Vascular surgery needs millennials!
2019; Elsevier BV; Volume: 70; Issue: 1 Linguagem: Inglês
10.1016/j.jvs.2019.03.065
ISSN1097-6809
Autores Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoIt has been an amazing honor to be the Forty-seventh President of the Society for Clinical Vascular Surgery (SCVS). I started coming to this meeting my first year in practice circa 1999 and believe I have been to every meeting since. I first attended the SCVS when I worked at the University of Michigan. At the time, no one from the University of Michigan really came to the SCVS annual meeting. However, when I attended the SCVS annual meeting as a young faculty member, I was drawn to it mainly because of the great energy from the other young people who participated in it. I named it affectionately the “Society for Cutting Vascular Surgeons” to justify going to the meeting to learn new techniques to bring back to Michigan. In addition and importantly, the SCVS annual meeting in March in warm and sunny places helped partially to treat my seasonal affective disorder that occurred every winter living and working in Michigan. I need to start by acknowledging that I am a blessed man. Unfortunately, we don't use words like joy and blessing enough in vascular surgery. It is clear that there is a lot of joy in my life, as I have always aspired to make family the focus of my life. I heard it expressed that while vascular surgery is my vocation, my family is my avocation. As evidence of this commitment, it is not lost on me that not many people are ever able to give a Presidential Address with their parents present. My parents, Mary Anne and Rivers Upchurch, are the most giving people I have ever known. I tried to figure something prophetic to say about them, and while I likely should have used something from the Bible as my Dad has taught Sunday school for 40 years, I came across a tweet from John Lennon to describe my parents' philosophy raising my sister Gina and me. John Lennon's Mom and Dad taught him growing up that happiness was the key to life. When John went to school, a teacher asked him what he wanted to be when he grew up. He said Happy! The teacher sort of scolded him and suggested he did not understand the assignment. John told the teacher, “They did not understand life!” My parents understand life. They always encouraged my sister and me to follow our dreams and that experiences were far more important than anything material was. Life with the Upchurches has always been an adventure. My wife, Nancy, is captain of the Upchurch ship and our moral compass. Most people call her Saint Nancy. We, my boys included, have tested her sainthood especially at annual SCVS meetings in Las Vegas and Miami. She suggests to us that while the destination is important, we should live to “enjoy the journey.” Here is to our amazing journey! One does not get to this place in any Society without great partners. I have worked at three major medical centers and trained at another one. I have been associated with some of the most knowledgeable, skilled, and caring vascular surgeons. For that, I say thank you. I also have to shout out to all of my trainees. More to come on that. I have many people at PRRI to thank. Stan, Heather, Brittany, Shelagh, and all the professionals at PRRI are amazing and make the running of this meeting a joy. Having been both the Chair of the Program Committee and the Treasurer, working with PRRI is like operating with a partner. Everyone knows what that means. It is operating with a sense of peace and calm. I would like to have them stand and take a bow. Sam Money, MD, provided us with an amazing Distinguished Lecture entitled “The Tolls of Being a Vascular Surgeon.” A lot has already been said about Sam, so I can only acknowledge that he did a great job of setting me up—Bad Cop = Money, Good Cop = Upchurch. I have to acknowledge publicly a couple of other people as well. First, Joanne Lohr, MD, our only female President of the SCVS ever, called me about 10 years ago and said she was putting me on the Program Committee. I am not sure she will remember this, but she also said, “I also expect you to lead this Society one day.” That proclamation was important and fueled my passion for this Society. I hope your confidence in me was justified. I also need to acknowledge Fred Weaver, MD, and Tom Bower, MD, previous Presidents of the SCVS. Both of these individuals are great role models, not just as vascular surgeons but also more importantly as amazing human beings. Their Presidential Addresses of the SCVS serve as the “gold standards” to which many of us should aspire. Finally, I could not give a talk where I get to reminisce a bit without mentioning James C. Stanley, MD. Dr Stanley is really one of the premiere academic surgeons of the last 40 years, having been a master surgeon, President of the Society for Vascular Surgery, editor of the Journal of Vascular Surgery, and editor of Current Therapy in Vascular Surgery. While