Portal de Periódicos da CAPES

Masters and Commanders

2005; Elsevier BV; Volume: 41; Issue: 4 Linguagem: Inglês

10.1016/j.jvs.2005.01.021

1097-6809

Mitchell H. Goldman,

Cardiac, Anesthesia and Surgical Outcomes

It is said that a president’s speech should be short, succinct, and concerning something about which you are passionate. I am a vascular surgeon and physician. Therefore, a subject pertaining to a vascular topic would seem appropriate if it were not for the tradition of erudition on a subject not of a vascular nature set forth by my predecessors. I would like to speak, hopefully briefly, about but two of my deepest passions: the sea, and mentoring. In the series of sea novels by Patrick O’Brian that chronicle the late 18th century exploits of a somewhat corpulent rising captain, Jack Aubrey, and a not so dashing ship’s surgeon and sometimes spy for the Royal Navy, one vignette captured my attention and the attention of the producers of the movie, Master and Commander. It is the mentorship of a midshipman by Stephen Maturin, the surgeon. The fact that this tutelage plays an essential role in the drama of the movie notwithstanding, it is a fact that the training systems of the navies of the past bear a striking resemblance to the systems of surgical education we have practiced up to now, but without the “cat o’nine tails.” It is not a coincidence that many physicians and, in particular, surgeons have succumbed to the lure of the sea, to its amalgamation of rigorous life, uncertainty of outcomes, natural beauty, need for preparedness, scientific data suffused with experiential lore, traditional harbors and new found gunk holes, and finally, a tradition of mutual aid and mentoring. For a moment, I must digress and pay homage to a few of my mentors. I first have to note that while all parents are mentors, for better or for worse, I was particularly lucky to have been launched by two whose approach permeated my life and suffused my career with the elements necessary for success: the taciturn commander, stickler for detail, parsimonious with praise but fair with criticism and commendation; and the nurturing boson, interpreter of command, ameliorating disappointment, and celebrating achievement. These two established the structure of my approach, on the sea and off. Next, an English teacher, Peter Benelli, had the audacity to fail my first paper and the creativity to show me how to build from that failure and that perseverance, coupled with self-criticism, results in ultimate success. He unknowingly prepared me for many a morbidity and mortality conference. Finally, my medical mentors are too numerous to mention without leaving out some important ones. However, I must recognize Francis Moore and Joseph Murray, mostly for their contribution to the ambiance and esprit that filled the Brigham of the early 70s and propelled an aspiring internist into an academic career in surgery. This society, The Southern Association for Vascular Surgery, has served as the ultimate mentorship experience for me. Robert Barnes, HM Lee, and Lazar Greenfield promoted my early membership, and with the help of Mel Williams, Hugh Trout, and Tim String, to name just a few of the many exemplars, my growth was fostered in the society and in vascular surgery as a whole. Perhaps it just a manifestation of age, but I have recently been surprised by others who have now been giving me the appellation of mentor. It kind of sneaked up on me, caught me by the lee. I had been comfortable with the role of surgeon, sometime scientist, and teacher. Propelled by the insecurity of misnomer, I have tried to dissect the meaning of the appellation as it applies to what I do. The term mentor derives from Greek mythology, where Athena takes the form of Mentor and is enlisted by Ulysses to watch over his son, Telemachus. Ulysses’ admonition, to, “Tell him all you know,” sets one of the parameters of mentoring but leaves open the aspect of self-development that is implied in mentoring as we know it. It may be of no small coincidence that Ulysses’ journeys were mostly at sea, that Athena’s upbringing was orchestrated by Triton the son of Poseidon, the god of the sea, and that surgical training and mentorship mimic that of the sea. I have forgone the excellent papers on mentoring and on teaching in surgical education. Unfortunately, most of them have to do with the academic environment and progression in that venue. The literature is also replete with how to mentor or coach in business, in education, in sports, and in the family.1Whitmore J. Coaching for performance.3rd edition. Nicholas Brealey Publishing, London2002Google Scholar Coaching, however, differs from mentoring in that it takes a shorter more objective-oriented approach, and although many of the aspects of the coach-disciple and mentor-mentee relationship are similar, as pointed out by the Olympic medallist Dave Hemery, mentorship should occur in an environment where the end point is less concrete and the lessons are more universal.2Hemery D. Another Hurdle. The making of an Olympic champion. Taplinger Publishing Co, Inc, New York, NY1976Google Scholar In fact, all of life seems to be mentoring in one form or another. This makes sense to me as a biologic imperative transcendent into a societal and cultural imperative. Perhaps we are simply