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The Athleticism of Surgery and Life: Super Performing at Work and at Home …And Beacons of Light

2014; Elsevier BV; Volume: 98; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2014.05.103

1552-6259

Robert J. Cerfolio,

History of Medical Practice

Dr Cerfolio discloses a financial relationship with Intuitive Surgical.My address is different from prior Presidential Addresses, both in delivery and content. I am not standing behind a lectern but rather uncloaked on a stage, and my content is more personal.Many of you knew my wife of 22 years, the love of my life, Lorraine, who died during my Presidency on April 14, 2013 at 10:23 AM. It has been indescribably difficult for me and my three boys but we will persevere in her honor. Lorraine loved to watch the Oscars’ acceptance speeches. When someone gives a laundry list of thank you's about a host of faceless people it means little. So I will only acknowledge today, those in attendance, and ask them to stand.My goals are to entertain you, to respect your time, and most importantly to change your culture. I will do this by telling 4 simple stories. Please put away the great distractors of the third millennium, your cell phones. During my introduction, my three teenage boys have already texted me about how bad my hair looks, my tie is crooked, etc.Our culture and our value set define us. It is wasteful for me to talk about changing your culture unless I provide specific strategies to implement. Life is full of opportunity. Someone sitting next to you right now could change your life. Unless you recognize these opportunities and have fully prepared for them you will squander them and not actualize their full potential. Diligent and disciplined daily preparation is the best way to fully capitalize on opportunities.Today, when I talk about my spouse I want you to think of yours, when I show pictures of my children think of yours, and think of your residents and medical students.My first advice is to recognize and then aggressively seize the ubiquitous opportunities around you every day. See the positives in all circumstances no matter how negative or dark they seem. My Lorraine, my wife, my life, died five months ago. What positives are there? Lorraine had lots of food in the house that was not necessarily good for you. Now they are gone, replaced with protein shakes.It is shortsighted for a medical student or resident to lament “I have two years left.” You do not magically change when you graduate high school or medical school or when your first child is born. Live and enjoy each phase of life and see the positive that each offers.To execute this strategy you need to write down the pluses and the minuses of each phase of your life. Whether you're an all-American baseball player or an intramural co-ed soccer player is irrelevant, capitalize on the experience.During my introduction you heard a list of awards, honors, and accolades, but they do not define me. Rather, our relationships with our families and friends define us. But if accolades, grades, honors, and awards are irrelevant then why not spend more time at home and underperform at work or at school?Most here today are super performers in our roles at work, but what are we in the roles we play at home? How can we super perform at home and at work? What is the end result of being a super performer in only a few roles?Story 1It was June 14, 2010. It was a typical day for me. I had eight operations and a few visiting surgeons watching. What made it different was Lorraine was going to the operating room to have bilateral mastectomies for a 9-mm cancerous nodule in her left breast. So I, like so many of you, went to work that day after sitting with her preoperatively.I had just started sewing the pulmonary artery back together during a sleeve left upper lobectomy and was “in the zone.” The chest was shallow, the wound well lit, and the artery thick. Lorraine's surgeon walked in. “The sentinel node was positive” she said. And I knew my life, our life, had changed.There was going to be chemotherapy. Lorraine was a cancer patient and I the husband of one. As I turned my headlight back into the patient’s chest, I, as a performer, had changed, despite my vast experience of having performed over 14,000 operations. I, like many of you, perhaps thought I was invulnerable. I was not. The wound was suddenly deep and dark, the artery thin and fragile, and my hands were shaky. I let my emotions affect my ability to perform. I'm embarrassed to admit it. But it happened, and today I want to openly discuss it and how we do what we do every day as human beings who are super performers. One visiting surgeon observer said to me, “Your wife is having surgery and you are operating and lecturing to us. Why are you here?” We all perform at our jobs under personal stress. But why do we do it when most do not? It is because we honor our