I, and I suspect most of you, would not be here. Personal Identity I was born and bred in Minnesota, in the heartland of the United States, the area known as the upper Midwest. Much of my identity (like our organizations identity) was derived from my early years. I spent the first 18 years of my life in Minnesota: land of 10,000 lakes and 10 gazillion mosquitoes; land of the loon and Paul Bunyan and the headwaters of the mighty Mississippi; land of farming and grain mills and General Mills and Little House on the Prairie; land of iron mines and timber and railroad barons; land of Garrison Keillor,1,2 and the fictional, but oh so real Lake Wobegon. The Lutheran Church Protestants and pastor Ingqvist, and the Catholics of Our Lady of Perpetual Responsibility. Where all the women are good looking, the men strong, and the children above average. A place of European immigrants, farmers, and mine workers. My paternal grandparents immigrated to the United States shortly after the turn of the 20th century from Croatia of the old Yugoslavia. My maternal ancestors came to America even earlier, before the turn of the century, from German-Russian border towns. Driven by the quest for a better life, they left their homes, their comfort zones, their families, and began a new life. They chose a new identity, and they were not alone. Approximately 15 million people entered the United States from 1900 to 1920, the largest percent of population legally admitted during any 20-year period, and a population that contained my father’s soon to be parents (Fig. 2). Before 1890, 82% of immigrants came from north and Western Europe, like my German great grandparents of my mother. By 1920, that number decreased to 25%, with a dramatic increase in immigrants from East, Central, and Southern Europe. Although immigration has increased over the last century to current levels of about 1 million legal immigrants per year, the foreign born share of the population was still higher in 1900 (∼20%) than it is today (∼10%).3Figure 2.: US Immigration, 1820–1970 (from United States, 2009 No. 71).The lesson of the great immigration to the United States is one of a realization of new identity. My grandparents referred to the past life as “the old country.” These immigrants kept much of the “old country” life they valued deeply: a sense of family and community, the food and the recipes, the work ethic, and the love of their children. But the drive and the desire for a better life, for the opportunity to be something more, unsettling though it was, that drive was strong, and for many it was a drive to survive. Here in lies the crux of the paradox of identity. Identity defines who we are. It runs heart deep and bone true within us. I believe our identity, along with our progeny, and our need to be loved are uniquely defining human elements. Identity is crucial to happiness. And yet, although identity can, and does, define you, it can limit you from becoming who you are meant to be. A corporation that is wedded to its identity may not have the adaptability to survive. Blacksmiths, cowboys, Pony Express and telegraph operators, lumberjacks, miners, and even fisherman have found in their tools of identity an essential need so constrained as to not adapt, and hence, not survive. Adaptability, accepting change, and allowing the possibility of another identity are the individual’s equivalent of corporate survival, human society adaptation, and Darwinian species adaptation. Certainly, biological evidence of adaptation for survival should be an unmistakable message as to how to accept the necessary tension or even conflict between having a strong sense of identity, yet harnessing the power derived from allowing a change. That power to change allows survival. It allows regeneration, rebirth, continuity, and in secular terms, immortality. Bloom,4 writing in her novella “Away,” tells a unique American story of a young Russian Jewish immigrant in 1924 New York and her quest to find her identity. The book is replete with lines that beautifully depict the struggle her characters have with their own identity. Describing the relationship the main character has with Yakov, an older man, a kind, yet sad benefactor: “She does not bring him back to the man Yaakov knew thirty years ago; she brings the man he is now closer to who he might have been.” Closer to the possibility of a different, alternative identity. This line is reminiscent to me of one of the great quotes from Hank Devereaux, Jr., author Richard Russo’s central character in the book “Straight Man.”4 Hank is the 50-year-old head of an academic department in financial difficulty and full of departmental squabbling. He is under tremendous stress with his fledgling academic career, a prominent academic father coming for a visit, and impossible management choices he must make in the midst of severe budget cut backs (sound familiar?). Too add to his stress, Hank is also accused of killing a campus icon, a goose. Hank’s wife, increasingly frustrated with his behavior, his poor choices, his moping, and the general struggles of his mid-life crisis, one day demands of him: “Hank, be the man you are. Be the man I married” to which he replies: “Which one? Make up your mind.” Struggles with identity and solutions to this age-old question line the shelves of airport bookstores and self-help sections of the mega booksellers. A search term “identity” on Amazon.com book section Website garners 535,637 results. Adoptees have a particularly difficult time with personal identity