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Looking forward through the past and changing me to we in the evolution of team-based vascular care

2019; Elsevier BV; Volume: 70; Issue: 2 Linguagem: Inglês

10.1016/j.jvs.2019.04.480

1097-6809

R. Clement Darling,

Human Resource and Talent Management

Being president of the Society for Vascular Surgery (SVS) is the highlight of my career, not only professionally but personally for me, for my family, and for my partners in Albany. I would like to thank Michel Makaroun for his wonderful introduction, although most of it may not be true. I attended my first SVS meeting when I was 6 years old with my parents, and at that point, it was mostly a scientific spectacle; but for my father, the SVS meeting was much more important than being president of the United States. And my father, who I loved dearly, although it took a long time to get there, deserved this position more than I. He did not achieve it because of his personality quirks, personal misadventures, and disregard for authority. I would like to acknowledge the incredible hard work, expertise, and support from the executive committee of the SVS under the expert guidance of Ken Slaw, Patricia Burton, and Elsa Hall. I thank Ron Fairman, Michel Makaroun, Kim Hodgson, Sam Money, Ali AbuRahma, Mike Belkin, and Bill Shutze for their diligence, friendship, and vision. I am proud that we have made great strides in building a Society that serves all the varied practices, those that serve the community and also the academic centers. We strive to serve you and your patients each and every day. I also want to thank the many past presidents who have put the SVS on a powerful and stable course. There are too many to thank, but Tony Sidawy has always given me sage political advice; Peter Gloviczki, a close friend who nominated me; Ramon Buerger, who gave me my first SVS position; Frank Veith and Jim Stanley threw me headfirst into the political arena; Rich Cambria, Hazim Safi, and Greg Sicard have been technical inspirations. Although I love what I do, and I annoyingly treat each day at work as if it were opening presents at Christmas, my first team is my family (Fig 1). I met my wife, Julie, 45 years ago in college. I was at preseason football camp and she was an incoming freshman. On Christmas break, I knew she and her parents were going to Miami Beach, so my friend and I drove 2000 miles to Miami to pretend we were “just in the neighborhood” for a visit. After that, we have been inseparable. She has supported me and our family and has raised three incredible kids, many times without me or in spite of me. Without her, I would still be listening to loud music in my room or in jail. I would never have ventured to Paris or Nairobi for work and never be standing up here without her support, dedication, and love. I love you dearly, Julie. And yes … someday we will take a month off. After my training, where I was on call every night for a year, I promised we would take a month off, but it never happened. On June 27, at the end of my fellowship, I thought I had my first weekend off, and as I was swimming with the kids, my beeper went off. It was the operating room (OR). They said, “Your ruptured abdominal aortic aneurysm is on the table.” I said, “I'm not the fellow on call anymore.” They answered, “We know. Dr Shah said you are now the attending on call.” As I mentioned, one of Julie's greatest feats was to raise three wonderful children. I'm so proud of who they are and the incredible people they have become. They all are smart, hardworking, honest, wonderful people who I cannot say enough about. Clem works and lives in California. He is truly an inspiration. To see him perform defines passion. He has excelled in most art forms: music, screenplays, stand-up comedy. He's following his dream and has an artful sense of humor, and his ability to put himself out there without a safety net is spellbinding. Jeremy is a second-year medical student, just recently married 2 weeks ago to Laura, who is a wonderful woman getting her PhD in psychology. I can't leave out mentioning their dog Butter. Jeremy is one of the hardest workers I know. He has worked hard for Marc Schermerhorn, has already presented at the Vascular Annual Meeting three times, and published more than 32 peer-reviewed papers. He's serious, analytic, determined, and the most focused individual I've ever met in my life. And last but not least, my wonderful daughter Melanie, who has been a true inspiration. Not only is she brilliant, but she is thoughtful, caring, and determined. She is getting her master's degree in somatic psychology. She is independent, has traveled abroad working on organic farms, and is bolder and more fearless than I will ever be. She is going to be a wonderful therapist and asset to the world. She makes this world a better place, and she makes me a better person. Now, I'll tell you a couple of stories about each. When I first started, I was on call most weekends. One weekend, I was making