I learned so much from him, he really taught me how to write scientifically. No detail was too small. No personal pronouns. At times, he was tough on me, as evidenced by this quote from him: “Gib—my last shot at making this a class act. I hope you can get it all together. Peace JCS.” His commitment to detail helped make me the surgeon and scientist I am today. One can ponder to the point of being paralyzed attempting to determine what to talk about for a Presidential Address. I have heard people suggest that it is most important that one pick a subject matter that you are passionate about, so that is what I have done. I remember this quote from Maya Angelou in deciding to talk about the future of vascular surgery and millennials: “I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” My goal is to make you feel great about the current and future state of the SCVS and vascular surgery. Moreover, I have 30 minutes to do it. Here goes. The title of my talk is “Why Vascular Surgery Needs Millennials.” I will add that the first time I showed this presentation to my wife, she said very politely, “Your talk is really good, but I think you misspelled millennials.” She was correct. While this talk is about why vascular surgery needs millennials, it could also be why surgery needs millennials or, more specifically, why the SCVS needs millennials. Last year at the SCVS, I was a bit overwhelmed with the constant and critical discussion focusing on the problems we have in vascular surgery. Before proposing solutions to these problems, I thought it was important to provide a balanced examination of the subject matter and not appear as a “Pollyanna.” Therefore, it is important that I acknowledge our problems, only briefly, to produce a partial solution to the problems vascular surgery now faces. From data presented last year by John Rectenwald, MD, at the SCVS from the Association of American Medical Colleges, we will have a surgery workforce shortage of between 20,000 and 30,000 surgeons by 2030. Specific to vascular surgery, Bhagwan Santiani has written a lot about this. He suggests that by 2050, we will be close to 1000 vascular surgeons short, which amounts to approximately 20% shortage.1Satiani B. Williams T.E. Go M.R. Predicted shortage of vascular surgeons in the United States: population and workload analysis.J Vasc Surg. 2009; 50: 946-952Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Bruce Perler, MD, is one of the smartest people I know. In his Eastern Vascular Society Presidential talk, he lists many of the same issues Sam Money suggested yesterday in his talk, further highlighting that the problem of burnout is both contemporary and real. According to Dr Perler, 20% of vascular surgeons have symptoms of depression, 25% to 45% drink alcohol daily, and 29% withdraw emotionally from family and friends.2Perler B.A. When I grow up, I want to be successful like daddy: I just don’t want to be a doctor.J Vasc Surg. 2007; 45: 627-634Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In a more recent paper, of the 16 specialties studied, pediatric and endocrine surgeons demonstrated the highest career satisfaction, whereas a portion of plastic surgeons and a full 64% of vascular surgeons were least satisfied.3Pulcrano M. Evans S.R. Sosin M. Quality of life and burnout rates across surgical specialties: a systematic review.JAMA Surg. 2016; 151: 970-978Crossref PubMed Scopus (186) Google Scholar The CEO of Google, Sundar Pichai, suggests that “a diverse mix of voices leads to better discussions, decisions, and outcomes for everyone.” Dr Perler, further in his Eastern Vascular Society Presidential Address, suggests that the number of female applicants for vascular surgery fellowships decreased from 21% to 10% over the years 2004 to 2006.2Perler B.A. When I grow up, I want to be successful like daddy: I just don’t want to be a doctor.J Vasc Surg. 2007; 45: 627-634Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Summarizing, we have a few problems: we work too much, we are all burnt out, and we are not very diverse. To propose changes that will address those three topics, I would like to spin the tale (highly subjective of course) about how the SCVS was saved. More important, it is imperative that we learn from the “saving of the SCVS” to instruct us on how we can use that same sort of approach to promote vascular surgery. Circa 2004, the SCVS was financially broke. While it met in great places and was always socially a lot of fun, the organization had not really defined what it was going to be or uniquely provide to the vascular community. Kim Hodgson, who was President of the SCVS in 2004, was an early adopter of endovascular therapy. He described for me bringing sort of rudimentary models to the SCVS and having the residents and fellows learn endovascular skills. Over the next 5 years, and finally under the leadership of President Alan Lumsden, in collaboration with Marty Sylvain and Don Lass at Gore, the Top Gun Program