patients; and super performers honor their commitment to excellence.How did I get there I wondered. I blame my parents. They helped shaped my culture, which is a byproduct of a value set that is inculcated by our coaches. Our parents are our first and most important coach. They taught me accountability. “Take pride in your work,” my dad told me. “You own it, you are responsible for it.”When I was a young boy, my Dad had me cut the grass. I loved seeing the wheel marks in the lawn, the “lines of gratification,” as I call them. “I did that,” I would say. These principles were inculcated in me by my parents and by my mentors; doctors and others in this room who honor me today by being here. But “lines of gratification,” of which there are many types, are empty when there is nobody to share them with. I used to love to have Lorraine look out the kitchen window and revel at our lawn work, “It looks really nice today, honey; you and the boys did a good job.” And she knew just how to say it and gently place her hand on my shoulder and smile to completely fulfill me.What brings the most joy to us in life are the people around us, “our beacons of light.” It is not the awards and not the titles, but the sharing of them with others. I have had, and have allowed people around me, to serve as beacons of light in the night. They have helped me navigate through the dark and rough seas to dock in a warm harbor. The first and most important beacons in my life are here today, my Mom and Dad, the real Dr and Mrs Robert Cerfolio (Fig 1).Fig 1Dr Cerfolio’s parents, Dr and Mrs Robert J. Cerfolio.View Large Image Figure ViewerDownload (PPT)They have something I'll never have, 60 years of marriage. And they worked together every day as well. My mom is a nurse and ran my Dad’s urologic office every day for 40 years. A work ethic and desire to be excellent is first taught in our home with two parents who are committed coaches and who showed their children how to super perform both inside and outside the home. In the operating room, we as surgeons act like surrogate parents to our trainees. We should take the same pride in our medical students, residents, and fellows as we do in our own children. If we did this, almost all of the problems in our specialty, the number and quality of our applications, the number of female applicants, even the money, would get better. Major problems quickly are solved when we make culture changes, not when we promulgate new policies or rules.Super performers, great athletes, and surgeons require continued realignment from mentors; from beacons in the night. Thus, my next strategy is to become a beacon of light to others. This is best executed by listing who are your beacons and how and why they became your beacons. Could you do the same for others around you? Next, when was the last time you reconnected with your beacons? At Lorraine’s funeral, I saw more of them than I had in 20 years. Why did it take a funeral for me to see them? Don't make the mistake I did. Re-establish old connections now. Don’t wait for the love of your life to die to see old friends or to be a better person.What are your lines of gratification? When I was a boy, it was wheel marks in the moist lawn. Now it is subcuticular skin closures in the chest. They are no different really. I am accountable for both marks. There are many lines of gratification in life. Some medical ones are shown in Figure 2 which depicts the reduction in our morbidity, decreased operative times, and reduction in mortality from 3.2% to 0.24% in over 15,000 operations, and in 2,114 lobectomies that I have performed. And we choose to get better. We choose to work harder to improve these numbers as a team.Fig 2Reduction in morbidity and mortality (M/M) and decreased operative times over 15,000 operations and in 2,114 lobectomies performed by Dr Cerfolio. (LOS = length of stay.)View Large Image Figure ViewerDownload (PPT)The bar graph in Figure 3 shows the surgical volume at the University of Alabama at Birmingham (UAB). I started in 1996 but it is the blue bars that I am most proud of as these represent the volume of operations that my partner, Dr Doug Minnich, has performed. I am proud to call him my partner and of his international accomplishments.Fig 3Bar graph showing the surgical volume at the University of Alabama at Birmingham (UAB).View Large Image Figure ViewerDownload (PPT)One of my first thoracic coaches, Dr Mark Allen, is here today. Thank you so much for all you have done for me.This type of surgical volume doesn't happen unless you have incredible support from your boss and mentor, Dr Jim Kirklin. He and his wife Terry are two beautiful beacons of light because without resources everyone knows I wouldn't be doing that volume of surgery.Most of you know my next beacon, Dr Ayesha Bryant. We have presented probably 30 papers at the 4 national meetings over the years. Thank you so much for all you have