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Presidential address: One man's odyssey

1990; Elsevier BV; Volume: 11; Issue: 2 Linguagem: Inglês

10.1016/0741-5214(90)90261-8

1097-6809

D. Eugene Strandness,

Health and Medical Research Impacts

Being elected president of the Society for Vascular Surgery is a great honor. As you all recognize, it is largely a symbolic office because the president's tenure is very short, and there are very few second terms of office. The amount of power one has in this post is limited and consists of trying to convince one's colleagues that one's ideas for the Society have merit and are worthy of consideration. I have been pleased, indeed honored, to work with our former president, Stanley Crawford, in implementing changes that will continue to ensure the proper place for the Society for Vascular Surgery. A new dedication to our purpose for the field is clearly under way and will benefit all of us. The one formal requirement of this office is to give the presidential address. I and, I suspect, my predecessors have all looked on this task as a difficult one. Perhaps the Society should stop this practice and heed the words of Sam Rayburn who did not believe in giving speeches. He said, “You can't be asked to comment on something you didn't say.” What can one say that will be remembered? I suspect very little—particularly as it relates to the major problems facing us as individuals and as a profession. Nevertheless, preparing this address forced me to think and rethink many issues that are important to me. I have had to review not only my own professional life but the future of our profession—most particularly as it pertains to an academic life. After considerable thought, I decided to devote this talk to my own experiences and how many of these affected my career. I realize this is presumptuous, but I know this best even though my views are very biased. Simply being here giving this address is proof that I have achieved some success in my endeavors. However, as you all know, being chosen for the position of president cannot occur without having friends in high places. In academic life your work is reflected in your academic rank (except at Harvard). In my case I discovered that for each level of achievement and higher academic rank I was really not much different—just older. I finally came to realize and accept that my place in academic life was to work on the small parts of the puzzles we all face. The challenge of the jigsaw puzzle rests in the hope that by putting the little pieces in place, the big picture will finally emerge. That victory in the solution of major problems is rarely shared by any of us in this profession. Look at the problem of atherosclerosis. Although some of my work has made its detection and quantitation a reality, the impact of this effort on its final solution is at best uncertain. I suspect none of us will be alive when that puzzle is finally put together. Perhaps this is too limited a view of my role, but I think not. For me, there are no other professions outside of medicine that could have brought me to a similar place in time. For example, my professional life has been a whole series of fortunate accidents for which I can claim very little credit. I wanted to be a coach and ended up in medical school. It was my greatest desire to be a family doctor, but I ended up in surgery. I wanted to practice surgery in a fine community I had already picked out but ended up in academic medicine. I intended to pursue research in gastrointestinal disease but became involved in studies of the vascular system. Where did I go wrong? This curious series of events has always fascinated me because it seemed that at key times in my life I was being pulled—often quite violently—in opposite directions. I think it all turned out well, but it has certainly made me wonder about how careers are chosen, and how one succeeds and why another one fails. Those of us in academic life are always attempting to pick the best young men and women for tomorrow. We use their background, family history, academic record, and an interview to arrive at a decision. What would you think of a young man whose well-known father had advanced syphilis? It was also known that he hated his son. His mother was alleged to be constantly slipping between the sheets with men of status. To make things even worse our candidate had an abysmal academic record. To top it off, he walked into the interview smoking a cigar. “I am sorry Mr. Churchill—we don't believe you are qualified for the post.” I have come to the conclusion that success occurs because of a combination of family-taught values and ideals, stubbornness, a modest intellect, and an ability to work hard when others are playing. Let me explain what I mean. What about values and ideals? To what extent do they play a role in our success? Professor Allan Bloom in a challenging and depressing book entitled The Closing of the American Mind has commented on many of these issues with particular emphasis on the current generations.1Bloom A The closing of the American mind.in: Simon and Schuster, New York1987: 58Google Scholar This book forced me to reassess my background, and I think it might have a similar effect on you. I will quote him at length because what he says is true, and it is perhaps one of the saddest features of our society. “In the United States, practically speaking, the Bible was the only common culture, one that united simple and sophisticated, rich and poor, young and old—as the very model for a vision of the order of the whole of things, as well as the key to the rest of