pancakes for my children as a surprise. My oldest son wakes up, looks at me, and says, “Did you get fired?” I said, “No.” And he replied, “Are you sure?” Wow, they really weren't used to me being home. Jeremy once asked me when he was about 10 years old, “How come all the other fathers stay home on weekends and you always go to work?” and I said, “Well, because I make more than they do.” He looked at me, paused, and said, “Well, can we give some of that money back?” In the end, he was the one to choose medicine as a career. I took Melanie to work with me on Bring Your Daughter to Work Day. I showed her what I thought were impressive operations and really complicated problems. I thought she would be impressed. That evening, I asked her, “What's the thing you liked the most about today?” She turned to me, thoughtfully, and said “What I liked the most is all the doctors called you Dr Darling, and all the janitors called you Clem.” Again, tremendous insight from my intelligent and insightful daughter. I love you and am so proud of you all. Thank you for all the happiness and joy you bring into my and others' lives. I also want to thank my sisters Cindy, Wendy, and Elisabeth as well as “cousins” for their resilience, love, and support. Also, my friends and the dogs who have helped me in more ways than I can name (especially the dogs). Also, I want to mention my wife's parents and our Clan. My talk today is “Looking forward through the past and changing me to we in the evolution of team-based vascular care.” After more than five decades of working in an OR as a tech, a student, and a surgeon, I have found a few take home concepts to be particularly useful, and I hope you do as well.1.I believe Einstein was right when he said, “None of us is as smart as all of us.” We learn from each other, which is the foundation of team-based training.“By three methods we may learn wisdom: First, by reflection, which is noblest; second by imitation, which is easiest; third by experience, which is the bitterest.”— Confucius2.The key to resilience, healing, and health, whether for our patients or for ourselves, is caring and supporting each other more. We need to support each other for our personal health, for our patients, and for our specialty.“Facts do not cease to exist because they are ignored.”— Aldous Huxley, Complete Essays 2, 1926-19293.Failure is not an end result. It is the path to success through learning.“Success consists of going from failure to failure without loss of enthusiasm.”— Winston Churchill4.Remember the past but look to the future. The best predictor of future behavior is the past, but the future we are experiencing now is like no other!“Life can only be understood backwards; but it must be lived forwards.”— Søren Kierkegaard The evolution of vascular surgery and surgical education was not pretty, and I was lucky enough to see much of it firsthand. We have come a long way, however; many times we think we are more advanced then we really are. I cherish each of the parts of our team, but Dhiraj Shah deserves this honor more than anyone else I know. Excellent technical surgeon, educator, leader, and friend, he with Bob Leather and Alistare Carmody established the practice that I have the honor to presently steward. Ben Chang, my surgical soul mate, helped me be a better thinker and surgeon, and it is rare to have the privilege of saying you've done thousands of operations together; Sean Roddy, a close friend, coder extraordinaire, and brilliant, hardworking clinician; the organized and thoughtful Paul Kreienberg, who has run our residency and helped educate our fellows and residents. Both Paul and Sean counterbalance my aggressive surgical style and made me realize some are emotionally suited to build airplanes while others build parachutes. Jeff Hnath, who has run our outpatient facility beautifully and is as endo skilled and fearless as anyone I know; John Byrne, Devon Bock, and Courtney Warner, who rule the North Country; and the group that I can only refer to as “vascular wonder women”: Molly Shah, Chin-Chin Yeh, Stephanie Saltzberg, Courtney Warner, Xzabia Caliste, and Adriana Laser, who are skilled vascular surgeons and such great assets to our program. I am proud that we have a representative number of women in our practice, not for any socially conscious reason, rather that we hire the best and most capable. These women and men make me proud as vascular surgeons. Also, and especially, I must extend my deepest thanks to Jane Mangan, who's worked with me for 20 years and run our entire academic, scholastic, and work life. She has probably written more papers than I have; she at least has corrected more than I've ever read. Jane and more recently Fredd Brewer have been invaluable assets to me and the group. They, with their attention to detail, completeness, and organization, make up for many of my faults. They are worth my weight in gold, and we could not do what we do without them. Thank you, Jane and Fredd. Karen Fitzgerald has been with us for more