done for me professionally.A lecture is nothing more than a series of empty words unless you apply strategies that help you change your behavior. The next strategy is to write down your lines of gratification and ask how they might evolve. How has the culture around you allowed you to maximize those lines and how can you change it? Do a 360° analysis and change what you do not like when you get the results. Another exercise is to write your own eulogy. When we wrote Lorraine's eulogy it seemed she maximized her beacon of light to so many others, but I have not. How can we all do the same?Story 2It was a Wednesday two years later in 2012. Lorraine was cured, her cancer was gone, and her beautiful blonde hair was back. I was doing a routine lobectomy and I caused a small hole in the pulmonary artery. In thirty seconds we had lost a liter and a half of blood. This patient had unsuspected pulmonary artery hypertension. She developed right ventricle failure and, despite going on-pump, she did not survive. I recalled her husband saying, “How could this happen?” I felt so ashamed, embarrassed, and that I had abandoned them. I went back to my little office near the operating room. The next patient was already prepped and draped. I had to get ready to perform because our patients are counting on us to super perform under pressure and irrespective of circumstances. My head light lit up a poster in my office that Lorraine had given me a long time ago (Fig 4). Although I had looked at it many times I hadn't really understood its message until just then. We're not alone in that operating room or during a baseball game. There are many beacons of light in our life with us. My wife Lorraine remains my brightest beacon and I still receive her messages today. She helped me get through the rest of that week with the Good Lord’s help. When I got home that night, Lorraine in her loving and sweet way consoled me and hugged me. But as I walked around for a few days feeling sorry for myself and for that patient’s family, my middle son Alec parroted back a speech to me that I had given to him many times. Alec said, “Be a man, grow up, and stop feeling sorry for yourself and go do your job.” Alec, you were right. You are one of my beacons of light as well. I love you.Fig 4Inspirational poster from Dr Cerfolio’s wife that hangs in his office.View Large Image Figure ViewerDownload (PPT)I have many other important beacons in this room today: Rob and Anita Headrick, John and Anne Howington, Joe and Ann Dearani, Mark and Diane Krasna, and many of Lorraine’s great friends who are here as well.I have told you two stories of me in trouble in the operating room. I employed specific strategies that I learned and honed from years of playing sports in high school and in college to help me super perform. I cannot describe them all today but my book has them all. Some are muscle relaxation techniques, deep breathing, and visualization. There are several ways to visualize. You can view yourself from afar as if you are a spectator or you can view yourself from your own perspective. If you compete in a static field like a bowler or a professional singer you will employ different strategies than a performer who plays on a dynamic field and who has opponents who alter the playing field; like a baseball or football player, or a surgeon who competes against cancer. These are all outlined in depth in my book.During my introduction you heard that I was a high school All-American athlete from playing three sports in high school, football, hockey, and baseball, and in college I was an Academic All-American Baseball player. But what you did not hear is that the year before I was an All-American I was not so good. I played shortstop that year in college and made 12 errors in a 25-game season. So what changed between 1984 and 1985? I changed my pregame routine and my intra-game anxiety management. I created an image of pouring a bottle of calmness over my head as I ran out to play shortstop. I could literally feel the calmness run down my shoulders into my fingertips. This is a great image that I have given many residents and medical students as they are about to sew in the operating room. If I get in trouble in the operating room now I often think of Lorraine. She, unlike me, was always so calm, quiet, and classy. Just the thought of her delivers calmness to me.We, as surgeons, are athletes. Despite defeat or failure, we compete the next day. Surgeons are like a relief pitcher who blows a save one night but must have a short memory and come back the next night to super perform.What drives us day after week after month after year to super perform? There are few things in life that are worth believing in. There is love, there is our family, and if you are a super performer at work it is your career. For surgeons it is our patients. If you are an athlete, it's your sport. Surgery is our code of honor, our courage, our