and have been pushing to open adoption records in many states, with Maine being the most recent to grant adoptees total access to their original birth certificates (Maine LD 1084/Public Law 409). As quoted by a legislator who was an adoptee herself: “this is about identity and the truth of a human beings existence.”5,6 Our social identity may be tied to our pursuit of happiness more than any other single factor. The Canadian Institute for Advanced Research (http://www2.cifar.ca/) has an entire program dedicated to the study of identity and well being. A key finding of their work is that the key to happiness is belonging—to families, clubs, sports teams, churches, the American Association for the Surgery of Trauma (AAST), whatever. Belonging, or social connectedness, predicts happiness far better than wealth, health, or intelligence.7 It even predicts how well one will recover from an illness. The happiest Canadian cities are not the largest or wealthiest but those with the greatest sense of community and the most neighborly trust (defined as returning a lost wallet with $100). Happiness depends on belong to something and deriving ones identity from it.8 I mention this to emphasize the importance of our association, the AAST, in both our professional and personal happiness. It is in many ways an integral part of our identity, and the social connectivity of that shared identity is necessary for happiness. So, where is our society? Where is the AAST? What is the identity of our profession? Is it, as some of our members have written “near extinction,” “gasping for air,” or “undervalued?”9–11 If that is so, can we adapt? There is a new NBC television series called “Trauma” that premiers this fall (2009). In an advertising trailer for the series, one of the key characters, in a moment of extreme stress and high risk reward exclaims “I love this job!” Well, I do love my job, but will we survive? Can we allow ourselves to acknowledge the identity we were, understand the identity we are, and adapt to the identity we might be? Identity and Branding of the AAST The board of directors of the AAST have partnered with SmithBucklin Corporation’s Market Research and Statistics Group to examine the identity and branding of the AAST. Brand and identity can be defined as a mixture of tangible and intangible attributes, experiences, images, and associations that people have in their minds about a particular organization or trademark that helps distinguish products/services of one organization from another. Three things seem to best define the most successful brands of the past century: performance, relevancy, and consistency (Fig. 3). The goal of this strategic activity of the AAST is to examine who we are as a professional organization and how we can best position our society to adapt, survive, and thrive in this time of rapid evolution in medicine.Figure 3.: Key determinants of successful brand identity.Ivory soap may have been the first corporate brand, and since 1890, it has consistently touted itself with the claim of “100% pure.” Companies like McDonald’s, Levi’s, Coke, and Disney took their products national in the 1960s with mass communication and advertising to boomer generation. McDonald’s claim of consistency at every store was novel in the 1960s. Disney’s cartoons and movies set the standard for trusted family entertainment. Levi was the pant of choice for a generation, and Coke captured the emotions of the generation and linked it cold refreshment. More recently, brand management has extended beyond packaged goods to a variety of professional services and technological products and the dot.com industries. Branding an association is certainly not the same as branding a product. We are not selling Ivory soap, but we are promising something, we have an identity, and we are trying to distinguish ourselves and celebrate our uniqueness as a profession. A successful professional association brand is a complex fusion of market positioning, identity, image, and messaging that together has the power to influence people’s decision to become a member and give to our organization, participate in our programs, attend our meetings, read our journal, and importantly, seek our input, opinion, and work product. If the three things that define the most successful brands are performance, relevancy, and consistency, how are we doing? Our performance might be measured by the providing of a useful annual meeting and a valued journal. What else do members get from this organization? Is it relevant to their needs? Is it unique? On trend? Are the meeting and the journal contemporary in research and clinical practice topics? Is the meeting unique and special and provides something worthwhile? Are we consistent in our promise and message? Do we have a brand identity? Our logo and the graphics of our journal all influence our brand identity, but the key to consistency is the message we are delivering. To that end, we have had one of three planned retreats on the topics of (1) brand discovery, (2) brand development, and (3) marketing strategies. The results of the first phase, that of brand discovery or current brand identity, can be reviewed in detail on the AAST web site (http://www.aast.org). The perception and image of the AAST is illustrated in Figure 4, with the central tenet being a premier trauma surgical organization. We believe that the three greatest challenges facing the membership of the AAST are the economics of health care, the recruitment and retention of surgeons willing