fulfilling a long string of molecular messages begun by some nucleic ancestor in response to the need to carry on. It seems like a winning process, not a zero sum game, one that has served creation for eons.3Wright R. Nonzero The logic of human destiny. Pantheon Books, New York2000Google Scholar In that context, what we do seems not only natural, but, ordinary. It is simply part of life. We may not even be able to control its genetic process. It just happens. However, our tradition’s emphasis, beginning with the exhortation in that oath that many of us took at the beginning of our medical journey, has been firmly rooted in both coaching and mentorship, first as the only method of passing on the body of knowledge and later as an adjunct to the universities’ curricular endeavors. Unfortunately, teaching and mentorship in the last 50 years has often taken a back seat to research and, more recently, to financial responsibilities (Fig).4Ludmerer K.M. Time to heal.in: Oxford University Press, Inc, New York, NY1999: 215Google Scholar What is it that happens? A student, a resident, a faculty member, a child, a team member, all benefit from support, encouragement, resources, kind words, and direction to the extent to which they can use them. That’s the issue, the extent to which they can use them. Although I may be clear in my mind about what is needed or what direction to take, they, the users, don’t always concur and take only pips of my mentorship and distort it, reframe it, and combine it with other bits and pieces and come out with a novel concoction that becomes their own. Should I be disappointed that I am not a catechism? Certainly not! I am a catalyst to an exciting and unpredictable reaction that has no bounds. For that reason, the ability and skills of the mentee are immaterial. It’s the fact the they have a potential—an unknown potential—that when mentored moves in a kinetic way along its own course to its natural endpoint. I can just watch with amazement. Also, whether they are “stars” seems immaterial. In the first place, although I might know what a star is now, I am uncertain of what a star will be in the future: a black hole, a quark, a glittering sun. Who knows? Mentoring is simply helping someone become closest to what they will be. Coaching the best players is gratifying. Coaching the lesser players is likewise fulfilling. Perhaps even more. The elements of mentoring have been described in the context of modern academic surgery, and they essentially form the mnemonic “mentors”: motivating, empowering and encouraging, nurturing self-confidence and self-reliance, teaching by example, offering wise counsel, raising the performance bar, shining in the reflected light.5Souba W. The essence of mentoring in academic surgery.J Surg Onc. 2000; 75: 75-79Crossref PubMed Scopus (13) Google Scholar However, I hold that the approach, the attitude is—or should be—inherent in all of medicine and in all who practice its arts, whether in the halls of the academic center or in the clinic of the rural practice. Mentoring is an indispensable portion of medicine. It is probably not a coincidence that it is part of the Hippocratic oath. If medicine were business, we would have no business mentoring—creating our competition. In fact, while some of our confreres tried, historically, to retain a franchise right to a cure or, even more recently, the patent for a therapy, they have been given monikers that were less than flattering, often cast out, looked askance at, or just disliked. It still happens: the forceps was a good example, snake oil a bad one, the genome and biologics perhaps the next. But, isn’t it also true that you have to mentor to cure? Isn’t it part of the healing process that the sick trust the physician, are guided and nurtured by him, and for better or worse, follow the advice given with the expectation of success. Support, kind words, resources, encouragement, and direction are integral to the doctor’s effort to effect a treatment. I cannot imagine a complete and empathetic physician who doesn’t mentor. It strikes me as fundamental to physicians loosing the meaning of what they do, that they, early on, give up the role of guide and friend as part of their therapy. It wears away early, the empathy and connection erodes when they don’t have time to teach students, nurses, associates, and ultimately, seems to be exemplified by the timed office. Once, when I was running for a class office, a reporter from the school newspaper asked me what the “scam” was. He meant to ask, what was in it for me. While I waxed on about doing things for the class bringing gratification, I was left with a sense of incompleteness with the answer. I sensed that the reporter was likewise unsatisfied. That incompleteness persists in mentoring if the only reward or gain perceived is on the recipient’s side. The mentor gains satisfaction—satisfaction in seeing growth, accomplishment, and response to the mentorship.6Souba W.W. Mentoring young academic surgeons, our most precious asset.J Surg Res. 1999; 82: 113-120Abstract Full Text PDF PubMed Scopus (58) Google Scholar But what if there is none of that? Like the experiment, the picture, the plant, the failed English paper, what if the mentee follows a different course than what is offered? Is there still gain for the mentor? There