virtue. But it also is our mistress. It seduces us away from our family foundation and grounding beacons.It is our passion for the patient, our desire for excellence, and our thrill to produce lines of gratification that pull us away. The truth is we like it. We enjoy super performing in the surgical arena. We enjoy the challenge and satisfaction.Surgeons like athletes need ego. It is a necessary building block for success. We teach it to our children and students early so they love themselves, make good decisions, do not injure God’s finite gift’s that he bestows on us. It helps us ascend the valleys of life and navigate the dark beaconless nights. But, when you have bountiful success early too much ego leads to hubris and arrogance. So ego must be balanced with humility. Humility is poorly understood. Humility is not thinking less about yourself, but rather thinking about yourself less often and respecting those with a culture that differs from yours.One technique I teach to maintain ego while preventing hubris is what I call “shrinking the playing field in your mind.” This means treating all team members, especially those who may not perform directly with you but help prepare your performance, with the same respect and dignity you show to other performers, especially in the moments just prior to your performance.When I was in the locker room before my baseball games I also applied several thick layers of ego long before the game started. What I have learned is how to apply it in smaller amounts and closer to the event. The goal is to make it invisible under your uniform or under your scrubs. Then learn to shrink it further so it is even smaller than the field of play and it only exists in the mind of a humble super performer. So when handed the wrong instrument during a critical part of an operation (ie, your shortstop boots a routine ground ball at a crucial part of the game) your response is tempered. You decide you will respond to his or her mistake by interacting with him positively and that your team will prevail because the team has properly prepared for this next moment. You cannot prepare for everything that may go wrong, but you can prepare your reaction to any adversity.Surgeons, like athletes, love to compete. Early in our careers we mistakenly view our contemporaries in our specialty at neighboring hospitals as competition. This perspective could not be more wrong. They can be your brightest professional beacons if you treat them right. I have many here today: Dan Miller; Steven Yang; Josh Sonett; Doug and Johanne Wood; Alec Patterson; Mark and Diane Krasna; Jeff and Stacey Jacobs; Joe and Louise Miller; Dave Jones; and Jack Thayer, some of my earliest coaches.Coaching is everything. The best athletes in the world have coaches and they only hit, kick, and shoot a ball. Yet, we as surgeons who make life and death decisions every day do not. Why? I've enjoyed coaching many surgeons over the past several years. Perhaps we are better called mentors, advisors, mental coaches, leadership advocates, or even surgical psychologists. We must learn to be better coaches because our students are our future caregivers and our legacy.Teaching is coaching and coaching is an opportunity and an opportunity is an honor, and therefore teaching is an honor. The entire basis for the robotic program that I have developed called PRI2ME (Programmatic Robotic Minimally Invasive Mentoring Experience) is rooted in this point. Its goal is to teach excellence to teams.To train the uninitiated or the government restricted is problematic. In 1988 the average general surgical resident finished with 2,340 operations and now it is 750. How can you become a super performer, which mandates at least 10,000 hours of practice when rules prevent practice?My three boys grow tired of hearing me espouse the culture of “10,000 hours.” The government does not come to our house and tell us to stop lifting weights or get out of the batting cage or the bullpen because we have practiced too long. This philosophy is anti-American and anti-super performer. But since we have allowed them to restrict our training hours then we have to learn to practice more efficiently. This takes me to my next strategy, simulation.Many of you know that I have a high-tech Pro Batter video pitching machine in my backyard and I have four high-speed cameras that allow the athlete to watch himself on videotape hitting, bunting, pitching, or fielding in slow motion. This device allows us to practice more efficiently and to better duplicate game conditions. We pray for cold days to simulate hitting in playoff weather. Simulation exists for athletes on most every level, but surgeons need better simulators that mimic game situations.I have videotaped several of our residents and fellows operating. They often say after review, “That's why my elbow is sore.” The instant feedback of videotape review leads to quicker