and able to take emergency call, and the visibility and credibility of trauma surgeons. Although there is strong recognition of the annual meeting and the Journal of Trauma and their value is considered high, there may be an opportunity to better promote and advocate for an enhanced awareness of the AAST to the public, payers, and policy makers. Although “competitors” exist, AAST is positioned as a leader in the field of trauma with additional opportunities for creating new resources and/or educational training in the area of enhancing nonsurgical skills. But although the AAST is viewed as the premier organization of thought leaders in academic trauma surgery, there is some confusion about the AAST brand and the primary audiences the association should serve.Figure 4.: Current perceptions or brand identity of the American Association for the Surgery of Trauma by member and nonmembers.The source of this anxiety resolves around our identity. As manifest by the discovery phase process, the primary decision facing the AAST at this time is whether we should pursue growth by directly serving the broader critical care community (including acute care and general surgery) or by focusing on trauma exclusively. Most input into this process, to date, supports reaching out to acute care surgeons, including providing training opportunities and funding scholarships in trauma and acute care. Key illustrative quotes are as follows: “… it (adopting acute care surgery) will broaden membership and this will increase our influence” (Member). “Supporting young people (who are mostly in acute care) is the only way (AAST) will get their name out there. We are the future of these organizations in the field of trauma and acute care research” (nonmember). “… because of acute care surgeons, we don’t know what we are. We need to come to some internal understanding of what this is and where we are going” (member). Generational Identity An interesting thread in these discussions and exploration of our identity is the effect generational differences are having in choosing and practicing careers in medicine and surgery. The Pew Reach Center has characterized the last four generations with distinct biosocial development as Generation Y, Generation X, Baby Boomers, and Seniors (Table 1).12 Unique characteristics of each of these generations can manifest in how they select a surgical career, and what they expect out of their workplace, and what they are willing to contribute to a career or job. The newest generation is Gen Y, sometimes called the Echo Boomers, Millenniums, and Next or Net Generation, are those turning 21 years of age after the year 2000. The unique characteristics of this group in the workplace are yet to be fully defined or characterized, but they represent the immediate future of our society and profession. They are often characterized as optimistic and team oriented, sports minded, innovative, and of course, environmentally conscious and obsessed with technology. Their immediate predecessors, the Generation X, have been characterized as tattooed, dot.com entrepreneurs who are media savvy and embrace diversity; and although they take marriage and parenthood seriously, they are less willing to sacrifice personal lives for the sake of workplace demands and have little employer loyalty.TABLE 1: Current Social GenerationsThese generational stereotypes do not of course necessarily apply to all subgroups, and although those choosing medicine or surgery may not be nearly so consistent in their social interplays, there is some evidence our profession must accept and adapt to this changing identity. Veysman,13 while a resident at Yale, drafted an insightful tongue-in-cheek illustration on how contemporary medical students choose their careers. His branching tree diagram is a must read for those wondering how our resident choose career pathways (Fig. 5). The lay press has noticed these trends, an example being a New York Times article noting that “Today’s medical residents, half of them women, are choosing specialties with what experts call a controllable lifestyle.”14 Dermatology tops the list.Figure 5.: Selecting a field of medicine, from “Physician, Know thyself.” Reproduced with permission from Veysman.13According to a report presented at the 2008 Association of American Medical Colleges annual meeting, the three most influential factors to choose a medical specialty are a controllable lifestyle, the options for fellowship training, and the influence of a mentor or role model.15 A 2009 report on a national survey of US general surgery residents attitudes, training experiences, and professional expectations documented that although there is a high degree (82–87%) of overall satisfaction with training and professional relationships, 14% considered leaving surgery training at some time, 62% to 64% think fellowship training is needed to safely and effectively practice, and controllable lifestyles are of increasing interest.16 There were little gender differences in attitudes and experiences. The increasing number of women in medicine and surgery and the declining number of practicing general surgeons in the United States have been well documented.17–21 Perhaps, most apparent is the fact that ∼1,000 new general surgeons have been trained each year for the past 20 years in the United States, with nearly 80% going on to another more focused or specialized fellowship and practice, leaving only about 200 new general surgeons per year added to the pool.22,23 This, coupled with the