is, if the underlying focus of the event is the action of the event itself, the act of mentoring. We are drawn by that inherent force, some more driven than others, to effect success in each other. The satisfaction of doing that, alone, ought to suffice; but as it turns out, we are often given even more reward for the attempt. Adulation, praise, new ideas generated by the interaction, love, a sense of importance, and meaning are all parts of the gain for successful mentorship. These responses are culturally ingrained and may be biologically entrained to ensure continuation and contribution to societal success. However, a lot depends on how one defines success. Preconceived end points, like preconceived results in an experiment, can be the downfall of a relationship involving mentorship. It risks throwing out the supernatant containing the real solution to an experimental hypothesis but retaining the originally more interesting but ultimately unenlightening pellet. Although a view of the goal is essential, it must be that the vision is only an option, like a cosmologic event, one of many options. Success rests in the recognition of the value of many end points. An experiment gone awry may have more meaning than obtaining the desired result. A revised paper represents one of many solutions. A person who chooses a path different from the original one is not a failure of the mentorship, unless the mentor has been so unidirected himself, so tied to one goal for a sense of success, that the value of the interaction itself has been lost. The scam for the mentor is boundless if the reward is inherent in the doing and if the mentor is capable of seeing the benefit of any of a number of outcomes. How analogous is the training in surgery to that of the rising post-captain of the navy? For this comparison one must look at the origins of our educational system, surgical training, in the Halstedian manner: 1It took a long time to train2Time was indefinite3A close personal relationship developed4Gradual appreciation of autonomy5Advancement dependent on the good will of the professor But more important than the rites of advancement is the analogy of content that the trainees of both endeavors encountered: 1Complex and changing systematic knowledge2Dead reckoning—making decisions with little data3Part of a team where all must contribute4Working under adverse conditions5On your own—situations you can’t get out of—you are all alone on a big ocean6Long hours of boredom interspersed with moments of acute terror7Standing watch—the recurrent call to rise to a new situation despite personal needs.8Making quick decisions that have lasting impact9There is an end and a rehash—ability to assess the decisions’ results critically and adjusting10The preparation before the voyage11The start, the initial sense of expectation, excitement12Use of complex tools, the choice of the right sails13All done in the context of fleet, a hierarchy, a geopolitical system Indeed the training and the progression that Aubrey evinced in O’Brien’s navy, with its keel weighted with mentorship, has its parallel in our surgical system. But, is the parallel appropriate to today’s environment with what I would call the “Squeeze” of surgical training and practice?2Hemery D. Another Hurdle. The making of an Olympic champion. Taplinger Publishing Co, Inc, New York, NY1976Google Scholar, 7Wanzel K.R. Ward M. Reznick R.K. Teaching the surgical craft from selection to certification.Curr Probl Surg. 2002; 39: 573-659Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar I would aver that it is even more essential, given the rapidly changing and insecure environment of surgical training and practice, especially vascular surgical practice, that we maintain the core values of our profession: empathy, learning, inquiry, fastidious attention to details, and charity, and that we steadfastly imbue those values in our mentees. As we consider other paradigms of training in vascular surgery, the time available is becoming shorter, yet the experience to impart is even fuller as knowledge, responsibility, and commitment increase. Some advocate computer-based curricula, some simulation-based experience, some actor/patients, virtual trainers, or other devices that objectify, reduce, and standardize what we do. Even the much-used analogy of pilot training through simulators has to encompass initial rides as a copilot. In as much as I wouldn’t like to take the first ride with a pilot who has only flown a training simulator, I don’t foresee, nor do I feel completely comfortable with HAL as the complete mentor. Adjunct perhaps, but the suffusion of the human spirit—the spirit of those who have mentored us—must remain essential to the successful continuance of our profession. The fact is, short of lifestyle, the lack of a surgical mentor is the second most common reason given for not having chosen surgery as a career. Some of you will say, “What does this have to do with me? After all, I am in practice, I have no students, I don’t teach.” Some actually advertise the latter with pride, as if the badge confers some indication of higher quality. I would chasten you with a lost opportunity, an opportunity to bring the excitement and the joy you find in your profession to those young people, those midshipmen in your community, who will tentatively