was established circa 2009. Today, this learning opportunity represents our premiere learning event every year at the SCVS. At Top Gun, the vascular surgery fellows compete to see who is the most “skillful” using various sophisticated simulation models. I know personally that fellows practice for this and they compete! In addition, they are quite proud when they win (ie, see Amani Politano, my vascular surgery fellow from the University of Virginia in 2017). While Top Gun is the headliner, we have three other amazing educational programs (Fellows Program, Young Vascular Surgeons, Incoming Fellows Program) that functionally bring all the vascular surgery residents, incoming and present fellows, and young vascular surgeons together to this meeting. In a completely respectful manner to the other vascular societies, the SCVS has become the premiere educational opportunity in all of vascular surgery. Thus, the SCVS survived because of its ability to adopt new ways to educate and mentor young vascular surgeons. What can we learn from this? If one examines Kim Hodgson's SCVS Presidency talk, we learn that innovation, like the SCVS's introducing simulation early, is tough. As documented in Fig 4 of his address, as one ages and gets more political power, one's risk tolerance goes down.4Hodgson K.A. Canine or chameleon (revisited): a never-ending challenge in a perpetually changing world.J Vasc Surg. 2004; 40: 1050-1056Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Yet, we know that to stay a cutting edge specialty and Society, we need to innovate. Dr Hodgson suggests that the reasonable man (or woman) adapts himself or herself to the world. The unreasonable ones persist in trying to adapt the world to themselves. Therefore, all progress depends on the unreasonable person. He concluded that vascular surgery could use a few more unreasonable men and women. I personally think this is true for all of medicine, not just surgery. I am reminded of a quote from Albert Einstein, who suggests that “a ship is always safe at shore, but that is not what it is built for.” I suggest that if we, the SCVS and vascular surgery, do not continue to evolve, we will cease to exist. Let us now examine how we help millennials decide to become vascular surgeons. My friend Spence Taylor, MD, who is a leader and a vascular surgeon, suggests that all good boards, societies, and organizations need to understand their mission and then develop strategies and tactics to make their mission a reality. Therefore, I went to the SCVS mission statement. The mission statement suggests that the purpose of the Society is “to advance the art and science of vascular surgery; to provide a forum for vascular surgeons, and to improve the delivery of health care in vascular disease.” The mission statement further goes on to read that “the Society is particularly committed to fostering educational programs.” Based on our goals of attracting millennials into vascular surgery, do not be confused. The future of our specialty and Society is at stake here. A tweet by “Millennial med” helps to document this conflict between (vascular) surgery and other specialties. “I love the idea of being a surgeon, but the lifestyle freaks me the … out. I liked surgery, I enjoyed the technical challenges and the team environment. It's a big deal, with big consequences for my life, and this decision is overwhelming me.” A millennial was born roughly from 1980 to 2000 and now represents about 75 million people in the United States.5Millennials.https://en.wikipedia.org/wiki/MillennialsGoogle Scholar As a generation, they have lived in the digital age and have been exposed to AIDS, 9/11, and school shootings. They have typically grown up as children of divorce and are more sheltered than any other generation. They were kept so busy as kids that they are the first generation of children with schedules. As opposed to Bill Clinton and Meryl Streep, who are prototypical baby boomers, millennials are represented by Serena Williams and Ashton Kutcher. Generations such as millennials are defined by values, expectations, and ethos. Yet, honestly, millennials have a bad rap. They are labeled as impatient, distracted, overly socialized, and entitled. However, I have raised millennial sons and I know they are amazing young men and will have spectacular careers and contribute important things to society. This reminds me of being told as a young father about the “terrible twos” when I first had kids. My kids were great at 2 years old, at 3 years old, at 4 years old, and so on and are still great today and my best friends. It is incumbent on us to recognize that not every millennial is Justin Bieber! Millennials are shaped by profound expansion of technology, have enhanced social networking, and want to be engaged in global surgery. Instead of thinking of them as impatient, distracted, overly socialized, and entitled, we need to flip this and think of them as deeply empowered, collaborative, and