corrections.Surgeons, like athletes, practice their individual skills to get better. We review films pregame. Our films are angiograms and CT (computed tomographic) scans. We eat our favorite pregame meal, we put on our lucky socks, we do a pre-scrub gut check, we check our ego at the white lines, and we work as a team to get a “W” for the patient. Even when we get bad calls from the umpire (the blood bank, the anesthesiologist, the resident, or the patient’s anatomy), we work through it.We learn to “live in the moment,” which is a critical strategy for super performers. We sweep away the bad events that just occurred because we know we cannot change the hole in the pulmonary artery, but we can change our attitude to fix it quicker, better, and more safely. We, like athletes, perform under bright lights. Our mistakes are glaringly visible for all to see. And just because we possess a set of individual skills does not mean that we can perform as a team member under pressure.And after a tough game, while soaked with sweat we sit in the locker room and we talk to co-combatants. We lament our failures, exalt our wins, and learn from both. We learn more from our mistakes. A loss is an opportunity to learn. These events boost our confidence and experience to better super perform.Surgeons, like athletes, deal with physical injuries. We must be prepared to be injured. It may not be unlucky but rather a sign of improper technique. All super performers get hurt or have injuries. We are all just a moment away from a career ending injury.Surgeons, like athletes, choose to get better every day. We “need to learn a new pitch every year,” I say. Change is hard but super performers want to evolve. Robotic surgery was an entire and painful paradigm shift for us. But I knew robots and computers are our future. We needed it to evolve to deliver better results for our patients. And we have. Darwin’s philosophy is often misquoted. It was never survival of the strongest but rather survival of the fittest. The super performer who wins is the one who adapts the quickest and most ingeniously.And so I challenge you all. Be bold; be daring, because only those who dare to be great become great. The master knows that mastery is not obtainable but we choose to pursue it nonetheless. The super performer always sets the bar higher even if he fails to clear it.My next strategy is to desire mastery in all roles in life. This requires critical self-reflection. Some metrics are easily determined. The robot provided me with a videotape of every operation. And our surgical database does that as well. Every year we add new columns to apply new metrics that measure quality patient care. But have you set a column in your database that measures your quality as a parent or spouse? Last year I missed most of Robby’s baseball games because I was at Lorraine’s bedside, but this year I have a column to record the number of games I see. If I can measure it I am accountable for it and I can get better. Super performers choose to objectively measure their outcomes at home and at work and be accountable for the results. Do not assume you can do it tomorrow because tomorrow may not come, as our family found out this year.Story 3It was November, 1988 at St. Francis Hospital in Hartford Connecticut. I was an intern and this incredible, beautiful blond walked into the cafeteria. I was told that she would not date surgeons. So the challenge was set and the bar placed high. I eventually got her to speak to me. We shared a value system and a culture that centered on hard work, family, and faith. We dated, fell in love, and married on November 10, 1990. Together we knitted a culture in our home. Every person in this room creates a culture in their home, in their work place, in their operating room, and in their clubhouse.My ego, brashness, and work ethic were tempered by Lorraine’s humility, softness, and her amazing innate intellect. We blended our strengths and created a hybrid culture and medium that was a fruitful agar. It nurtured our children to grow into super performers. I wish to thank the three beacons I love the most; my three sons, Robby, Alec, and Matthew. Lorraine and I were strikingly different types of coaches. We had different lines of gratification and different love languages. She loved to dress up for Halloween (Fig 5). I hated it.Fig 5Lorraine Cerfolio dressed for Halloween, one of her favorite holidays.View Large Image Figure ViewerDownload (PPT)My idea of fun on a Saturday off work was to get the boys up early, to have a high-protein breakfast, cut the grass as a family, have a chin-up and push-up contest, lift weights together, and study. We would then hit in the batting cage, study some more, and go to a nearby baseball park to practice; just like my dad did with me and my brother every weekend. Lorraine wanted us to have dinner and go to a movie as a family. So we did both. We blended our value sets