Western art, the greatest works of which were in one way or another responsive to the Bible—and provided access to the seriousness of books.” He goes on to state that we as a society are highly attuned to the concept of a healthy body, but we know virtually nothing about the development of a healthy soul. As he notes, reason cannot establish values, and belief in this is a stupid and pernicious illusion. For psychologists to tell us it is okay to feel guilty and for sociologists to talk about the sacred is, as Professor Bloom states, like a man who keeps an old toothless lion around to experience the thrills of the jungle.2Bloom A The closing of the American mind.in: Simon and Schuster, New York1987: 216Google Scholar Fortunately for me, I was spared many of these problems. I was raised in a Norwegian Lutheran environment where the rules of God and the fallibility of man were continually impressed on me. If you have ever heard Garrison Keillor talk about a Lutheran confirmation, you will know what I am referring to. Even today, I can awake from a deep sleep and recite in order the books of the Bible. The message of the Sermon on the Mount was real for me and remains a constant reminder of how we should treat our fellow man. I was pleased to find out that they erected a statue to the unknown Norwegian in Lake Wobegon. What does this all mean? Living through this period of transition of differing values that Professor Bloom discusses has made me reassess the meaning of my background. Even though I question much of what I was taught, I have not been able to erase its impact on my thinking and my conduct. I strongly believe that the mission of a physician is one of a higher calling, with a level of moral and ethical responsibility that is unique in our society. Although there are many who now question such views and the Judeo-Christian tradition, which is the basis for much of this belief, what is there to offer in its place? Certainly such a background during one's formative years provides one with a large number of prejudices, but a mind that has none is empty. It is much better to have a guilty conscience than no conscience at all. In my case, the ideals taught by my parents and my church are always there as reminders of the greater things I should aspire to but never reach. There is no doubt that these values had the greatest influence on my views toward my work and my patients. No matter how far I stray from these beliefs, they are always there and never go away. I am sure that some of these ideals are as important to many of you, but it is not fashionable to speak of them these days. My role models were an added bonus of my upbringing. This was most evident in my early years with sports figures, and later was extended to teachers, historical figures, and to physicians. I believed that my heroes possessed ideals and standards that I should try to fashion my life after. Why are heroes important? Whether or not you can ever truly emulate their lives, simply trying to follow their example provides you with an intellectual, moral, and ethical genealogy that is unique and satisfying. Good healthy role models are scarce these days, and it is a pity. In my case, my early success was in a large part due to my respect for and the guidance of Dr. Henry Harkins, my first chief. He persuaded me that becoming an academic surgeon was an important goal I could attain, and he would help me to do so. I do not see much of this today. I wish there were more. Stubbornness is a laudable trait. Perhaps other words such as devoted or dedicated are better terms, but I prefer it as it is. One must in this business stubbornly assume that one's goals are real, attainable, and worthy of the effort. This is very important, because there will be many times when others will share neither your enthusiasm, nor your goals, nor your belief in the value of your work. My own career appears on the surface to be one of steady growth. However, each goal was reached only with considerable effort and was interrupted by valleys of failure and despair. It was during the down times that my stubbornness and convictions kept me going. Possessing a modest intellect was, as it turned out, a great asset for me. I was never an academic superstar, in fact I had to work very hard to reach my goals. I was rarely asked to come to the head of any class because of my achievements. I was elected to Alpha Omega Alpha, but that occurred several years after holding the rank of professor. At the time I was not sure if it was an honor or an insult. Having to work harder than many of my colleagues left me with the knowledge that success for me could only come by this route. I never resented it once I realized the goals that I set for myself were both realistic and worth-while. Work then became fun. However, the transition from being a formal student to a student for life did not come easily. Our dean welcomed us to medical school as “students for life.” At the time, the prospect of studying in perpetuity was not very appealing. However, this represented my immaturity at the time and my lack of knowledge about medicine and its challenges. As many of you know, this remains one of the most worrisome aspects of a medical career. If we fulfilled this role—that of students for life—most of the concerns about our competence would disappear. The transition to an academic career was a gradual one as I have noted. As my place in this field evolved and as I have analyzed my successes and failures there have been many lessons I would like to review for the benefit of some of the younger members of our profession. These lessons may