than 30 years as a vascular nurse, is a past president of the Society for Vascular Nursing, and as head of nursing for our group has done a tremendous job of teaching hundreds of nurses the intricacies of vascular disease and vascular patient care for our practice and beyond. I would be remiss if I didn't mention the late Kate Fitzgerald, who created and ran our vascular registry. Without her, I would not have had an academic career. We could not exist without our well-trained vascular nurse clinicians, nurse practitioners, physician assistants, vascular laboratory techs, floor and vascular intensive care unit (ICU) nurses, and support from administrators like our practice manager, John Sano. Abdul Khan has been our lead tech for more than 20 years, and he is indispensable. I would also like to thank our Chief of Surgery, Steve Stain; our CEO, Jim Barba; Fred Venditti; and Steve Frisch for his support establishing our vascular ICU as well as the tremendous infrastructure needed to run our extensive network. This system was built with the goal of excellent patient care without concern for pulling patients into the system but rather providing the best care and support for the region. And last, I want to thank our fellows, who have suffered with me and made our patients' lives better. I am very proud to have been involved in your training. I've been exposed to this wondrous specialty for almost my entire life. I was born when my father was a surgical resident, and my mother was the backbone of the family. She supported us not only financially but also emotionally. She was sweet, funny, and fiercely loyal. I learned the value of hard work, technique, and tenacity from my father, but my mother showed me how I could have those qualities and still be positive and caring. I learned that one can get a lot more done with a smile instead of a threat. As a 12-year-old, I remember my father telling my sister Cindy and me that “for every dollar we spend, these hands have to make two, and this gravy train is not going to last forever.” That's when I got my first job. When I was 15, my mother realized that my relationship with my father was strained and she suggested I apply for a job in the hospital. I met Jeff Raines, who was finishing his PhD at Massachusetts Institute of Technology on the pulse volume recording. He was working with my father and Steve Holford on developing noninvasive technology. My first hospital job was to help solder the motherboards and do pulse volume recordings. I must mention that Dr Jeff Raines is truly also one of the pioneers of noninvasive peripheral vascular imaging. He was also extremely active in duplex ultrasound with Gene Strandness, did some of the early studies on the prevention of deep venous thromboses with sequential compression boots with Bill Harris at the Massachusetts General Hospital (MGH), and also designed the first autotransfuser at the MGH. He was grossly under-recognized and really deserves credit for pushing us forward with many of our mechanical technologies (Fig 2). Eventually, I became an OR tech working with the vascular team. This also made me realize how important the team concept is in providing comprehensive care. Each person had his or her role, each respected for their expertise and each committed to a “shared vision.” It didn't matter if you were a nurse, surgeon, tech, or staff; if you did your job, you were rewarded, and if you didn't, there was hell to pay. To me, this was a simple and straightforward world. My father, in his own unique discourse, explained it to me in his misanthropic way. One time, he took me on rounds, and we met this woman who was a maintenance person emptying the wastebaskets. As we walked in, my father greeted her very, very nicely. He asked her how she was doing, asked about her family, introduced me, and thanked her for her hard work. Two minutes later we ran into the Chief of Vascular Surgery, not one of his favorite people. My father then starts berating his chief, finally saying, “This is my son, Clemmie, and I'm taking him to the operating room. The operating room is where vascular surgeons operate. You may want to come up and visit it some time.” As we walked away, I was startled at that interaction, even as an 8-year-old. I turned to my father and asked him, “Why are you so nice to the lady and so nasty to the man?” He turned red faced and said, “Because she works, and he doesn't.” Note to self, working hard is good. As I mentioned, my father was a driven, intelligent, hardworking surgeon who did not tolerate fools well and had a Machiavellian approach to teaching or getting things done. I will probably make a few people uncomfortable here as I go through some of the stories of my father, but that was generally his modus operandi. He loved to make people uncomfortable, no matter who you were or how old or important you were. His sister once tried to confront him about his condescending attitude and said, “Ralph, I'm not as stupid as you think I am!” and his response was, “You