explore a career in medicine. In fact, whether they sign on depends somewhat on whether they have found a mentor and whether you, the mentor, found the scam. I give you as an example the Medical Explorations program at West High School in Knoxville (http://gsm.utmck.ed/medexp/main.htm). In the last 12 years, more than 50 practicing physicians have taken more than 180 high school juniors and seniors into their practices, into their radiology suites and histology labs, and into their operating rooms and emergency rooms for periods of 1 to 2 weeks in a 6-week summer course. The students are full time members of their mentors’ practices, be they in the office or “on call” with the trauma team. Those students have had the benefit of early mentorship, and the early graduates of that program currently populate residencies, nursing schools, pharmacies, and EMT facilities. One, in fact, is on the academic staff of one of our own southern medical centers, UT, San Antonio. Some did not go on to medically related careers. One would like to think we helped with those decisions too. There is a risk, the risk of the disaffected mariner, the individual who is so vexed with his field, or for that matter his life, that he feels compelled to tell his tale of affliction to anyone who he can stop to listen. He finds the compulsion to infuse these young people with the so-called realities, all negative, of a medical career. Sometimes, I hear from a student sent to shadow a physician, “medicine is in trouble,” or “I would never advise my child to pursue a medical career.” Perhaps not; not, at least, his career, as I wager that the premise, the underlying motivation that led the errant mentor to his vocation had less to do with the prospering and succoring of mankind than the prosperity and success of the man. The malcontents don’t last long in the Medical Explorations program. The students, idealistic as they are, weed them out. The upshot is that there is opportunity for all to attract and to mentor bright young people who are called early by the honored ethos of medicine. In short, what we do now to better our profession in great part depends on whether we recognize the impact of mentorship. How many medical student applicants mention a physician mentor as their reason for choosing the profession?8Colletti L.M. Mulholland M.W. Sonnad S.S. Perceived obstacles to career success for women in academic surgery.Arch Surg. 2000; 135: 972-977Crossref PubMed Scopus (140) Google Scholar How many medical students note the positive or, in some noteworthy cases, the negative examples of our profession as reasons for not choosing surgery as a career?9Thakur A. Fedorka P. Buchmiller-Crair T.L. Atkinson J.B. Fonkalsrud E.W. Impact of mentor guidance in surgical career selection.J Pediatric Surg. 2001; 36: 1802-1804Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar We asked that question of general surgery interviewees and found that they confirmed what others have reported: mentorship is important (Table). Women note the absence of mentors in surgery as one of the failures of our current system. How many residents have shown interest or disinterest in vascular surgery because of our relationship to them. And finally, how many of us still do it the way a mentor did? We have an opportunity to use these gifts that have been bestowed upon us by a lineage of mentors to create a future of unquestionable excellence, commitment, and humanity. If we all strive to achieve that in our own venues, the need for official competencies is obviated from the appearance of earliest interest in medicine.Table Importance of mentoring among applicants to surgeryMentor importance Medical schoolSurgerySex importance Medical schoolSurgeryMen2.811.943.64.00Women3.003.02.83.5Total2.912.473.83.15Legend: Scale of 1to 5; 1, very; 5, not important. Open table in a new tab Legend: Scale of 1to 5; 1, very; 5, not important. Well, what about Aubrey and Maturin? It turns out that the young midshipman is able to pass to Captain Aubrey the concept of camouflage, a nautical Phasmid, elucidated by the ship’s surgeon, enabling him to extricate his ship from a desperate situation and press his mission to successful conclusion. I urge you all to take up the mantle of mentoring; in your practices, in your communities, and in your academic setting. Pass on the spark of the profession that has nurtured and mentored and given us the exciting and fruitful lives we enjoy. It is a singular privilege and honor to serve as guides and catalysts to those who would embark upon a venture affecting the lives of mankind. I would leave you with the words of the English poet, Tennyson, so dear to one of our medical mentors, William Osler.10Hinohara S. Niki H. “Aequinimitas,” Sir William Osler in Osler’s “A way of life and other addresses.”.in: Duke University Press, Durham and London2001: 28Google Scholar Whatever way my days decline, I felt and feel, tho’ left alone, His being working in mine own, The footsteps of his life in mine.11In Memorium A.H.H. In: Day A, editor. Alfred Lord Tennyson, selected poems. London: Penguin Books, 1991; part 85, stanza 11, p. 183.Google Scholar Again, I would like to thank all those who have guided and sustained my voyage and, especially, the Association for its mentorship of me and for this singular honor.8,9