and inculcated a burning and lasting desire to super perform.We did not have a Camelot, rather the results of hard work. And Lorraine super performed by always serving others. She was a beacon to so many (Fig 6).Fig 6Lorraine Cerfolio happily providing food and sustenance for others.View Large Image Figure ViewerDownload (PPT)Culture is the key, because culture and hard work and dedication beat talent every day. My children represent the results of our hybrid culture. Robby, my oldest, currently a junior at Yale, is the captain of the pitching squad again this year. And if you devote your life to excellence of character, dedication to the classroom and to the athletic field, one day you can turn on your television and hear that your son got drafted by the Los Angeles Dodgers in the major league baseball draft. My middle son, Alec, is another great student athlete who recently graduated high school with a 3.9 GPA and, like Robby, was captain of the high school baseball team. And my third son and youngest beacon of light, Matthew Cole Cerfolio, currently has a 4.1 GPA. He was recently named a finalist for the 2013 Under Armor preseason All-American. Since so many have a natural curiosity about the details of Lorraine’s illness I will tell you.Lorraine had breast cancer in 2010 and received chemotherapy and that chemotherapy caused her to developed acute myelogenous leukemia. It was diagnosed after she first developed back pain at this very meeting (the STSA [Southern Thoracic Surgical Association]) in November 2012. She received aggressive chemotherapy just before Christmas in 2012. On Christmas Eve, I sat at her bedside in the hospital and we FaceTimed our boys and watched them open the gifts that she bought them a month earlier. We watched the New Year's Eve ball fall in New York City to ring in 2012 as a family at her hospital bedside while her white blood cell count fell as well.For four months, they gave her chemo in the hospital. They could take away her hair, they could take away her strength, but they couldn't take away her dignity, courage, culture, or humility, she never lost her class.It was a Friday, a beautiful, glorious Friday, April 12, 2013. Robby was pitching at Harvard. She called him and wished him well. She didn't tell him how she had bled into her retina and was becoming blind in one eye or about her excruciating abdominal pain. No, she only wished him luck and said, “I'm proud of you, pitch well; I’ll be praying for you.” Alec, the captain of the high-school baseball team, traveled to Florida to sing in a national choir competition. Lorraine called him and said, “Alec, I love you. I am so proud of you. Good luck tomorrow.” She never martyred herself. She was their beacon of light. She was the ultimate team player.Saturday, the next morning, I awoke at her bedside as I had done for four months, we had a nice breakfast. I wanted to watch Robby pitch on T.V. with her as we always did, but she said, “No honey, not today. I'm so tired.” Her parents had flown in. They were going to leave that afternoon and they planned to spend the day with her before their flight. She said, “I know you want to go home and cut the grass and exercise in the sun.” And so I left her. For the first time I abandoned her alone in that hospital room. Her parents spent a few hours with her. I cut the grass in such a way that when I brought Lorraine home in a couple of days before her bone marrow transplant she could see those perfect lines in the lawn, our lines of gratification. I pictured us pulling into the driveway and me stopping the car and her seeing the lines; she would place her hand on my thigh and say, “Honey, it looks great.” How I yearned to hear those words. But that never happened. I got called at 5 PM while cutting the grass. She had a massive bleed into her brain because of thrombocytopenia and she was essentially brain dead but instantly pain free. The good Lord works in interesting ways. I was able to fly my children home, my mom and dad and Lorraine's parents got off an airplane and then back on another one. And the next day, while the theme song from the Television show Lost, “Life and Death,” played, she passed away. Lorraine loved the TV show Lost because we watched it as a family and it brought us together. She died Saturday, April 13, 2013 at 10:23 AM and started her new life. I look at the 24 years I had with her as a great blessing and remember everything she taught me. You have to see the positives in every negative no matter deep they are. And so, my 3 boys and I now strive to create a new culture. This is our family now (Fig 7).Fig 7Dr Cerfolio and his 3 sons, Robby, Alec, and Matthew, on a family cruise vacation.View Large Image Figure ViewerDownload (PPT)She is there with us.Story 4Five weeks after Lorraine’s death, my family threw a surprise birthday party for me on May 24th. During that party I took this picture of Lorraine’s parents now 94