couldn't possibly be!” My father had this propensity to say nasty and colorful things to people just loud enough so they could hear him. In one of my early memories of the SVS meeting, as we walked through the entrance, he pointed to a vascular surgeon and turned to me and said, “See that man over there? Most people are stupid, but that man is exceptional.” Of course, the physician heard this and turned toward my father irately, and my mother gently went up to him, softly put her hand on his arm, and said, “Don't worry, he's not talking about you.” She mostly defused the situation, which somewhat aggravated my father, but that was her superpower, being able to minimize the damage done by my father's artful tongue. Unfortunately, she was not always there to protect him from himself. He could be a bear to deal with, but there was no one in the world that could deal with my father better than my mother. She was one of the strongest, loyal, and most perceptive people I know. She was instrumental in keeping our family team together. My father was difficult, emotionally challenged, and with a very short fuse; he was feared by many. But to my surprise, when I started working with him, I found he was adored by most of his fellows and residents. He was a stern taskmaster. However, he was extremely supportive of those people he trained, and as I worked with him, I was shocked at how somebody who could be so difficult could also be so adored. I have been lucky to be raised by incredibly strong women—my mother, my sisters, my wife, my daughter, my staff at work, and my women partners. You all have had an incredibly stabilizing influence on me, and I thank you. Your passion to protect me and support me is sometimes undeserved, but your mother would be proud. Much like my mother, my family was my passion. I wanted to work in an environment that rewards taking care of your family as well as your patients. I thank my partners for their help in creating that environment and indulging my vision. My path to this esteemed position is circuitous at best, and one of the invaluable things I have learned is the value of failure, evaluating the past to avoid the same mistakes and the benefit of the team in providing support and care. The concept of team-based care is well established in the history of surgery. Most advances occurred not by surgeons conceptualizing solutions in a vacuum but by working in a group of dedicated individuals with a shared vision. Each person, no matter what their position, was treated with respect. Their input, critical thought, and ability to question the hypothesis were equal to the boss. Everybody's quest was “to do the right thing” and get the correct answer, learning equally from failure as well as success. During the 70s when I was an OR tech, we had no self-retaining retractors, such as the Buckwalter, the Omni, or the Thompson. What we did have was surgical technologists whose sole job was to retract the bowel during large open cases, such as abdominal aortic aneurysms. To put this in perspective, in those days, open surgery after completing an aneurysm, at least at MGH where I worked, every patient got a Witzel gastrostomy tube, which was taken out in the office to get the nasogastric tube out early and prevent pulmonary complications. Interestingly enough, if you look back at the data from that era, mortality for open aneurysm repair was less than 2%, which many would have a hard time repeating in these days and times. One thing I did notice was how well choreographed the OR was because of the team responsibilities. As authoritative as my father and many of the surgeons of his time were, each had their own private scrub nurse who knew exactly what instruments, sutures, and retractors they needed. There was one time when I was working with one of the pancreatic surgeons at the Lahey Clinic, Dr John Brasch, who was well known in his specialty. A senior resident tried to impress Dr Brasch by knowing what he specifically used for his pancreatic anastomoses. However, Dr Brasch had absolutely no idea what sutures he used. The resident turned to the scrub nurse and said, “We will use the 3-0 and 4-0 Vicryl for this anastomosis.” The nurse sharply responded to the resident, “Dr Brasch will use what I give him.” As we all learned in our residency, there was a direct pecking order in that era, and the residents were not even close to the top, but the scrub nurses and technologists that worked with those surgeons daily as part of the team knew the dance, and there was almost no verbal communication needed to perform these exquisitely complicated operations. This team effort is what I fully attribute to the incredible outcomes during that time period despite rudimentary ICU and anesthesia care. It even morphed, at least in the MGH system, to have one single anesthesiologist do most or all the aortic work. Dr Kenny Davidson, for many years, was the Chief of Vascular Anesthesia if not the only anesthesiologist who was used during big operations. There were some