innovative. I provide a narrative to help us define why it is so important that we, as vascular surgeons, understand and develop a strategy to connect with the millennial generation. My Dad was a freshman in 1954 at UNC-Chapel Hill. He went to see this person named Elvis “the pelvis” Presley in Raleigh with some friends. When he left that event he stated, “That guy will never amount to anything.” He has told my sister and me this story for years, and this is why it is applicable here. We, unlike what my Dad failed to recognize with Elvis Presley, need to acknowledge and embrace that like rock and roll, millennials are our future and here to stay. “Mentoring millennials” from Jen Waljee, who was a resident when I was a faculty person at the University of Michigan, has provided us with some important tactics to help attract millennials into vascular surgery.6Waljee J.F. Chopra V. Saint S. Mentoring millennials.JAMA. 2018; 319: 1547-1548Crossref PubMed Scopus (59) Google Scholar She rightfully suggests that “generational diversity” is really amplified in medicine, where training, advancement, and mentorship are steeped in tradition and where change often comes slowly. She further points out that by 2020, 40% of the workforce will be millennials. I am going to paraphrase a case scenario and make it more vascular surgery centric to help understand the tension that occurs between different generations.6Waljee J.F. Chopra V. Saint S. Mentoring millennials.JAMA. 2018; 319: 1547-1548Crossref PubMed Scopus (59) Google Scholar Three members of the surgical team including an attending vascular surgeon, a fellow, and a third-year medical student interested in surgery are standing at the scrub sink when the attending notices the medical student punching on a tablet. The attending, a bit miffed because this case will be somewhat difficult, asks the medical student in sort of an aggressive tone, “Why don't you tell me the five ways to revascularize the internal iliac artery when performing an endovascular aneurysm repair with common iliac involvement.” The medical student speaks up and says, “Well, based on the most recent AAA guidelines published in the Journal of Vascular Surgery and with you as a co-author, there are actually seven ways to revascularize or occlude an internal iliac artery during aneurysm repair. I was wondering whether we were going to use the new iliac branch device.” The medical student then proceeds to show the attending vascular surgeon the new device that is in trial on the tablet. They then walk into the operating room chatting about which specific method they are going to use to manage this problem. During the case, the attending and medical student decide to query their own local experience with this type of case as a quality project. Six months later, the medical student is up at the podium at the SCVS starting a talk by saying, “I am a third-year medical student from …”. This scenario plays out every day in vascular surgery, where there is this dynamic tension between the young learner, who is tech savvy, and the older attending surgeon. It suggests loud and clear that millennials now learn differently. Therefore and importantly, it is incumbent on us to recognize this and acknowledge that we need to mentor and teach them differently. The concept of accepting generational differences is not new and is especially critical in mentorship, which is the cornerstone of academic surgery. In a paper from 2015 entitled “Surgical Mentorship from Mentee to Mentor, the Lessons from the Life of Alfred Blalock, MD,” mentorship is acknowledged as a dynamic relationship between two individuals aimed at fostering the development of the less experienced person.7Kensinger C.D. Merrill W.H. Geevarghese S.K. Surgical mentorship from mentee to mentor: lessons from the life of Alfred Blalock, MD.JAMA Surgery. 2015; 150: 98-99Crossref PubMed Scopus (5) Google Scholar Mentorship is a vital component of success in complex endeavors in which confidence and experience are integral to the process. It is clear that mentorship is critical for success in vascular surgery and for the SCVS. The paper defines why Blalock was a successful mentor. First, he was able to recognize and develop all talent, then use that talent even when it was outside the social norm of the day (diversity). He generated a successful and collaborative environment (team) and motivated others to achieve. He had the confidence to let others flourish. Finally, he led by example with a tireless work ethic and high expectation of self. Based on the characteristics of a millennial I earlier described, doesn't it sound like Dr Blalock may have been an early millennial? In the Waljee paper,6Waljee J.F. Chopra V. Saint S. Mentoring millennials.JAMA. 2018; 319: 1547-1548Crossref PubMed Scopus (59) Google Scholar she documents why it is important for us as mentors to be cognizant of common generational misconceptions regarding millennials to make vascular surgery and the SCVS