retirement of current general surgeons, accounts for the decline of 7.68 general surgeons per 100,000 population in 1981 to 5.69 surgeons per 100,000 in 2005.24,25 The developing crisis in the national general surgery workforce affects all levels of hospital and community care but is most pressing in the smaller more rural communities,26 and of course, in those willing to take trauma and emergency general surgery call. Future Trauma Surgeons Recognizing these challenges and changing face of general surgery, the trauma community developed an active response to patient and provider needs. A combined meeting of representative members of the AAST, Eastern Association for the Surgery of Trauma, Western Trauma Association, and American College of Surgeons Committee on Trauma met in August 2002 to consider the future of trauma surgery in light of the changing demographics and economics of trauma care. That initial meeting was cochaired by David Hoyt, then President of the AAST and Wayne Meredith, Chairman of the American College of Surgeons Committee on Trauma. The AAST was assigned primary responsibility for developing a plan of action, and Dr. Hoyt appointed me as the chairman of an ad hoc committee to accomplish just that. We had a metamorphosis of names and membership in its first 4 years, becoming a standing committee of the AAST in the fall of 2006 (Table 2).TABLE 2: The History of the Acute Care Surgery Committee Structure of the AAST (2002–2005)This committee considered much of the economic and demographic changes that were apparent to all practicing trauma surgery for the last decade of the 20th century. The unwillingness of many surgeons to take call, the frustration with the nonoperative nature of the specialty, and the rising interest in focused operations and lifestyle control afforded by certain specialties were all leading to a decline in recruitment and retention of trauma surgeons and most distressing, a lack of access to surgical care in many hospitals for the sickest of patients. To that end, this committee attempted to define a new identity for trauma surgery that first and foremost serves the needs of patients, while offering an attractive, viable, and sustainable career and lifestyle that maintained a solid foundation of operative experience. It was hoped that the public and other medical professions should recognize this new specialty as a valuable specialty that better defined the “trauma surgeon.”27 The primary recommendations of this committee were that the AAST should take a leadership role in defining, developing, and promoting a new postgraduate training fellowship. It was believed that this fellowship should be built on a foundation of “general surgery,” meaning it would follow core general surgery training, currently a 5-year Accreditation Council for Graduate Medical Education (ACGME) residency in the United States. The primary purpose of this new training fellowship would be to define and train a surgeon with expertise in trauma, critical care, and emergency general surgery. It was expected that this broad training would allow for great flexibility in local practice patterns, including encouraging an elective practice in general surgery if desired. This training paradigm, and the fellowships and specialty practice patterns it has spawned, has come to be know as acute care surgery.28 The details of this 2-year fellowship have been well elucidated in other publications and on the Webpage of the AAST.29 In brief, the fellowship is 2 years in length, and it follows the successful completion of an ACGME-approved general surgery residency. The fellowship includes within it the requirement of an ACGME-approved surgical critical care residency, supplemented with additional core rotations in thoracic, vascular, and hepato-biliary-pancreatic surgery, areas felt to be most deficient in core general surgery training, yet commonly encountered in the acute care setting. Extensive exposure and direct care of the injured patient is the bedrock of this fellowship. Knowledge of the management concepts and techniques of critical injury areas in neurosurgery and orthopedic surgery are highly recommended, with elective time also available for focused training in an area of the fellows choosing. Academic activities are expected, and a core curriculum, including operative experience, has been mandated. Finally, a measurement of knowledge (multiple choice test) in trauma and general surgical emergencies has been developed. It is clear that this fellowship is in its infancy, with ∼25 programs expressing an interest and intent to become acute care surgery training centers, with eight programs having been site visited (as of late 2009) by the AAST, with four approved and the others pending. A “maintenance of certification” session and examination was attended by 200 of our members at this year’s annual meeting. It is anticipated that the match program for surgical critical care will be used to select fellow applicants in most programs. The American Board of Surgery has established an Advisory Council for Trauma, Burns, and Surgical Critical Care, with ongoing discussions on the pathway to board-certification status for acute care surgery. Programs are advertising acute care surgery positions, hospitals are recruiting to acute care surgery positions, other medical specialties are talking about acute care surgery, and importantly, medical students and residents are asking questions about a career in acute care surgery. Although many criticisms have been leveled