bumps in the road as I became a physician. After working with my father, I decided that I would never want a career in medicine, nor ever want to be a surgeon and never, ever go into vascular surgery. I saw his extreme passion but also his personal implosion due to the stress and constant battles internally and externally. It was too consuming. I also saw how our specialty was built on success through failure. These were long cases with little relief. Every anastomosis had to be perfect. In the words of Dr Linton, “If you don't have time to do it right the first time, when will you have time to do it over again?” Anastomoses were routinely taken down until they were perfect. Training was brutal. Some residency programs didn't allow you to be married. Residents were routinely fired. I can still hear the insults tossed onto the fellows and resident. “You operate like a veterinary gynecologist.” “Use both hands or one will atrophy and fall off.” “Are you stupid or you just don't care?” or my favorite, “Son, are you sleeping with this patient's wife? Then why are you trying to kill him?” I was amazed by the determination and intensity these surgeons brought to their work every day. It was impressive but also overwhelming. The only thing I knew was that I didn't want to go into medicine and I was definitely sure I wound never be a surgeon and I was damn sure I would never, ever, ever go into vascular surgery. After hearing my father's comments to his fellows, what he said to my sisters and me didn't seem so bad. It also left an impression on me that despite his criticism, he was respected by his fellows, which was enlightening. I wanted to find my passion, something special. The one thing I knew was that I was never going to go into medicine, never ever go into surgery, and definitely never, ever go into vascular surgery. After college, I took 3 years off to work with Judah Folkman, Bob Langer, and Jay Vacanti. I became a trusted part of a team where I was supported and valued. With Dr Folkman's support, I eventually got into medical school while taking night classes, being on call for the MGH, and working for Dr Folkman for the day. He taught me hard work, independent analytic thought, and rigorous scientific evaluation. Once I was accepted to medical school, I thought I was home free, but it was not to be. My Chief of Surgery in medical school took a particular negative interest in me, either my heritage or my laid-back approach. I needed an 80 for honors in surgery on my final exam, and somehow the Chief of Surgery showed up at my test. As I approached the proctor to hand in my exam, he took my paper and said, “I'm going to grade this myself.” Without reading a word he wrote 79, not good enough, and left. I never found out exactly why, but he informed me he would do all he could to make sure I did not get a surgical residency. But I relied on my father's gentle supportive words of wisdom when I was younger, “I don't think you're smart enough to know how stupid you are.” Most would consider this negatively, but for me it was rather emotionally freeing. You cannot allow others to dictate your future. Failure, no matter how arbitrary, would not define me. I had nothing to lose, so I persisted. I applied to surgical residency, and Dr McDermott, who was the chief of surgery at the Deaconess, on reviewing my application, looked at me right in the eyes, kind of smiled, and said, “You're Chief of Surgery hates you,” and I said, “Yes sir, I think he does.” Despite that, I was accepted to his surgical residency program and went through residency. I decided I was going to ultimately be a liver transplant surgeon but do a vascular fellowship first, and so I applied. I had a good application, was considered a strong resident, and again, maybe because of my cavalier approach, when I opened my match envelope, it said “none.” I was the privileged son of a prominent pioneer in vascular surgery who, despite my extreme trepidation, decided to follow his father's footsteps. Now, oddly, again, I was a failure. I could have taken this as a personal failure and I could have decided to do something else, but falling back on my father's words of wisdom when I was young, I think I was just too stupid to know how dumb I was. Maybe he was right, but for some reason, I wasn't deterred. So I shrugged it off, and eventually met Dhiraj Shah, who invited me to apply to his fellowship; and I was accepted. He convinced my wife that I should skip my transplant fellowship and take a job in Albany “because they needed a cutter,” and 29 years later, I am still in Albany, New York. Now, one would have thought that my small missteps would have stopped there. But ironically, my issues didn't end there. When I applied for membership to the SVS, someone had written a note saying that I should never be considered, nor was I deserving to be a member of the SVS, and never should I be admitted into this austere Society. But with Dr Shah's support, I was accepted, and as they say, the rest is history. I am