have as much relevance to your lives and careers as they did for me. Like many other surgical residents during my time, the decision to spend time in the research laboratory was not voluntary. It was considered a broadening experience that was resented by many of us. I wanted to work with Dr. Harkins in the gastrointestinal research laboratory, but there was no room. I was told that I had been assigned to work in the area of vascular disease—a subject about which I knew nothing and had no interest. I was given strange material to read about indicator dilution curves and methods of measuring flow and told to go to work. Since I knew nothing, I was forced to start from scratch. In trying to generate ideas and projects, I was horrified to find that the only tools available to me were my fingers, eyes, ears, and arteriography. I tried several things that at the time seemed like deadend streets, but in retrospect were very useful. I spent endless hours in the autopsy room dissecting amputated limbs in an attempt to relate the sites of tissue necrosis to the levels and extent of arterial occlusion. There were no definitive answers. I did the same thing with arteriography, but still there were few answers and no solutions to my dilemma. I needed new tools. Where could I look? I decided to turn to our physiologists, who spend their lives measuring things, to see if they could help. The only studies being done of potential value were by a Canadian by the name of Charles Egan, who was measuring blood flow in rabbit ears using a mercury strain gauge. Would it work on fingers and toes? In fact it did, and I spent a year adapting it to these appendages and using it to estimate flow, examine volume pulse waveforms, and measure limb blood pressure. Lesson number one—do not give up too soon, cast your net widely, look outside your own field. Finally, consider adopting other people's approaches to your problem. This was a great year in many respects. I learned that I could accomplish something if I tried hard enough. After I completed my residency, Dr. Harkins helped me get a position as a clinical investigator for the Veterans Administration, but now I was really on my own. My year in research was just a start. Once again I realized that I was over my head. I needed to get more research training and additional experience if I were to succeed as an academic surgeon. Fortunately, there was a 3-month course in biophysics and electronics available that I supplemented with a mathematics tutor. Lesson number two—do not be afraid to get some extra training, it always helps. As a result of this experience I was exposed to the use of ultrasonography that was being developed to measure blood flow in animals. It was immediately apparent to me that this technology would work in the human, and I began some of the early studies in this area. Lesson number three—take advantage of unique situations when they are presented to you. Serendipity is marvelous—take advantage of it. It was also at this stage in my life when I began to try to sell my ideas to my colleagues. How many of you have been there and are there now? I was encouraged to send one of my first papers to a renowned vascular physician for comments. I was sure he would share my enthusiasm for my work, and I looked forward to his constructive comments. His response was devastating to me, both personally and scientifically. I tore the paper literally to shreds, never to see it again. Saul Bellow makes the following observations about this kind of experience—“A piece of writing is an offering. You bring it to the altar and hope it will be accepted. You pray at least that rejection will not throw you into a rage and turn you into a Cain. Those who do not recognize its value now may do so later. It may well be that your true readers are not here as yet, and that your books will cause them to materialize.”3Bloom A The closing of the American mind. Simon and Schuster, New York1987Google Scholar Fortunately another event occurred at the time that helped restore my confidence. Dr. Geza DeTakats, a man of great warmth and integrity, had seen some of my work. I had the pleasure of meeting him to discuss the direction of these efforts. He seemed so genuinely interested that I felt saved. He even wanted me to keep him informed of the progress of my work. I will always be in debt to him. Lesson number four—there are people in this world who are not threatened by new ideas and are supportive of the work of young investigators. The next hurdles included submitting my work for publication. The problems are bad enough for surgical journals, but try to step outside your specialty, and you find that the problems are often magnified. You think you write well, but no one else does. When submitting manuscripts to a nonsurgical journal, being a surgeon placed you at a disadvantage—they often will not believe you. And yet publishing is the only way we have of communicating with each other, and this is the only mechanism by which we can share ideas. In addition, I believe that although it is difficult, it is essential that we publish some of our best material outside our specialty. Think what the situation might be today if we had followed this course with regard to the issue of carotid endarterectomy. The nonsurgeons in our country will not read our journals—we must take our information to them. This is unfortunate but true. We are often perceived as less than objective and certainly not true scientists. This is changing, and this trend must continue. If we were to educate each other instead of just ourselves, many problems would disappear. One of the