thrive. Understanding these generational differences will lead to opportunities for better relationships and make vascular surgery more attractive to millennials. Dr Waljee provides three strategies to help us adopt new trends in mentoring. First, micromentoring. This is more similar to coaching and can occur over an abbreviated time, allowing flexibility and cognitive diversity. Meetings with millennials can be frequent and rapid. An example of this may have you only helping on a personal statement, rather than the entire residency or fellowship application. This “as needed” meeting may, for example, occur over a cup of coffee vs the scheduled engagement. My example of micromentoring is the relationship/friendship I have developed with Anahita Dua, MD, MBA, and Sapan Desai, MD, PhD, MBA. I have never actually clinically worked with either one of these amazing and talented young vascular surgeons. Honestly, we have never even lived in the same city. Yet, through social media, e-mail, and brief encounters at various surgical meetings, we have written some impactful papers using the micromentoring process.8Dua A. Kuy S. Lee C.J. Upchurch Jr., G.R. Desai S.S. Epidemiology of aortic aneurysm repair in the United States from 2000 to 2010.J Vasc Surg. 2014; 59: 1512-1517Abstract Full Text Full Text PDF PubMed Scopus (318) Google Scholar, 9Dua A. Upchurch Jr., G.R. Lee J.T. Eidt J. Desai S.S. Predicted shortfall in open aneurysm experience for vascular surgery trainees.J Vasc Surg. 2014; 60: 945-949Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 10Dua A. Koprowski S. Upchurch G. Lee C.J. Desai S.S. Progressive shortfall in open aneurysm experience for vascular surgery trainees with the impact of fenestrated and branched endovascular technology.J Vasc Surg. 2017; 65: 257-261Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar A second tactic to help interact with millennials is “reverse mentoring.” According to Waljee,6Waljee J.F. Chopra V. Saint S. Mentoring millennials.JAMA. 2018; 319: 1547-1548Crossref PubMed Scopus (59) Google Scholar reversed mentoring helps to create a flat leadership structure and allows the younger to impart perspective, skills, and guidance to older colleagues. It also empowers the mentees and can be easily linked to technology or social networking. Everyone loves the graphic abstract, which was developed at the University of Michigan and taken to the next level by Chelsea Harris, MD, a surgery resident at the University of Maryland (Fig 1). Nike has taken this to the next level with workshops for senior executives organized by employees in early career stages. Finally, a third tactic to engage millennials has to do with the development of mentorship teams, where mentorship occurs in a collaborative fashion. This approach can occur across many different academic levels and may include members from industry, quality, and policy. This is where process (the need to be promoted and publish papers) is countered by purpose (I got a patent and am using the device in a clinical trial in patients already). We have known about collaborative teams for a long time in science; it is called team science. Two of my initial mentors were George Johnson Jr, MD, and Al Banes, PhD, in plastic surgery. One of my mentors was a vascular surgeon, and he always insisted I bring the science back to the patient. My other mentor was a basic scientist who helped with the specifics of the methodology and with the interpretation of the results. They both helped me equally, as did multiple other people in the laboratory. “Team science” translated into me getting my initial first authored paper published in the Journal of Vascular Surgery as a second-year medical student, which has been cited a total of 29 times!11Upchurch Jr., G.R. Banes A.J. Wagner W.H. Ramadan F. Link G.W. Henderson R.H. et al.Differences in secretion of prostacyclin by venous and arterial endothelial cells grown in vitro in a static vs a mechanically active environment.J Vasc Surg. 1989; 10: 292-298Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The importance of understanding these generational differences must be recognized and embraced, perhaps using some of the aforementioned tactics to achieve productive mentoring relationships. Remember, all surgeons seek purpose, collaboration, and advancement. Millennials are no different. They are looking for opportunities, and if vascular surgery cannot provide them, they will look for other opportunities in interventional radiology or cardiology. This also applies to your younger faculty, who are migratory and will look for better opportunities elsewhere if they are not being fulfilled. The bottom line is that it is incumbent on us to “keep an open mind at the scrub sink!” There is a little good news. While we are far from being a leader in diversity, last year my friend John Rectenwald, MD, documented that when the Accreditation Council for Graduate Medical Education examined the number of women going