at the concept and development of this training paradigm, it has gained traction and has also magnified the identity questions we as a profession of trauma surgeons are facing. These are challenging times for our organization. We are challenging our identity, asking ourselves to consider change, to adapt, to explore, to expose, and to risk. It seems a truism that the place and time of greatest growth stems from the greatest challenges. Yet at the times of our greatest challenges, we are most unsure. Challenges force us to question the reality we have been living, and given a severe enough challenge—an illness, a death, a dependency, a natural or man-made disaster—we are forced to lay aside everything we thought to be true. Yet this offers us the time needed for reflection on our values, our purpose, and our identity. The grace that comes with this is that although we are forced to acknowledge a loss, we are given an opportunity to redefine ourselves with a greater understanding of whom we are and who we might become. And yes, I do speak from some personal experience here, but I also know from so much of the artistic forms of human expression that these moments of transition are one of emotional torment, even to the point where the pain becomes too much to bear and we give in, we retreat from the potential of discovery back to our place of complacency and comfort; only to see the challenge resurface with the arrival of a new season. The Tao Te Ching, or simply the Tao, or the Way, is a cornerstone of Chinese culture. This writing is likely to have been authored by the Chinese philosopher Lao Tzu in the sixth century B.C. Lao Tzu was probably an older contemporary of Confucius, but his life is mostly that of legend. It is said that the 5,000 words compressed into 81 short chapters of poems or prose have been translated more often than all writings except the Christian Bible. Perhaps the most famous English translation is the Paul Carus edition from 1898, but there have been hundreds of other attempts at English language translation, all editors noting some failure on their part to exactly capture the meaning. As a very casual and novice observer, and rarely a practitioner of the Tao, I likely will embarrass myself with even quoting the Tao and I beg the forgiveness of those well practiced and versed in the way, but the essence of “doing without doing” or “power without force” is often short-handedly used to describe one of the tenets of this writing. This paradox is reasonably easily understood to the Western mind by Chapter 78 (as interpreted by Le Guin and Tzu30). It begins: Nothing in the world is as soft, as weak, as water; Nothing else can wear away the hard, the strong, and remain unaltered. Soft overcomes hard, weak overcomes strong. Everybody knows it, Nobody uses the knowledge. This paradox can be extended into a discussion on identity, and although not literally translated from any chapter of the Tao, the following quote is also attributed to Lao Tzu: When I let go of what I am, I become what I might be. You cannot become who you are meant to be without letting go of who you are. I mentioned briefly that identity, love, and progeny are to me the essence of human existence. Although I have spoken at some length of identity, the AAST progeny are key to our organization’s identity and future. It is the newest and the yet to be members of this organization that must contemplate our identity and have the charge to accept the challenge to explore, expose, give up, and become what we might become. I think this a good place to stop, and hopefully, you can continue to ponder the questions of identity as a member of the AAST, and in your own lives. In closing, I want to acknowledge the tremendous support, guidance, leadership, and opportunity so many have given me along my surgical career. I already mentioned the legacy of Tom Starzl, John Najarian, and Ben Eiseman. To that, I must add Bill Curreri who gave me my first job at the University of South Alabama. The academic career training I received there by apprenticing with Arnie Luterman and others was a gift I will appreciate forever. Gene Moore and Ron Maier have been more than mentors, leaders, and role models: they have been my friends, and they, along with so many of you, have helped me find my home, and my identity in academic medicine. And my academic career owes much to the friendship of Fred Rivara and our longstanding collaboration with Ellen Mackenzie. Thank you. At the University of Washington and Harborview Medical Center, I want to thank C. James Carrico and Chip Rice for hiring me, and Ron Maier and Carlos Pellegrini for not firing me at any number of points along this 20-year journey. I could not work for a better department, nor witness finer leadership. I wish all of you could be so fortunate to work for, and with, such a talented and caring group of surgeons and staff as I have been privileged to do so for that past two decades at Harborview. It is a special place. I mentioned briefly that my wife, Deanne, and my children, Jessica, Allison, and Chelsea, and my mother and father, Greg and Elaine, are with me in the audience. I was afraid of even speaking to them, or about them and my brothers earlier, knowing the emotional lability that is a part of the catharsis of a presidential address. Although the AAST is my professional identity, they are also my personal identity. They are my past, present, and future. They are all to me, and I love them deeply and never appreciate them enough.