more frequent complaints about academia is the “publish or perish” attitude that exists. Yes, it is there and for good reason—the only efficient way to transmit information is to write. The complaints about publishing usually come from people who publish very little and are too lazy to do so. Part of this difficulty may rest in the fact that it is not easy to write well. When I first began writing papers it was a very discouraging experience, made even worse by the truth of Lord Byron's remark that “Good writing is re-writing.” Surgeons are impatient people and do not like the experience of rewriting a manuscript several times to satisfy the whims of an editor. The reward, of course, is seeing a well written paper with your name on it. What of research in a surgical environment? Are we mere dabblers? Is it worth all the time, effort and money? Should we not simply confine ourselves to that which we do best, surgery? Some of our leading critics in academic general surgery have been vocal about our research, decrying its poor quality and high volume. Yet as vascular surgeons we stand in a unique position in medicine. We don't even yet have a large group of nonsurgical competitors to deal with. The cardiologists have taken over much of the exciting research in heart disease, leaving the academic cardiac surgeon in a weakened position vis-a-vis research. I do not want that to happen to us, and I hope it will never transpire on the same scale. Certainly we need companions but not directors. Research in vascular disease must remain the primary focus for the academic surgeon; without it we will die as a vibrant specialty. It is the one thing that I enjoy the most. It is a very satisfying experience to discover something that no one else is aware of. It is good for one's soul and keeps the interest level high, because there is so much more to do and uncover. The joy of recognizing something that no one before you has appreciated is a wonderful experience. Perhaps we should heed the famous words of Einstein—“God is slick, but he is not mean.” If we discover the truth, regardless of how small or insignificant it may be, God will not deny us that right or satisfaction.4Einstein: a centenary volume. Harvard University Press, Cambridge1979: 32Google Scholar What about success in research and its meaning to you and to me? Most of what I have done in my life is to contribute to the half-way technology described by Lewis Thomas. Yet it is my hope that it may assist in peeling away the layers of the onion as we search for some final answers. Ultimately, and we must never forget this, the answers to many basic biologic questions will have to be verified in the human by careful, objective studies. Perhaps we can find the truth by looking at the problem directly rather than by doing the multimillion dollar clinical endpoint studies that rarely provide an answer. At the present time there is not a single clinical trial under way that is asking questions about the disease process itself, even though we have the tools to do so. Although those in academic life continue to search for solutions to our problems and the diseases we treat, we must never lose sight of the fact that we are doctors first and surgeons second. In the transition and evolution of our knowledge, the welfare of our patients must remain first. We must always strive to do better. This can come about only by continuing to search for the truth through ongoing research. Certainly, we are doing things better and safer than when I started in this field. We understand the physiology better, we can make the diagnosis with more certainty, and we are more objective about the results of therapy. This has come about only because of research designed to answer difficult questions. Yet we must be continually vigilant and accept our role and the problems we all face. Some of our research has not been of the greatest quality. Look at the problems associated with the prosthetic graft. We have been vigorously trying to design the ideal prosthesis with very little success. We have made the walls thinner, bonded heparin to them, changed the pore size, put fuzz on the inside, outside, both sides, and given it an external support. Finally, we are planting cells on the surface to make it look and act like a real blood vessel. The human body is not totally happy with these results. On the positive side, these failures have led to the realization of the importance of the response of the arterial wall to injury and its repair. This new and enlightened approach has already enlisted a new cadre of vigorous young surgeons into an area of research that is going to have enormous benefits for the future of this field. For me, this has been one of the most promising developments in vascular surgery. We are beginning to address the fundamental problems. One of the most difficult aspects of academic life is the need to maintain one's clinical and operating skills. Is there anything worse than to be seen as only a talking surgeon and not a working surgeon? I have tried to maintain my skills and achieve the results expected of me, but it has not been easy. One of the difficult problems in this field is that incompetence is immediately recognized by one's peers and on occasion by one's patients. In vascular surgery the patient is never again the same even if the operation turns out well. If it turns out poorly, the patient is often worse and left with a situation that may not be correctible. This is a terrible prospect for the patient and for the surgeon; it can be a bitter defeat. Although few of us have done things to adversely affect history, the