into vascular surgery in 2015, our specialty far exceeded interventional radiology and cardiology. In the infamous words of Charlie Sheen—“winning.” The question then becomes, Are there other areas where millennials may be favored? In his Presidential Address to the Academic Surgical Congress in 2016, Justin Dimick, MD, MPH, discussed “the rookie advantage,”12Dimick J.B. Association for Academic Surgery presidential address: the rookie advantage.J Surg Res. 2016; 205: 43-48Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar which may be another area where millennials may be favored. While respecting the tradition of surgery and the experience required to be a skilled surgeon, Dr Dimick puts forth some alarming statistics. He suggests that the total amount of information in the world doubles every 18 months. Innovation cycles are shortening so rapidly that expertise is becoming outdated faster and faster. This is driven by what he terms “disruptive technology,” by what I call a disruptive generation (ie, the millennials). In addition to the rapid expansion of knowledge, he acknowledges that the rate at which knowledge becomes obsolete is also increasing, with a 30% decay per year in many high-tech industries. Therefore, if knowledge doubles every 18 months and decays 30% per year, how long does one's expertise last? Presently, when all of health care is experiencing volatility, uncertainty, complexity, and ambiguity, it is becoming imperative that the SCVS and vascular surgery give young vascular surgeons a voice because learning agility has become as valuable as experience. In vascular surgery, we must build a balanced culture where, while respecting tradition, we also engage everyone, including those of different generations (yes, even millennials) in the process. I recently moved from the University of Virginia to become the Chair of Surgery at the University of Florida. While I honestly love my job and the University of Florida, during this transition in 2017, I did a lot of self-reflection. I had honestly planned on finishing my career at the University of Virginia. One of my sons was in college there, and my parents and sister lived within 3 hours of Charlottesville. To leave them felt like I was abandoning my family. I also felt like I had contributed to the culture at the University of Virginia in a positive way. Therefore, this transition was harder than I expected. In my self-reflection, I recognized a number of characteristics about myself that help to define who I have become. First, I have moved around a lot. I have felt the need to seek opportunities that were not available where I was. I think it is important not to confuse this with being overly ambitious. I loved working at the University of Michigan, but the people who occupied the Division Chief, Heart and Vascular Center Director, and Department Chair jobs still occupy those jobs today. I needed to move to be able to express my leadership skills and grow professionally. Second, as an aspiring “triple threat,” I have had to embrace technology. I actually get most of my news on social media. Third, I am extremely collaborative. In Michigan, I learned a lot about the management of complex aortic patients and the pathology of this disease from Dave Williams, MD, an interventional radiologist, and G. Michael Deeb, MD, a cardiac surgeon. Not only are they both great physicians, they are also my good friends. Fourth, I actually like flat systems and cannot stand meetings for the sake of meetings. I will often go over to the medical school to have interviews to get away from the office, so it is more of a “flat” site. Fifth, diversity is important to me. Having raised an African American son, I am committed to making vascular surgery more diverse. My Department of Surgery at the University of Florida is almost 25% female, which is well above the national average. While I am extremely proud of this, we are not satisfied with it and will strive to do better. Finally, I believe in “value-based” leadership rather than time in service. At the University of Florida in the Department of Surgery, we have an assistant chair of promotion, so we can get people promoted faster. In self-reflection, I learned that I have many of the same characteristics that a millennial has, despite being born a baby boomer. The question then became, How can we use the characteristics that define a millennial and the millennials themselves to help promote vascular surgery? Based on what I have told you about how we need to change to remain relative, I have three personal requests for the young vascular surgeons to combat the aforementioned “problems” in vascular surgery. First, we need a video book in vascular surgery, and the SCVS should lead this; after all, we are the “society for cutting vascular surgeons.” I have edited 13 major textbooks. While I am extremely proud of each of them, they now primarily serve as a place I hang
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