forever indebted to Dr Shah for his superb skills, leadership, and friendship. He deserves this honor and my deep gratitude as much as anyone. I mention these minor setbacks not for self-aggrandizement but more to point out that no one goes into this field because it is easy. This is our passion. This is a specialty that finds you. I tried to escape it in every way possible, but it kept drawing me back in, which is indicative of the emotional reasons we all go into vascular surgery. We look at difficult problems and challenges every day. We deal with very sick and unhealthy patients. Everyday we're asked to do the impossible, and every day we get up, go to work. We do the best we can. We can make the best plans, treat the sickest patients, and get a personal fulfillment for what we do. We do the right thing for the patient. When I was playing football, I was taught that you never give up on the play. That's what I love about vascular surgeons. We never give up on the play. We are always willing to do and try the impossible. We're always willing to be the last person to call when things look bleak. It brings me great glee whenever we get called to the OR and people look around and go, oh thank God, the vascular surgeon's here. Our colleagues in other specialties are often afraid of blood vessels, afraid of death, afraid of complications. We thrust ourselves every day into situations where nobody else will go. We put ourselves in harm's way for the benefit of our patients, taking little consideration for our time and sometimes our families. I mention this in the context of how failure is truly a bridge to success. As vascular surgeons, we face failure and roadblocks daily yet still persist where others are scared to tread. Many of you have faced far worse barriers of discrimination, unreasonable arbitrary barriers, and I am constantly humbled by your ability to overcome. This innate ability to focus on the problem is what makes vascular surgeons great. No problem is too complex; no detail is too small. We do the right thing despite the odds against us. We do right by the patient. The extraordinary accomplishments of teams throughout human history have been well documented. One could talk about the Royal Society of London, which was formed in 1660 to promote the free exchange of ideas in promotion of “truth in scientific matters.” Members included Sir Isaac Newton; Christopher Wren, the architect of St. Paul's Chapel; Gotfried Leibniz, the inventor of calculus; Edmund Halley, an astronomer; and Robert Hook, the inventor of the steam engine, just to name a few. The Society invited membership of scientists regardless of nationality or state of war they were in. The free flow of shared information between Royal Society members led directly to the industrial revolution, embryonic evolution theory, mechanical computation, an understanding of planetary gravity, and more. There is perhaps no other period of history in which science moved so far and so quickly. The level of trust (truth, respect, understanding, support, and accountability) and shared vision in the goal to advance science that the members of the Society achieved places them in the high-performance team hall of fame. This surely required extraordinary communication and planning as well as shared vision. While Helen Brooke Taussig and Alfred Blalock both won deserved fame for their efforts, another key player is still unknown to most people: Vivien Thomas. In January 1930, Vivien Thomas, a young African American, came to work for Blalock in his laboratory. At that point, Blalock's increasing obligations were cutting into the time he could spend in the laboratory and he needed a surgical assistant. Vivien Thomas learned to perform the surgical operations and chemical determinations needed for their experiments, to calculate the results, and to keep precise records. Blalock and Thomas worked closely in the surgical laboratories. Thomas was a major contributor in the development of operative techniques. Thomas supervised the surgical laboratories at Hopkins for more than 35 years, and in 1976 he was appointed instructor in surgery at The Johns Hopkins University School of Medicine. In 1979, on his retirement, he became instructor emeritus of surgery. Vivien Thomas's achievements were widely recognized by his colleagues. In 1976, he was awarded the honorary degree Doctor of Laws by The Johns Hopkins University. Without him, this lifesaving operation would not be available (Fig 3). Each of these examples have common themes of broad shared vision and teams of individuals with unique talents and knowledge looking at the same problem and coming up with complementary, cross-cutting solutions. The members on all of these teams did not always like each other, but they developed a deep respect for the higher mission, each other's individual contribution, and they respected each component of the team, knowing one gap could spell failure. This is why I am so proud that the Society for Vascular Nursing has joined us in