surgical outcome for Sir Anthony Eden clearly illustrates how a mishap not only affected his life but history as well.5James RR Anthony Eden: a biography. McGraw-Hill Book Company, New York1987Google Scholar He needed to go into the hospital to have his gall bladder removed. According to his biographer, Eden's response to the notion was, “I have to go into a nursing home for a tiresome operation, not dangerous, for my gall bladder! Isn't it stupid? But they all say I shall be the better for it.” According to his biographer he was operated on by an experienced surgeon whose name is not given. Eden's bile duct was accidentally cut. He was told later, “The knife slipped.” A clear blunder! A second operation was required. The biographer records, “... his life had been saved by the energy and skill of a junior surgeon and his team—it had been a very close thing.” Fate can be very cruel and seldom more so than it was to Anthony Edein in 1953. He had lost his health and his premiership as a direct result of a medical mistake. This story has many threads one can use to weave a whole series of tales we can relate to. The lessons from this example are clear. Imagine how many similar tales are played out daily in our society where we continue to struggle with the issue of competence. It is most unfortunate that although we recognize incompetence within our ranks we continue to act as if it did not exist. The struggle by the late Jack Wylie is a case in point. He did not want vascular surgery identified as a speciality for our own gratification. He felt strongly that patients with vascular disease deserved better treatment than they were getting, and he was right. Why do surgeons undertake tasks for which they are not properly trained? Getting in over one's head in vascular surgery is a very unpleasant experience. Do we have to tolerate this simply to please those who are opposed to the concept of vascular surgery as a discipline? Our patients and the hospitals in which we work are beginning to say no, and it is time we listen more closely. We must be the patients' advocate and not their adversary. The perceived need for extra training in vascular surgery was vigorously resisted by our General Surgery colleagues. The fact is that general surgery, as I knew it and you know it, is in serious trouble. Everyone knows it, but it has only been recently that the leaders in the field have begun to discuss the changes that are needed. We all hope that it will not die a slow death as the forces for change pass it by. With few exceptions those general surgeons who want to do vascular surgery should have extra training. As an academician, I am involved in the training of vascular fellows and working with them has been one of the more rewarding experiences of my career. When I look at them in practice, I realize they have talents that I do not possess. In fact, most of them have demonstrated the two qualities most important for a successful career—a true love of their patients and the desire to do the best possible job. This makes our job much easier and also provides assurance to the public that our product is one we can all be proud of and that they can trust. In a nutshell, this is the essence of good medicine and exactly what we need at this time in our profession. Like all of you, I am here because of the influences of many people. My success has been possible only because of the help and support of my family and friends. My patients, my wife, and children must take a great deal of the credit for my success. Without their support it would not have been possible. As Goethe said, “If you remove from me what I owe to other people, there would be little left.” I also want to thank all of the trainees, residents, fellows, and technologists I have had the pleasure of working with. Thank you for a job well done. You have added immeasurably to my professional and personal life, and I will always be grateful for that experience. There are people in my life to whom I am particularly grateful, and I would like to acknowledge them at this time. First, there is David Sumner, whose intellect and honesty have no match. His friendship and scholarly approach to everything he does will always be admired and respected by me. Mr. Gene Hokanson came into my professional life at a special and unique time. He was the first non-physician I ever hired, and he proved to me how good ideas can be put to practice if you put your mind to it. When I let Bob Barnes join our group I was not sure what I was getting into. His vigor and enthusiasm were infectious, as was his constant reminder that he was going to make me famous. I appreciated that, but even more important he came to Seattle on his own to counsel me at a difficult time in my professional life. This is something I will never forget. In my residency I made a friend who is the most generous human being I have ever known. Dr. Richard Schultz of Omaha has been a true and loyal friend throughout my professional life. I had to go to far away places to meet the next two people who have had an impact on my life. Dr. Marc Cairols of Barcelona, Spain, has an appreciation of the meaning of life, medicine, and people that I will always admire. Finally, Dr. Brian Thiele, an import from Australia, is in many ways my sounding board for ideas. He is a surgeon's surgeon, who understands better than most the role of excellence. He has a view for the future that most of us will never have. Our friendship continues to grow. Thank you to all of you. Our lives, careers, successes, and failures are all enmeshed in our friendships, which have stood the test of time.